Every finding on record at Oasis at Pearland

Based on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 3 of 18 staff (RN H LVN C, and CNA I) reviewed for Dementia training. The facility failed to ensure RN H , LVN C and CNA I were trained in Dementia management. This failure could place residents at risk of receiving care from incompetent/untrained staff and not having their Resident Rights met. Findings included: Record review of CNA I's personnel files revealed hire date of 10/14 /25 and no evidence of dementia training. Record review of LVN C's personnel files revealed hire date of 12/6 /23 and no evidence of dementia training. Record review of RN H 's personnel files revealed hire date of 2/28 /26 and no evidence of dementia training. During an interview on 8/7/26 at 11:09 AM HR assistant stated she was continuing to work on personnel files which were requested via email from the administrator on 8/6/26 at 10:21a.m. and she still did not have a file for two staff that transferred from another facility (RN H & LVN C). She stated she could not call the other facility due to the facility had been sold and they would not provide her with any information. She stated she could not find a file for CNA I and could not provide an explanation for why the file was not in the facility. She stated the prior HR director had been responsible for the employee files and training, but she was no longer at the facility and could not be reached for assistance.During an interview on 8/7/26 at 1:45 PM the administrator stated that he had been assistant administrator prior to The sale of the facility to another company. He stated he had nothing to do with employee files during the time that he was in the position of assistant administrator. He stated he did not know why employees had not received the training required and he would see that they did receive all training going forward. He stated he would continue to assist the Assistant HR person to locate the missing training and files. He stated he did not realize that there was a problem with employee training and personnel files until he was told by the HR Assistant today. He stated as administrator he was responsible for the buildings function. Record review of the Facility assessment dated April of 2026 contained the following information which addressed training : Provide a link to all staff training and competencies needed by type of staff. Consider If It would be helpful to Indicate which competencies are reviewed at the time the staff member Is hired and how often they are reviewed after that. Consider the following training topics (not an inclusive list): care/management for persons with dementia and resident abuse prevention. The facility must Include as part of its Infection prevention and control program mandatory training that Includes the written standards, policies, and procedures for the program.Culture change (that Is, person-centered and person-directed care)Required In-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aids but must be no less than 12 hours per year.Include dementia management training and resident abuse prevention training.Address areas of weakness as determined In nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff.For nurse aides providing services to Individuals with cognitive Impairments, also address the care of the cognitively Impaired. Record review of the Policy Provided by Administrator Titled Competency of Nursing Staff dated revised 2017 revealed in part: Policy StatementAll nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law.In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: participate in a facility-specific, competency-based staff development and training program; and demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.Policy Interpretation and ImplementationThe staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents.The following factors are considered in the creation of the competency-based staff development and training program: an evaluation of the current program to ensure basic nursing competencies; Any gaps in education or training that may be contributing to poor outcomes; specialized skills or training needed based on the resident population; a method to track, assess, plan, implement and evaluate the effectiveness of training; and a method to evaluate critical thinking skills and management of care in complex environments with multiple interruptions. The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as:Dementia management.

ased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 17 of 17 staff (Admin, DON, SW, AD, DFS, DOR, HSK, WC Nurse, RN H, RN D, LVN B, LVN C, LVN E, CNA I, MA A, CNA F, CNA G) staff reviewed for training requirements. The facility failed to ensure The Admin, DON, SW, AD, DFS, DOR, WC Nurse, RN H, RN D, LVN B, LVN C LVN E CNA I Ma A CNA F, and CNA G were communication, Resident Rights, infection control, Abuse and Neglect, Dementia training, QAPI, HIV, Restraint reduction, fall prevention, and Behavioral Health. Findings included: Record review of RN H's personnel files revealed a hire date of 2/28/25 and no evidence of Resident Right, Communication, Infection Control, Abuse and Neglect, QAPI, Behavioral Health, HIV, Restraint Reduction, Falls, Dementia, Compliance and Ethics, Fire extinguisher, and emergency preparedness training. Record review of RN D's personnel files revealed a hire date of 1/3/24 and no evidence of Resident Right, Communication, Infection Control, Abuse and Neglect, QAPI, Behavioral Health, HIV, Restraint Reduction, Falls, Dementia, Compliance and Ethics, Fire extinguisher, and emergency preparedness training. Record review of LVN C's personnel files revealed a hire date of 02/28/2025 and no evidence of Resident Right, Communication, Infection Control, Abuse and Neglect, QAPI, Behavioral Health, HIV, Restraint Reduction, Falls, Dementia, Compliance and Ethics, Fire extinguisher, and emergency preparedness training. Record review of CNA I's personnel files revealed a hire date of 12/6/23 and no evidence of Resident Right, Communication, Infection Control, QAPI, Behavioral Health, HIV, Restraint Reduction, Falls, Dementia, Compliance and Ethics, Fire extinguisher, and emergency preparedness training. Record review of MA A's personnel files revealed a hire date of 5/15/2025 and no evidence of Resident Right, Communication, Infection Control, QAPI, Behavioral Health, HIV, Compliance and Ethics training. Record review of CNA F's personnel files revealed a hire date of 3/19/26 and no evidence of Communication, Infection Control, Behavioral Health, and QAPI training. Record review of CNA G's personnel files revealed a hire date of 3/26/26 and no evidence of Communication, Infection Control, QAPI, Behavioral Health training. Record review of the administrator's personnel files revealed a hire date of 8/13/25 and no evidence of Communication, QAPI, Behavioral Health, HIV, or Compliance and Ethics training. Record review of the DON's personnel files revealed a hire date of 3/19/26 and no evidence of Communication, QAPI, and Behavioral Health training. Record review of the Social Worker's personnel files revealed a hire date of 8/27/25 and no evidence of Communication, QAPI, Behavioral Health, or Compliance and Ethics training Record review of the Activity Director's personnel files revealed a hire date of 11/30/20 and no evidence of Compliance and Ethics training. Record review of The Director of Food Services personnel files revealed a hire date of 11/18/24 and no evidence of Communication, QAPI, Behavioral Health, Compliance and Ethics training. Record review of Director of Therapy's personnel files revealed a hire date of 6/15/2022 and no evidence of Communication, QAPI, Behavioral Health, Compliance and Ethics, training. Record review of the Housekeeper's personnel files revealed a hire date of 10/5/2023 and no evidence of Communication, QAPI, Behavioral Health, , Compliance and Ethics training. Record review of the Wound Care Nurse's personnel files revealed a hire date of 10/2/2025 and no evidence of Communication, QAPI, Behavioral Health, HIV, Compliance and Ethics training. During an interview on 8/7/26 at 11:09 AM the HR assistant stated she was continuing to work on personnel files which were requested via email from the administrator on 8/6/26 at 10:21a.m. and she still did not have a file for two staff that transferred from another facility (RN H & LVN C). She stated she could not call the other facility due to the facility had been sold and they would not provide her with any information. She stated she could not find a file for CNA I and could not provide an explanation for why the file was not in the facility. She stated the prior HR director had been responsible for the employee files and training, but she was no longer at the facility and could not be reached for assistance. During an interview on 8/7/26 at 1:45 PM the administrator stated that he had been assistant administrator prior to the Sale of the facility to another company. He stated he had nothing to do with employee files during the time that he was in the position of assistant administrator. He stated he did not know why employees had not received required training and he would see that they did receive all the training going forward. He stated he would continue to assist the Assistant HR person to locate the missing training and files. He stated he did not realize that there was a problem with employee training and personnel files until he was told by the HR Assistant today. He stated as administrator he was responsible for the buildings function.Record review of the Policy Provided by Administrator Titled Competency of Nursing Staff dated revised 2017 revealed in part: Policy StatementAll nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law.In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: participate in a facility-specific, competency-based staff development and training program; and demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.Policy Interpretation and ImplementationThe staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents.The following factors are considered in the creation of the competency-based staff development and training program: an evaluation of the current program to ensure basic nursing competencies; Any gaps in education or training that may be contributing to poor outcomes; specialized skills or training needed based on the resident population; a method to track, assess, plan, implement and evaluate the effectiveness of training; and a method to evaluate critical thinking skills and management of care in complex environments with multiple interruptions. The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as:Preventing abuse, neglect and exploitation of resident property.Dementia management.Resident rights.Person centered care.Communication.Basic nursing skills.Basic restorative services.Skin and wound care.Medication management.Pain management.Infection control.Identification of changes in condition; andCultural competency.

Based on interview and record review, the facility failed to ensure that all personnel and direct care staff received required annual training regarding the facility's specific infection control practices. This affected 8 of 18 (Director of Food Services, Director of Environmental Services, Director of Therapy, LVN-L, RN-H, LVN-C, CNA-I, MA-A) staff reviewed for infection control education. The facility failed to ensure Director of Food Services, Director of Environmental Services, Director of Therapy, LVN-L, RN-H, LVN-C, CNA-I, MA-A received infection prevention and control training. This could have placed residents at risk for transmission of infectious diseaseThe findings included: Record review of the Director of food services employment file revealed hire date of 11/18/2024 no evidence of completion of training of infection control training after 11/22/2024.Record review of the Director of Environmental Services employment file revealed hire date of 7/15/2022 with no evidence of completion of infection control training.Record review of Director of Therapy services employment file revealed hire date of 6/15/2022 with no evidence of completion of training for infection control training after 6/15/2025Record review of LVN-L employment file revealed hire date of 10/8/2024 with no evidence of completion of infection control training after 10/16/2024Record review of RN-H employment file revealed hire date of 2/28/2025 with no evidence of completion of infection control training.Record review of LVN- C employment file revealed hire date of 12/6/2023 with no evidence of completion of infection control training.Record review of CNA-I employment file revealed hire date of 10/14/2026 with no evidence of completion of infection control training.Record review of MA-A employment file revealed hire date of 5/15/2024 with no evidence of completion of infection control training. In an interview on 8/5/2026 at 6:40am with MA-A, she stated she had worked at the facility as CMA for 3 years. She stated having completed training on Abuse, neglect and exploitation, Resident Rights and Infection Control. She stated she received some training as in-service during monthly staff meetings.In an interview on 8/5/2026 at 7:00am with LVN-C she stated she was a charge nurse and had been employed at the facility for 4 years. She stated having current training in abuse, neglect and exploitation as well as resident rights. She stated she had completed training in several ways such as trainings on computer for her nursing license renewals and Inservice provided during staff meetings. In an interview with HR assist on 8/7/2026 at 11:09am she stated she was continuing to work on personnel files and she did not have a file for two staff that transferred from another facility (RN-H and LVN-C). She stated she could not call the other facility due to the facility had been sold and they would not provide her with any information. She stated she could not find the files for RN-H and LVN-C and could not provide an explanation for why the file was not in the facility. She stated personnel files were the responsibility of the HR Director. HR director was no longer employed with the company as of 7/31/2026.In an interview with DON on 8/7/2026 at 4:45pm she stated her expectation was for all staff to complete and stay current with mandatory training(s). DON stated HR was responsible for maintaining and ensuring staff competencies and training are completed and current. An adverse outcome of staff not having current infection control training could result in residents and staff becoming sick. In an interview on 8/7/2026 at approximately 8:30pm, ADMN stated the personnel files were as accurate as he can provide. He stated the previous HR director was no longer employed with the facility and he was unable to contact her for information. ADMN stated he cannot provide any negative outcome to residents of staff not having completed training. In a record review of a document titled Competency of Nursing Staff revised October 2017 stated:All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law.In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will:participate in a facility-specific, competency-based staff development and training program; anddemonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care. Policy Interpretation and ImplementationThe staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents.The following factors are considered in the creation of the competency-based staff development and training program:An evaluation of the current program to ensure basic nursing competencies;Any gaps in education or training that may be contributing to poor outcomes;Specialized skills or training needed based on the resident population;A method to track, assess, plan, implement and evaluate the effectiveness of training; andA method to evaluate critical thinking skills and management of care in complex environments with multiple interruptions.The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population.Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as:Preventing abuse, neglect and exploitation of resident property;Dementia management;Resident rights;Person centered care;Communication;Basic nursing skills;Basic restorative services;Skin and wound care;Medication management;Pain management;Infection control;Identification of changes in condition; andCultural competency.Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment. Facility and resident-specific competency evaluations will include:Lecture with return demonstration for physical activities;A pre-and post-test for documentation issues;Demonstrated ability to use tools, devices, or equipment used to care for residents;Reviewing adverse events that occurred as an indication of gaps in competency; orDemonstrated ability to perform activities that are within the scope of practice an individual is licensed or certified to perform.Competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge.

Based on interview and record review, the facility failed to provide required Compliance and Ethics training to 18 of 18 (ADMN, DON, SW Asst, AD, Director of Food Services, Director of Environmental Services, Director of Therapy, HSKP-J, LVN-L, RN-D, LVN-B, RN-H, LVN-C, CNA-E, CNA-I, CNA-F, CNA-G, MA-A) employees reviewed for compliance training. The facility failed to ensure ADMN, DON, SW Asst, AD, Director of Food Services, Director of Environmental Services, Director of Therapy, HSKP-J, LVN-L, RN-D, LVN-B, RN-H, LVN-C, CNA-E, CNA-I, CNA-F, CNA-G, MA-A had received required compliance and ethics training. This failure could have placed residents at increased risk of staff not effectively communication the facility standards, policies and procedures of the compliance and ethics program.The findings included:Record review of the ADMN's employee file revealed hire date of 8/18/2025 with no evidence of completion of training related to compliance and ethics.Record review of the DON's employee file revealed hire date of 3/19/2026 with no evidence of completion of training related to compliance and ethics.Record review of SW asst employment file revealed hire date of 8/27/2025 no evidence of completion of training related to compliance and ethics.Record review of AD employment file revealed hire date of 11/30/2020 no evidence of completion of training related to compliance and ethics.Record review of Director of food services employment file revealed hire date of 11/18/2024 with no evidence of completion of training related to compliance and ethics.Record review of Director of Environmental Services employment file revealed hire date of 7/15/2022 with no evidence of completion of training related to compliance and ethics.Record review of Director of therapy employment file revealed hire date of 6/15/2022 with no evidence of completion of training related to compliance and ethics.Record review of HSKP-J employment file revealed hire date of 10/9/2023 with no evidence of completion of training related to compliance and ethics.Record review of LVN-L employment file revealed hire date of 10/8/2024 no evidence of completion of training related to compliance and ethics.Record review of RN-H employment file revealed hire date of 2/28/2025 with no evidence of completion of training related to compliance and ethics.Record review of RN-D employment file revealed hire date of 1/3/2024 with no evidence of completion of training related to compliance and ethics.Record review of LVN-B employment file revealed hire date of 8/16/2019 with no evidence of completion of training related to compliance and ethics.Record review of LVN-C employment file revealed hire date of 12/6/2023 with no evidence of completion of training related to compliance and ethics.Record review of CNA-E employment file revealed hire date of 3/20/2026 with no evidence of completion of training related to compliance and ethics.Record review of CNA-I employment file revealed hire date of 10/14/2025 with no evidence of completion of training related to compliance and ethics.Record review of MA-A employment file revealed hire date of 5/15/2024 with no evidence of completion of training related to compliance and ethics.Record review of CNA-F employment file revealed hire date of 3/19/2026 with no evidence of completion of training related to compliance and ethics.Record review of CNA-G employment file revealed hire date of 3/26/2026 with no evidence of completion of training related to compliance and ethics. In an interview with HR assist on 8/7/2026 at 11:09am she stated she was continuing to work on personnel files and she did not have a file for two staff that transferred from another facility (RN-H and LVN-C). She stated she could not call the other facility due to the facility had been sold and they would not provide her with any information. She stated she could not find the files for RN-H and LVN-C and could not provide an explanation for why the file was not in the facility. She stated personnel files were the responsibility of the HR Director. HR director was no longer employed with the company as of 7/31/2026. In an interview with DON on 8/7/2026 at 4:45pm she stated her expectation was for all staff to complete and stay current with mandatory training(s). DON stated HR is responsible for maintaining and ensuring staff competencies and training are completed and current. An adverse outcome of staff not receiving/maintaining trainings or competencies could result in residents not receiving the highest level of care. In an interview on 8/7/2026 at approximately 8:30pm, ADMN stated the personnel files were as accurate as he could provide. He stated the previous HR director was no longer employed with the facility and he was unable to contact her for information. ADMN stated he cannot provide any negative outcome to residents of staff not having completed training. In a record review of a document titled Competency of Nursing Staff revised October 2017 stated[in part]:All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law.In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will:participate in a facility-specific, competency-based staff development and training program; anddemonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.Policy Interpretation and ImplementationThe staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents.The following factors are considered in the creation of the competency-based staff development and training program:An evaluation of the current program to ensure basic nursing competencies;Any gaps in education or training that may be contributing to poor outcomes;Specialized skills or training needed based on the resident population;A method to track, assess, plan, implement and evaluate the effectiveness of training; andA method to evaluate critical thinking skills and management of care in complex environments with multiple interruptions.The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population.Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as:Preventing abuse, neglect and exploitation of resident property;Dementia management;Resident rights;Person centered care;Communication;Basic nursing skills;Basic restorative services;Skin and wound care;Medication management;Pain management;Infection control;Identification of changes in condition; andCultural competency.Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment. Facility and resident-specific competency evaluations will include:Lecture with return demonstration for physical activities;A pre-and post-test for documentation issues;Demonstrated ability to use tools, devices, or equipment used to care for residents;Reviewing adverse events that occurred as an indication of gaps in competency; orDemonstrated ability to perform activities that are within the scope of practice an individual is licensed or certified to perform.Competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge.Inquiries concerning staff competency evaluations should be referred to the Director of Nursing Services or to the Personnel Director.

Based on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for of 2 of 18 staff ( LVN C, and CNA I) reviewed for Resident Rights training. The facility failed to ensure LVN C and CNA I was trained in Resident Rights. This failure could place residents at risk of receiving care from incompetent/untrained staff and not having their Resident Rights met. Findings included: Record Review of LVN C's personnel files revealed a hire date of 12/6/23 and no evidence of Resident Right training. Record review of CNA I's personnel files revealed a hire date of 12/6 /23 and no evidence of Resident Right training.During an interview on 8/7/26 at 11:09 AM HR assistant stated she was continuing to work on personnel files which were requested via email from the administrator on 8/6/26 at 10:21a.m. and she still did not have a file for two staff that transferred from another facility (RN H & LVN C). She stated she could not call the other facility due to the facility had been sold and they would not provide her with any information. She stated she could not find a file for CNA I and could not provide an explanation for why the file was not in the facility. She stated the prior HR director had been responsible for the employee files and training, but she was no longer at the facility and could not be reached for assistance. During an interview on 8/7/26 at 1:45 PM the administrator stated that he had been assistant administrator prior to The sale of the facility to another company. He stated he had nothing to do with employee files during the time that he was in the position of assistant administrator. He stated he did not know why employees had not received the training required and he would see that they did receive all training going forward. He stated he would continue to assist the Assistant HR person to locate the missing training and files. He stated he did not realize that there was a problem with employee training and personnel files until he was told by the HR Assistant today. He stated as administrator he was responsible for the buildings function. Record review of the Facility assessment dated April of 2026 contained the following information which addressed training : Provide a link to all staff training and competencies needed by type of staff. Consider If It would be helpful to Indicate which competencies are reviewed at the time the staff member Is hired and how often they are reviewed after that. Consider the following training topics (not an inclusive list): Resident Rights and facility responsibilities-ensure that staff members are educated on the rights of the resident and the responsibilities of facility to properly care for Its residents. Required In-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aids but must be no less than 12 hours per year. Record review of the Policy Provided by Administrator Titled Competency of Nursing Staff dated revised 2017 revealed in part: Policy StatementAll nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law.In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: participate in a facility-specific, competency-based staff development and training program; and demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.Policy Interpretation and ImplementationThe staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents.The following factors are considered in the creation of the competency-based staff development and training program: an evaluation of the current program to ensure basic nursing competencies; Any gaps in education or training that may be contributing to poor outcomes; specialized skills or training needed based on the resident population; a method to track, assess, plan, implement and evaluate the effectiveness of training; and a method to evaluate critical thinking skills and management of care in complex environments with multiple interruptions. The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as:Resident rights.

Based on interview and record review, the facility failed to provide required Compliance and Ethics training to 18 of 18 (ADMN, DON, SW Asst, AD, Director of Food Services, Director of Environmental Services, Director of Therapy, HSKP-J, LVN-L, RN-D, LVN-B, RN-H, LVN-C, CNA-E, CNA-I, CNA-F, CNA-G, MA-A) employees reviewed for compliance training. The facility failed to ensure ADMN, DON, SW Asst, AD, Director of Food Services, Director of Environmental Services, Director of Therapy, HSKP-J, LVN-L, RN-D, LVN-B, RN-H, LVN-C, CNA-E, CNA-I, CNA-F, CNA-G, MA-A had received required compliance and ethics training. This failure could have placed residents at increased risk of staff not effectively communication the facility standards, policies and procedures of the compliance and ethics program.The findings included:Record review of the ADMN employee file revealed hire date of 8/18/2025 with no evidence of completion of training related to compliance and ethics. Record review of the DON's employee file revealed hire date of 3/19/2026 with no evidence of completion of training related to compliance and ethics. Record review of SW asst employment file revealed hire date of 8/27/2025 no evidence of completion of training related to compliance and ethics. Record review of AD employment file revealed hire date of 11/30/2020 no evidence of completion of training related to compliance and ethics. Record review of Director of food services employment file revealed hire date of 11/18/2024 with no evidence of completion of training related to compliance and ethics. Record review of Director of Environmental Services employment file revealed hire date of 7/15/2022 with no evidence of completion of training related to compliance and ethics. Record review of Director of therapy employment file revealed hire date of 6/15/2022 with no evidence of completion of training related to compliance and ethics. Record review of HSKP-J employment file revealed hire date of 10/9/2023 with no evidence of completion of training related to compliance and ethics. Record review of LVN-L employment file revealed hire date of 10/8/2024 no evidence of completion of training related to compliance and ethics. Record review of RN-H employment file revealed hire date of 2/28/2025 with no evidence of completion of training related to compliance and ethics. Record review of RN-D employment file revealed hire date of 1/3/2024 with no evidence of completion of training related to compliance and ethics. Record review of LVN-B employment file revealed hire date of 8/16/2019 with no evidence of completion of training related to compliance and ethics. Record review of LVN-C employment file revealed hire date of 12/6/2023 with no evidence of completion of training related to compliance and ethics. Record review of CNA-E employment file revealed hire date of 3/20/2026 with no evidence of completion of training related to compliance and ethics. Record review of CNA-I employment file revealed hire date of 10/14/2025 with no evidence of completion of training related to compliance and ethics. Record review of MA-A employment file revealed hire date of 5/15/2024 with no evidence of completion of training related to compliance and ethics. Record review of CNA-F employment file revealed hire date of 3/19/2026 with no evidence of completion of training related to compliance and ethics. Record review of CNA-G employment file revealed hire date of 3/26/2026 with no evidence of completion of training related to compliance and ethics. In an interview with HR assist on 8/7/2026 at 11:09am she stated she was continuing to work on personnel files, and she did not have a file for two staff that transferred from another facility (RN-H and LVN-C). She stated she could not call the other facility due to the facility had been sold and they would not provide her with any information. She stated she could not find the files for RN-H and LVN-C and could not provide an explanation for why the file was not in the facility. She stated personnel files were the responsibility of the HR Director. HR director was no longer employed with the company as of 7/31/2026. In an interview with DON on 8/7/2026 at 4:45pm she stated her expectation was for all staff to complete and stay current with mandatory training(s). DON stated HR is responsible for maintaining and ensuring staff competencies and training are completed and current. An adverse outcome of staff not receiving/maintaining trainings or competencies could result in residents not receiving the highest level of care. In an interview on 8/7/2026 at approximately 8:30pm, ADMN stated the personnel files were as accurate as he could provide. He stated the previous HR director was no longer employed with the facility and he was unable to contact her for information. ADMN stated he cannot provide any negative outcome to residents of staff not having completed training. In a record review of a document titled Competency of Nursing Staff revised October 2017 stated [in part]:All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law.In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will:participate in a facility-specific, competency-based staff development and training program; anddemonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.Policy Interpretation and ImplementationThe staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents.The following factors are considered in the creation of the competency-based staff development and training program:An evaluation of the current program to ensure basic nursing competencies;Any gaps in education or training that may be contributing to poor outcomes;Specialized skills or training needed based on the resident population;A method to track, assess, plan, implement and evaluate the effectiveness of training; andA method to evaluate critical thinking skills and management of care in complex environments with multiple interruptions.The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population.Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as:Preventing abuse, neglect and exploitation of resident property;Dementia management;Resident rights;Person centered care;Communication;Basic nursing skills;Basic restorative services;Skin and wound care;Medication management;Pain management;Infection control;Identification of changes in condition; andCultural competency.Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment. Facility and resident-specific competency evaluations will include:Lecture with return demonstration for physical activities;A pre-and post-test for documentation issues;Demonstrated ability to use tools, devices, or equipment used to care for residents;Reviewing adverse events that occurred as an indication of gaps in competency; orDemonstrated ability to perform activities that are within the scope of practice an individual is licensed or certified to perform.Competency demonstrations will be evaluated based on the staff member's ability to use and integrate knowledge and skills obtained in training, which will be evaluated by staff already deemed competent in that skill or knowledge.Inquiries concerning staff competency evaluations should be referred to the Director of Nursing Services or to the Personnel Director.

Based on interviews and record review, the facility did not implement policies and procedures to ensure the resident's medical record includes documentation of receiving or refusal of influenza or pneumococcal immunization for 3 of 19 (Resident#39, Resident #44, and Resident #58) residents reviewed for immunizations. The facility failed to document evidence in the electronic medical record the offering or the refusal of the influenza and pneumococcal immunization status for Resident #39, Resident #44, and Resident #58. These failures could place residents at risk of contracting viral illness, influenza or pneumococcal disease, or of not being informed of the benefits and risk which could cause respiratory complications and lead to potential adverse health outcomes.Findings included: Record review of Resident #39's electronic face sheet, accessed 08/06/26, revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses including kidney disease, anxiety, and depression.Record review of Resident #39's Quarterly MDS assessment, dated 07/09/26, revealed a BIMS score of 09 which indicated moderately impaired cognition. Further review revealed Section O indicated that influenza vaccine was not received in the facility and pneumococcal vaccination was offered and declined. Record review of Resident #39's electronic record revealed no documented evidence of the facility offering or the refusal of influenza or pneumococcal vaccines. Record review of Resident #44's electronic face sheet, accessed 08/06/26, revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses including sepsis (infection of the blood), abscess of liver, and Cholecystitis (inflammation of the gallbladder). Record review of Resident #44's Quarterly MDS, dated [DATE], revealed a BIMS score of 00 which indicated severe cognition impairment. Further review revealed Section O indicated that influenza vaccine was received in the facility on 10/16/2025 and pneumococcal vaccination was up to date. Record review of Resident #44's electronic record revealed no documented evidence of the facility offering or the refusal of influenza or pneumococcal vaccines. Record review of Resident #58's electronic face sheet, accessed 08/07/26, revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses including Parkinson's disease, anxiety, and bipolar disorder.Record review of Resident #58's Annual MDS assessment, dated 06/12/26, revealed a BIMS score of 02 which indicated severely impaired cognition. Further review revealed Section O indicated that influenza vaccine was not received in the facility and pneumococcal vaccination was offered and declined. Record review of Resident #58's electronic record revealed no documented evidence of the facility offering or the refusal of influenza or pneumococcal vaccines. During an interview on 08/06/2026 at 11:22 AM, the DON stated when she became the DON for the facility, she discovered that there was no record of the immunizations. She stated she could not find any of the consents or refusals for residents. She stated she contacted the pharmacy to receive a list of what residents had received the vaccinations and then documented them to the best of her ability in the electronic records. She stated all residents should be educated regarding the vaccinations and given consent to sign or a refusal to sign. She stated she did not know what happened to the signed consent because it was done prior to her employment. Record review of facility policy titled Vaccination of Residents, dated 2018, revealed in part. Policy Statements: All residents will be offered vaccines that aid in preventing infectious disease unless the vaccine is medically contraindicated or the resident has already been vaccinated. Policy Interpretation: 1. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. 2. Provision of such education shall be documented in the resident's medical record.5. If vaccines are refused, the refusal shall be documented in the resident's medical record.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 of 19 (Resident #33, Resident #54, and Resident #65) residents reviewed for resident rights of environmental concerns. The facility failed to ensure Resident #54's window panel was not held together by tape. The facility failed to ensure Resident #54's overhead bed light was free from dust. The facility failed to ensure Resident #33's and Resident #65's the hot water pressure in sink was not low. The facility failed to ensure Resident #65's room wall was free from ripped wallpaper, scratched paint, and a hole in drywall under window.The facility failed to ensure Resident #33's room had intact caulking around the toilet and intact floor tiles in the restroom. These failures could place residents at risk for diminished quality of life due to an unsafe, unsanitary, and uncomfortable environment.Findings included: During an observation on 08/04/2026 at 10:30am, Resident #65's room had trickling hot water coming from faucet in the sink when the left faucet handle was turned on. Location of the sink was between the toilet and door. There was ripped wallpaper behind the head of bed A and scraped paint to the left of bed B on the wall. The drywall under the window had a hole in with visible metal screw anchoring devices.During an interview on 08/04/2026 at 11:03am with Resident #65 stated the scraped paint and hole in the drywall at window bothered him. He stated when he moved into the room it was already like that. He said he did not use the sink to wash his hands.During an observation on 08/04/2026 at 10:35am, Resident #33 had trickling hot water coming from faucet in sink between the toilet and door. In the toilet room, the floor tile was cracked and the caulking around toilet was not intact. During an interview on 08/04/2026 at 10:35am with Resident #33 stated her sink never had hot water pressure and she could not wash her hands with warm or hot water. She stated that the caulk under the toilet bothered her and she could see cockroaches at times. She stated the overall cleanliness in the bathroom and room bothered her because she did not want to get an infection.During an observation on 08/05/2026 at 9:56am, Resident #54's room had a broken glass window panel that was held together by tape. There was a layer of dust on the light above the residents' head of bed. Resident #54 was lying in bed and was unable to answer questions in the interview due to medical limitations associated with tracheostomy dependence.During an interview on 08/07/2026 at 11:20am, the HK stated she worked at the facility for two years and that she was responsible for cleaning the rooms including the window seals, furniture, and bathrooms. She stated she was unaware that Resident #54's room had dust built up on top of the light and she would clean the room.During an interview on 08/07/2026 at 1:00pm, the DON stated she expected the rooms to not have dust on the light if a resident was in bed. She stated dust on the light above the bed could potentially cause respiratory issues but stated it had not. She stated this was an old building and different people live in different environments outside in the real world. She stated she felt that ripped wallpaper, scratched paint in rooms, exposed metal with a hole in the drywall, cracked vinyl in the floor in the toilet room and cracked caulk would not be a safety concern. She stated the residents may not like the way it looked but she did not feel it was a safety concern.During an interview on 08/07/2026 at 11:22am, the Maint. D stated he had only been full time in the facility starting that week. He stated he was the corporate maintenance director before. He stated a reasonable person would want the dry wall to be intact, there to not be a crack in the floor tile, intact caulk around the toilet so that bugs did not crawl out from under the toilet, and hot water with better pressure to wash their hands. He stated he expected staff to tell him when there was an issue with the resident rooms so that he could fix them. He stated there should be a better hot water stream in the rooms. He stated these items could cause the residents to be unhappy with their living environment, and he was working to get the items corrected now that he was aware of them.During an interview on 08/07/2026 at 12:40 p.m., the ADMN stated the building was old and there were going to be things that needed to be fixed. He stated people lived in all kinds of environments and could not say if having ripped wallpaper, scraped paint, hole in drywall, crack in tile, crack in caulking under the toilet, trickling hot water in resident room sink, cracked window panel, and dust on the overhead light would cause any of the residents to feel their environment was not homelike. He stated he could not provide any grievances from the facility because they had a change in staff when the facility was sold to a new company. He stated he had not had any complaints from residents about their rooms now that he was the ADMN of the facility. He stated prior to the change in owners, he was the assistant administrator. He had no explanation for why he could not provide the grievances from the past owner. Review of facility policy titled Resident Rights, no date, revealed no evidence that the residents had a right to safe, decent, and clean conditions.Review of facility policy titled Physical Environment, no date, revealed, Policy Interpretation and Implementation:The facility staff shall work to provide:Clean environment;Adequate lighting;Clean bed; Neutral scents;Comfortable and safe temperatures (71 F - 81 F)

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators, freezers and dry storage. The facility failed to ensure hot foods were held above 135 F or reheated to 165 F for at least 15 seconds before holding for hot service. The facility failed to ensure food-contact equipment was sanitized in between use. The facility failed to ensure the indoor wall construction was sealed behind the stove area to provide a smooth, nonabsorbent, easily cleanable surface. The facility failed to ensure the floor was clean and free from food substances in dry storage area, under fryer, under stove, and behind stove area. The facility failed to ensure the dry storage shelves were free from food debris and signs of rodents. The facility failed to ensure the vegetable oil was stored at least 6 inches above the floor in dry storage area. The facility failed to ensure opened bleach bottle was stored away from food items in the dry storage area. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.Findings included:During an observation on 08/04/2026 between 9:05 a.m. and 9:30 a.m. the kitchen revealed: 1 of 1 Dry Storage:1.Jug of vegetable oil sitting on a plastic tray in a cardboard box on the floor.2.Elbow macaroni noodles in an opened bag sitting on shelf in a see-through plastic bag that was not sealed and open to air.3.Shelf beside unsealed elbow macaroni noodles had food particles in front of box of grits and a one black pellet shaped object that looked like a rodent dropping.4.Brown substance on the floor with a Worcestershire sauce in a jug above and brown substance on cardboard box below the jug.5.Shelf to the lower left side of the Worcestershire sauce with an opened bag of lemon cake mix in a sealed see-through plastic bag had splatters of brown substance on the outside bag and one black pellet shaped object that looked like a rodent dropping.6.Shelf to the lower right side of the Worcestershire sauce with a bag of dry noodles in a see-through bag that had a jagged hole through both bags that looked like it had been chewed by a rodent with an open date of 7/22/2026.7.A wire rack with a bag of granola that was opened and in a see-through plastic bag with a jagged hole through both bags that looked like it had been chewed by a rodent. 8.One opened bleach bottle with opened date of 7/16/2026 sitting on the floor in the middle of the dry storage area.1 of 3 freezer:1.3 unlabeled bags of unknown meat that the DM stated were pork ribs with no description or date.2 of 3 freezer:1.1 unlabeled bag of orangish / brown frozen food material with no description on it and the date was illegible. 1 of 3 refrigerators:1.Metal pan with a scoop inside of it and the plastic wrap was not secure to two of the four sides leaving the scoop handle hanging out at the top of the pan. It was labeled with Pudding and dated 8/3.2 of 3 refrigerators: 1.1 opened bag of sliced yellow cheese in its original packaging in an unsealed see-through bag that was open to air.2.1 opened bag of sliced white cheese in an unsealed see-through bag that was open to air out of the original package and no item description or date on it.3.1 Styrofoam plate of food with a plastic wrap on top of it and 4 different food items on the plate. There was no description or date on the plate of food sitting on top of the opened bags of cheese.3 of 3 refrigerators:1.1 small bowl of food substance with no lid on it sitting on an apple juice on a plastic tray that was not labeled with a description or date.2.4 plastic wrapped square food items that appeared to be white cake with icing that were not labeled with a description or date.1 of 1 fryer:1.Multiple piles of grease on the floor in front and under.2. 1 rodent trap to the back on the floor.1 of 1 stove:1.1 food item that appeared to be a churro under the front left.2.Layer of grime, one plastic wrapper, one paper wrapper between the stove and the wall behind3.1 hole in the wall that was not sealed up where the rubber floor trim met the wall behind. During an interview on 08/04/2026 at 9:26 a.m., the DM stated the food items should be in sealed containers to prevent cross-contamination. She stated if the food did not have a label with item description and discard date, it needed to be labeled so everyone knew what the food was and when to discard the food. She stated the food on a plate in the refrigerator with plastic wrap was a staff member's food from home. She stated the kitchen floors were mopped every shift and did not know why there was visible grease under the fryer. She stated there should be no food on the kitchen floors and did not know why the food item was under the stove. She stated she thought the people that cleaned the vent a hood cleaned behind the stove. She stated the company that cleaned the vent a hood had just been there Friday 07/31/2026 night for about 30 minutes. She stated she had not noticed the hole behind the stove before. She stated the kitchen was being treated for rodents by a pest control company and the food that had the jagged holes should be discarded. She stated there should not be signs of rodent droppings on the shelves and she would have them wiped down. She stated storing food inappropriately could cause rodents if the food was unsealed and could cause resident illness from cross contamination or potentially being served food past the discard date if not labeled. She stated she monitored that the kitchen staff was storing food appropriately and that they were cleaning. She did not have an explanation of why the food was not sealed, stating that the cooks knew how to seal up the food and label it. She stated she was monitored by a dietitian that came to the facility weekly on Mondays. She stated she was told it was okay to store food items on the floor if they were on a clean tray. She stated she would remove the bleach bottle from the dry storage. During an observation on 08/04/2026 between 11:30 a.m. and 12:00 p.m., [NAME] M washed her hands and removed vegetables with their juice from a pan and placed them into the blender and turned it on. She lifted up the lid and scraped down the sides of the blender then turned on again until the food was a pureed texture. The pureed vegetables were then put into a small aluminum pan and covered with foil then placed into the steam table. [NAME] M took the blender over to a sink and rinsed out the removable parts with hot water. She did not sanitize the parts before putting back onto the blender. [NAME] M removed chicken nuggets from fryer basket and put them into the blender. She turned the blender on and then removed the lid and scraped down the sides before starting it again. When the chicken nuggets were a pureed texture, [NAME] M put the food into a small aluminum pan and covered with foil then placed into the steam table. [NAME] M took the removable parts of the blender over to a sink and rinsed off with hot water then replaced the parts on the blender again. She removed rice from a pan and blended the rice until it was pureed texture. She then removed the pureed rice and put into a small aluminum pan and covered it with foil before placing it in the steam table. [NAME] M rinsed the removable parts of the blender in a sink with hot water and replaced them on the blender. She put more chicken nuggets from a fryer basket into the blender and turned on the machine until the chicken nuggets were a mechanical texture. She put the mechanical chicken nuggets in a small aluminum pan and put the pan on the steam table without putting a lid on it. She rinsed the removable parts of the blender out with water from the sink. At no time were the blender parts ran through the dishwasher to sanitize them. [NAME] M put the blender parts back onto the blender and washed her hands. She went over to the steam table and started getting food temperatures. [NAME] M put the end of the thermometer into the whole chicken patty and the temperature was 130 F. She left the chicken on the steam table. [NAME] M put the end of the thermometer into the pureed chicken and the temperature was 130 F. She left the chicken on the steam table. [NAME] M put the end of the thermometer into the mechanical textured chicken and the chicken was 115 F. She left the chicken on the steam table. She wrote down the temperatures in the temperature log. There were no temperature logs prior to 08/04/2026 lunch service in the binder. During an interview on 08/04/2026 at 12:30 p.m., [NAME] M did not know where the previous temperature logs were.During an interview on 08/04/2026 at 12:30 p.m., [NAME] N stated she had removed the previous temperature logs from the binder and had disposed of them because she was told to by the previous owner. She stated the facility had recently been sold and that was what she was told to do. She stated some of the logs may still be in the DM's office.During a follow-up interview on 08/04/2026 at 12:38 p.m., [NAME] M stated she did not know that she should run the blender parts through the dishwasher to sanitize them prior to putting a different food item in the blender. She stated she did not know that she should heat up the food items if they were below a certain temperature and could not state what temperature cooked chicken should be on the steam table. She stated she thought that the steam table would warm up the food items and thought that it was okay to serve because she did not want to burn the residents with food being too hot. She stated she was responsible for storing food items and had no explanation for why some of the items were not sealed, not labeled, or not dated. She stated not storing the food items appropriately could cause illness. She stated she did not know why the floor under and behind the fryer and stove were not clean and had food, dirt, and wrappings.During an interview on 08/04/2026 at 12:41 p.m., the DM stated the removable items on the blender should be ran through the dishwasher to sanitize them prior to using them for another food item. She stated chicken should have a holding temperature of at least 135 F. She stated it was not appropriate to use the steam table to attempt to warm up the food and the steam table was only to keep the food warm. She stated she would expect for the cook to put the food in the oven to get it to a temperature of at least 165 F prior to it being served. She stated not preparing the food to the right temperature and not sanitizing contact items in between touching different foods could cause illness from bacteria growth or contamination.During an observation on 08/05/2026 at 9:30 a.m., the dry storage area shelves and floor had been wiped down and mopped. The vegetable oil was now being stored on a rack off the floor, and the bleach bottle had been removed. There was a bag of dried pinto beans in a plastic wrap with a jagged hole through both bags that looked like it had been chewed on by a rodent. There was one black pellet shaped item on one of the shelves that appeared to be a rodent dropping. Another shelf had an open bag of dry pasta that was open to air. The fryer floor, stove floor and behind the stove had been cleaned. The hole in the wall behind the stove had been sealed up.During an interview on 08/05/2026 at 9:30 a.m., the DM stated pest control was in the building the night before. She stated the pest control had sealed up the hole behind the stove and treated for rodents. She stated she did not know why there was a bag that had been chewed through or that there was a pellet on the shelf. She stated the kitchen was working on cleaning up the area and they will power wash the floor in the future.During an interview on 08/07/2026 at 11:22 a.m., the maintenance director stated he was not aware of a rodent issue in the kitchen. He stated he was a corporate maintenance prior to being full time in this building. He stated he started working full time in this building this week. He had no information about the pest control services or the hole in the wall behind the stove. He stated the staff were responsible for telling him of maintenance issues that needed to be fixed.During an interview on 08/07/2026 at 12:40 p.m., the ADMN stated he expected the policy to be followed on food storage. He stated he would look for a policy on food temperatures. He stated he would expect food to not be left open when being stored in the dry storage area, refrigerator areas, or freezer areas. He stated food that was open and out of the original container should have a description on it. He stated he did not know how long food lasted in the freezer and did not know if there needed to be a discard date on frozen foods. He stated foods not being stored correctly and temperatures not being the appropriate temperature could potentially cause food borne illness. During a telephone interview on 08/07/2026 at 4:59 p.m., the dietician stated her expectation would be for food that was stored to be sealed. She stated food that was stored outside of the original package should have an item description on the food and a date of when to discard the food. She stated that frozen foods do have a discard date, and she expected for the facility to use the discard date on the original package. She stated the facility had been told on multiple occasions by her that food stored in the refrigerator needed to have a lid covering it. She stated temperatures should be obtained during food preparation and the temperature logs should be maintained so people would know what the food temperatures were. She stated she would review the temperature logs and had no concerns with them holding or serving food at inappropriate temperatures before. She stated it was not appropriate to serve mechanical chicken with holding temperature of 115 F, puree chicken with holding temperature of 130 F, and chicken with holding temperature of 130 F. She stated she would expect the chicken to be reheated in the oven and not on the steam table to a temperature of 165 F if the food temp was in the danger zone. She stated crumbs, unsealed food, and food on the floor could cause pest control issues. She stated if the chicken was an inappropriate temperature, it could cause the residents to get sick. She stated if the food is not labeled then the staff may not know what the food item is or when to discard the food. She stated the food not being covered or sealed could cause infection from cross contamination.Record review of the facility document, titled Matrix, dated 08/04/2026, revealed every resident did not eat out of the kitchen.Record review of facility policy titled, Food Receiving and Storage, dated October 2017, reflected: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 2. When food is delivered to the facility it will be inspected for safe transport and quality before being accepted. 5. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). Further review reflected there was no evidence about sealing foods to help prevent cross contamination / rodent infestation for foods stored in the dry storage area.Record review of facility policy titled, Refrigerators and Freezers, dated December 2014, reflected 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of de-livery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened.8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes. Record review of facility policy titled, Preventing Foodborne Illness - Food Handling, dated July 2014, reflected 1. This facility recognizes that the critical factors implicated in foodborne illness are: a. Poor personal hygiene of food service employees; b. Inadequate cooking and improper holding temperatures; c. Contaminated equipment; and d. Unsafe food sources.6. Potentially hazardous foods will be cooked to the appropriate internal temperatures and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms. 9. All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations.Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 08/07/2026 revealed: 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below or when combined as ingredients, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY TO-EAT FOOD such as fruits and vegetables, P (b) Cooked READY-TO-EAT FOOD, P and (c) Fruits and vegetables before they are washed; P (d) Frozen, commercially processed and packaged raw animal FOOD may be stored or displayed with or above frozen, commercially processed and PACKAGED, ready-to-eat food. (2) Except when combined as ingredients, separating types of raw animal FOODS from each other such as beef, FISH, lamb, pork, and POULTRY during storage, preparation, holding, and display by: (a) Using separate EQUIPMENT for each type, P or (b) Arranging each type of FOOD in EQUIPMENT so that cross contamination of one type with another is prevented, P and (c) Preparing each type of FOOD at different times or in separate areas; P (3) Cleaning EQUIPMENT and UTENSILS as specified under 4-602.11(A) and SANITIZING as specified under S 4-703.11; (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the FOOD in PACKAGES, covered containers, or wrappings; (5) Cleaning HERMETICALLY SEALED CONTAINERS of FOOD of visible soil before opening; (6) Protecting FOOD containers that are received packaged together in a case or overwrap from cuts when the case or overwrap is opened; (7) Storing damaged, spoiled, or recalled FOOD being held in the FOOD ESTABLISHMENT as specified under S 6-404.11; and (8) Separating fruits and vegetables, before they are washed as specified under S 3-302.15 from READY-TO-EAT FOOD. (B) Subparagraph (A)(4) of this section does not apply to: (1) Whole, uncut, raw fruits and vegetables and nuts in the shell, that require peeling or hulling before consumption; (2) Primal cuts, quarters, or sides of raw MEAT or slab bacon that are hung on clean, sanitized hooks or placed on clean, sanitized racks; (3) Whole, uncut, processed MEATS such as country hams, and smoked or cured sausages that are placed on clean, sanitized racks; (4) Food being cooled as specified under Subparagraph 3-501.15(B)(2); or (5) SHELLSTOCK. 3-302.12 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 58 FDA Food Code 2022 Chapter 3. 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.3-305.11 Food Storage. (A)Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor.3-403.11 Reheating for Hot Holding.(A) Except as specified under (B) and (C) and in (E) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74 C (165 F) for 15 seconds. P(B) Except as specified under (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD reheated in a microwave oven for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74 C (165 F) and the FOOD is rotated or stirred, covered, and allowed to stand covered for 2 minutes after reheating. P(C) READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that has been commercially processed and PACKAGED in a FOOD PROCESSING PLANT that is inspected by the REGULATORY AUTHORITY that has jurisdiction over the plant, shall be heated to a temperature of at least 57 C (135 F) when being reheated for hot holding. P(D) Reheating for hot holding as specified under (A) - (C) of this section shall be done rapidly and the time the FOOD is between 5 C (41 F) and the temperatures specified under (A) - (C) of this section may not exceed 2 hours.3-602.11 Food Labels.(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers.(B) Label information shall include:(1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement.(2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD.(3) An accurate declaration of the net quantity of contents.(4) The name and place of business of the manufacturer, [NAME], or distributor; and(5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf(6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling.(7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin.Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.4-602.13 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.6-201.16 Wall and Ceiling Coverings and Coatings. (A) Wall and ceiling covering materials shall be attached so that they are EASILY CLEANABLE. (B) Except in areas used only for dry storage, concrete, porous blocks, or bricks used for indoor wall construction shall be finished and SEALED to provide a SMOOTH, nonabsorbent, EASILY CLEANABLE surface.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan that included instructions needed to provide effective and person-centered care of the residents within 48 hours of a resident's admission and provide the resident with a summary of the baseline care plan for 2 of 7 residents (Resident #11 and Resident # 33) reviewed for baseline care plans. The facility failed to ensure a baseline care plan was completed within 48 hours of admission that addressed the PASARR recommendation of newly admitted Resident #11 on 07/02/2026. The facility failed to ensure Resident #11 and Resident #33 were provided with a summary of the baseline care plans that included the initial goals of the resident, a summary of the resident's medications and dietary instructions, and any services and treatments to be administered by the facility and personnel acting on behalf of the facility.These failures could place residents at risk of not receiving necessary care and services.Findings included:Resident #11Record review of Resident #11's electronic face sheet, dated 08/06/2026, reflected a [AGE] year-old male admitted on [DATE] with diagnoses including: pressure ulcers (injuries of the skin and underlying soft tissue caused by prolonged pressure), anemia (blood not having enough red blood cells to carry oxygen to the body's tissues), sepsis (life threatening condition that arises when the body's response to an infection injures its own tissues and organs), schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), neuromuscular dysfunction of bladder (brain, nerves or spinal cord problem that causes lost control of bladder function), urinary tract infection (when germs get into part of the urinary system and cause an infection), and anorexia (severe food restriction and significant weight loss). Further review reflected that Resident #11 was his own responsible party.Record review of Resident #11's admission MDS assessment, dated 07/09/2026, reflected he had a BIMS score of 15 indicating cognitively intact.Record review of Resident #11's Baseline Care Plan, dated 07/05/2026, reflected no admission goals were listed, no PASARR recommendations listed, and no evidence that the baseline care plan was provided to Resident #11.Record review of Resident #11's EMR on 08/06/2026 revealed no evidence that the comprehensive care plan was completed.Record review of Resident #11's PASARR level 1 screening, dated 07/01/2026, reflected Resident #11 had a qualifying diagnosis for Mental Illness.During an observation and interview on 08/05/2026 at 11:16 a.m., Resident #11 was lying in his bed. He stated he had not had a care plan meeting and was not given any information about the care plan in this facility or his medications that he was receiving. He stated he asked about going to see the plastic surgeon for his wounds and no one would tell him if he had an appointment scheduled with the plastic surgeon. He stated he did not remember who he asked about the appointment. During an interview on 08/06/2026 at 4:33 p.m., the DON stated there was no documentation of a physician's appointment to a plastic surgeon on Resident #11's referral. She stated Resident #11 could make his own physician appointments. She stated she told him to let the facility know when the appointment was made and the facility would transport him to any appointment he made. She stated he was competent to make his own decisions and had a personal cellphone in his room.During an interview and observation on 08/07/2026 at 10:24 a.m., Resident #11 stated he was asked to sign a Baseline Care Plan document yesterday and was given a list of his medications. Observation reflected the documents were on his bedside table in his room.Resident #33Record review of Resident #33's electronic face sheet, dated 08/06/2026, reflected a [AGE] year-old female admitted on [DATE] with diagnoses including: infection following a procedure, acquired absence of kidney (kidney removed), hypertension (high blood pressure), chronic kidney disease (damaged kidneys interfering with filtering out toxins from the blood), and muscle wasting and atrophy (loss of skeletal muscle mass). Further review reflected that Resident #33 was her own responsible party.Record review of Resident #33's Baseline Care Plan, dated 07/12/2026, reflected no evidence that the baseline care plan was provided to Resident #33.During an observation and interview on 08/04/2026 at 10:35 a.m., Resident #33 was sitting on the side of her bed in her room. She stated she was handed a Welcome Packet when she was admitted to the facility, but she did not participate in or was invited to any care plan meeting. She stated she was not given a medication list at the time of her admission. During an interview and observation on 08/07/2026 at 10:27 a.m., Resident #33 stated she was asked to sign a Baseline Care Plan document yesterday and was given a list of her medications. Observation indicated the documents were on her bedside table.During an interview on 08/06/2026 at 10:25 a.m., the Admissions Director stated the DON was responsible for the Baseline Care Plans.During an interview on 08/06/2026 at 4:33 p.m., the DON stated she and the weekend supervisor were responsible for completing the Baseline Care Plans. She stated she or the weekend supervisor would print out the medication list and the Baseline Care Plans to hand to the residents after their admission during the Baseline Care Plan meeting. She stated they would discuss care with the residents during the Baseline Care Plan meeting. She stated she had no evidence that the medication list or the Baseline Care Plan was printed and given to Resident #11 or Resident #33. She stated Baseline Care Plans needed to be completed within 48 hours of admission. She stated she did Resident #11's Baseline Care Plan but had no explanation for why it was not completed within 48 hours. She stated she did not do anything with the PASARR so that was why that section was not completed during the Baseline Care Plan. She stated the MDS nurse was responsible for anything to do with the PASARR, and the facility did not have a MDS nurse currently. She stated she did not feel there would be any negative outcome for the Baseline Care Plan being a day late. She stated she did not feel that the residents were not informed about their medications or care needs due to the nurses would go over that information during the assessment process. Record review of the facility's policy titled, Care Plans - Baseline, undated, reflected 1. To assure that the resident's immediate needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. 2. The Interdisciplinary Team will review the healthcare practitioner's orders (e.g., dietary needs, medication, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders; b. Physician orders; c. Dietary orders; d. Therapy services; e. Social services; and f. PASARR recommendation, if applicable. 3. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. 4. The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a. The initial goals of the resident; b. A summary of the resident's medications and dietary instructions; c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d. Any updated information based on the details of the comprehensive care plan, as necessary.

Based on observation, interview, and record review, the facility failed to maintain effective pest control for one of one kitchen reviewed for pests. The facility failed to have pest control effectively treat the kitchen for rodents.This failure could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.Findings included:During an observation on 08/04/2026 between 9:05 a.m. and 9:30 a.m. of the kitchen revealed:Dry storage area with two different bags of food (elbow macaroni noodles and granola) having both plastic bag and plastic cover with a jagged hole through both and there were two black pellets on the shelves that looked like rodent droppings. There was a rodent trap in the dry storage area and behind the stove area beside a hole in the wall that was not sealed.During an observation on 08/05/2026 at 9:30 a.m., the dry storage area had a bag of dried pinto beans in a plastic wrap with a jagged hole through both bags that looked like it had been chewed on by a rodent. There was one black pellet shaped item on one of the shelves that appeared to be a rodent dropping. Another shelf had an open bag of dry pasta that was open to air. The hole in the wall behind the stove had been sealed up.During an interview on 08/05/2026 at 9:30 a.m., the DM stated pest control was in the building the night before. She stated the pest control had sealed up the hole behind the stove and treated for rodents. She stated she did not know why there was a bag that had been chewed through or that there was a pellet on the shelf. She stated the kitchen was working on cleaning up the area and they will power wash the floor in the future.During an interview on 08/07/2026 at 11:22 a.m., the maintenance director stated he was not aware of past pest control issues in the building prior to this week. He stated he had just recently become full-time at this facility and was corporate for the prior ownership before this week. He stated the facility had pest control services in the building on Tuesday night for their initial treatment. During an interview on 08/07/2026 at 12:40 p.m., the ADMN stated he doesn't know what else could have been done to help prevent rodents in the kitchen. He stated the facility had a pest control company and they were coming to the facility regularly. He stated the facility got a new company and they did their initial visit Tuesday evening. He stated having food on the floor in the kitchen and open in the dry storage could make pests come into the kitchen. He stated he did not feel there was any negative impact but could potentially cause food borne illness. He stated the facility has not had any food illnesses. During a telephone interview on 08/07/2026 at 4:57 p.m., the Dietician stated she was aware of pests in the kitchen. The Dietician stated she had seen the signs of rodents in the kitchen area the week before and had brought it up with the maintenance director at that time. She stated the rodent issue was supposedly being addressed at that time. She stated she instructed for the kitchen staff to go through all of the food in the dry storage and throw out all the food with holes in them. She stated the kitchen staff had been instructed to sanitize all of the shelves. She stated the facility did not give her any further details about the pest control so she could not say if it was effective or not. She stated having signs of rodents in the building could cause a resident to receive food that was contaminated from the rodents and could cause infection. She stated she had given instruction to the kitchen staff her previous visits but there was no proof of her instructions because the old owner would tell the kitchen staff to throw them away for an unknown reason.Record review of the facility's [Pest Company] invoice, dated 05/01/2026, revealed an initial scheduled service was performed with target issues: Ants, Cockroaches, Spiders. Baseboards in common areas were manager showed of pest issues, kitchen, and laundry room treated.Record review of the facility's [Pest Company] invoice, dated 06/22/2026, revealed target issues: Mice, Mice / Rats, Rats. Treated interior baseboards in requested areas for all general pests, Placed 2 snap traps in kitchen pantry area. Inspected rodent bait stations, cleaned and added bait as needed.Record review of the facility's [Pest Company] invoice, dated 07/16/2026, revealed target issues: Mice, Mice / Rats, Rats. Treated the interior of multiple rooms. Inspected rodent bait stations, cleaned and added bait as needed.Record review of the facility's policy, titled Pest Control, dated April 2024 revealed: Our facility shall maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Any pest sightings are to be communicated to facility management: Administrator and Director of Nursing and written in the Maintenance Work Order Binder immediately.6. Maintenance services assist, when appropriate and necessary, in providing pest control services.Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 08/07/2026 revealed: 6-202.16 Exterior Walls and Roofs, Protective Barrier. Perimeter walls and roofs of a FOOD ESTABLISHMENT shall effectively protect the FOOD ESTABLISHMENT from the weather and the entry of insects, rodents, and other animals. 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under SS 7-202.12, 7-206.12, and 7-206.13; Pf and (D) Eliminating harborage conditions.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 4 (Resident #68) residents reviewed for resident rights.The facility failed to ensure Resident #68 was treated with dignity and respect by MA-A during an interaction on 8/6/2026 .This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.The findings included:Record review of Resident #68's face sheet, dated 8/7/2026 revealed a [AGE] year old female admitted to the facility on [DATE] with diagnoses of: Encephalopathy (disease, damage or malfunction of the brain that alters mental state and brain function), seizures, Human Immunodeficiency Virus (virus attacks body's white blood cells weakening the immune system), depression, insomnia, anxiety disorder, and contracture of muscle bilateral lower extremitiesRecord review of Resident #68's Quarterly MDS Assessment, dated 7/3/2026, revealed Resident #68 had a BIMS of 12 indicating moderate cognitive impairment. Resident #68 had no hallucinations or delusions reported and required a wheelchair for mobility. She required moderate assistance with eating, substantial/maximum assistance with oral hygiene and was dependent for all other ADLs. Resident #68 was incontinent of bowel and bladder.Record review of Resident #68's care plan updated on 5/10/2026 had goals and interventions, diagnoses, treatments and preferences. The care plan included: resident preferences with activities, confabulation (a memory mistake where a person creates a false, distorted or fake memory to fill in the gaps in memory)history with redirection directions, with interventions to include allow resident to verbalize feelings during episodes of confabulation - gently reorient and maintain safety, redirect resident during episodes of confabulation, caregivers provided opportunity for positive interaction, attention. Stop and talk with her as passing by.In an audio document reviewed (voicemail) and received on 8/7/2026 at approximately 12:15pm, Resident #68's representative stated, If you could give me a call, there was a situation that happened today, well, yesterday concerning some medications that was dropped on the floor and was trying to be served to my sister, everything is on the video. I just need you to give me a call. Um, she is upset. She doesn't even trust the lady to even take medication, so if you could give me a call, I can send you the video so you can look at it yourself.In an interview on 8/7/2026 at 12:25pm Resident #68 stated on 8/6/2026 an incident with MA-A did not make her feel good. Resident #68 stated she was tired of feeling like she was always being kicked. Resident # 68 stated MA-A dropped her medication on the floor and did not leave the room to replace the medications. Resident #68 stated MA-A was trying to give her the medication she dropped on the floor, and she refused to take them. Resident #68 stated MA- A made her feel bad because of the way she talked to her, did not listen to her and she no longer trusted MA-A with her medications. Record review of electronic monitoring video on 8/7/2026 at 12:15pm provided by Resident #68's representative, dated 8/6/2026 at 10:02am- 10:04am, revealed MA-A entering Resident #68's room with medications. Upon entering the room, MA-A dropped pills on the floor. Video shows MA-A picking up medications from the floor and approaching Resident #68's side of the room. During interaction, the resident was receiving personal care from another staff member. The video recording has the following verbal interaction:MA-A: I'll come back.Resident #68: It's too late.MA-A: what's too late?Resident #68: you dropped those pillsMA-A: it's not too lateResident #68: You dropped them on the floorMA-A okay, how many pills did I drop? (MA- A posture changes and her left hand was placed on her hip with medication cup in right hand, raises voice)Resident #68: all them pillsMA-A: How many pills were on the floor (calls resident by her first name). How many did you see on the floor (6 second pause in conversation) How many? Seriously, how many did you see on the floor?Resident #68: Unintelligible responseMA: You know what? If you don't want your pain pills, ok that's fine MA-A observed leaving the room with medications not being administered.Resident #68: unintelligible response (with raised voice)During this interaction, the staff member providing personal care remained silent, and left the bedside several times to gather supplies. In an interview on 8/7/2026 at 1:15pm, MA-A stated on 8/6/2026 she walked into Resident #68's room to administer medication and accidentally dropped 2 pills on the floor. She stated the only medications dropped were gabapentin and Dulcolax. She stated she picked up 2 pills from the floor, placed the 2 pills in her palm with the medication cup but not in the cup with the medications that had not been dropped. MA-A stated she told the resident she had dropped them. During interaction with resident, MA-A stated they had back and forth banter after explaining she had replaced the pills, the resident refused to take any medications from her. MA-A stated shortly after this happened, she informed the ADON and LVN-B. MA-A stated the interaction on 8/6/26 with Resident #68 was not appropriate, and she should not have gone back and forth with the resident. She stated she should have left the room and not argued with the resident. MA-A also stated, I couldn't give her the medications because the CNA was in changing her (Resident #68) anyway.In an interview on 8/7/26 at 1:45pm the ADON stated she was aware of the situation between MA- A and Resident #68 that occurred on 8/6/2026. She stated MA-A came to her and explained she dropped 2 pills on the floor and replaced them and resident refused medications. The ADON stated she went to Resident #68's room and attempted to administer medications, resident refused telling ADON, I don't trust you. The ADON stated the resident had a history of no matter what is offered her, it is never enough. The ADON stated she walked away and allowed resident time to calm down. The ADON stated her expectation of staff with residents was to de-escalate the situation by allowing residents to express concerns, find out the problem and fix the problem if possible. The ADON stated if a resident was unable to be calmed, the staff should have dismissed themselves from the room. She stated examples of an inappropriate behavior with a resident would be arguing back and forth. She stated staff should not point at a resident and should stand with their hands to their sides. The ADON stated she presented an in-service to staff covering Abuse, Neglect and Exploitation either late June 2026 or early July 2026 . The in-service was presented verbally in a meeting or for any staff not present, they would have had a presentation on paper to read and sign. She was unable to produce the documentation for this in-service. The ADON stated based on what MA-A told her about the interaction, she felt the situation was handled correctly.In an observation on 8/7/2026 at 2:10pm with LVN-B, she entered resident #68's room with medication cards and medication cup. Resident stated, Medication won't fix the problem if the staff problem isn't fixed. LVN-B showed resident each medication card with medication taken from card and placed in the medication cup with the resident watching her. Observation reflected four medications were administered to Resident #68 at this time.In an interview on 8/7/2026 at 2:15pm LVN-B stated she was told on 8/6/2026 by the MA-A the resident refused her medication. LVN-B was unaware of details related to Resident #68 refusing medication. She stated Resident #68 was paranoid stating everyone was out to get her. LVN-B stated she had Abuse, Neglect and Exploitation training last month during staff meeting. LVN-B gave examples of verbal abuse: Yelling, talking down to a resident or not being nice. She stated she would report abuse to the Administrator who served as the facility Abuse Prohibition Coordinator. She denied concerns of staff being abusive to residents and stated some residents have disorders that were being managed by psychiatric services. She stated an example of de-escalation would be to remove yourself and get someone else to assist a resident who was upset. In an interview on 8/7/26 at 4:45PM, the DON stated she had knowledge of the incident on 8/6/2026 involving one of the medication technicians having dropped a resident's medication on the floor and replaced them. The resident was upset and refused to take the medications. She was notified and went to the resident's room to discuss the resident's concerns. The DON stated her expectation of staff was if they were unable to resolve a matter with a resident, get the nurse or manager to interact with the resident. The DON stated de-escalation techniques should include staying calm, providing redirection, and/or get someone else to help. The DON stated Resident #68 has Mental health issues and narrows in on subject and sticks to it. She is difficult to redirect and stretches the truth. She stated staff often contact the resident's representative when she has behaviors. The DON gave examples of verbal abuse as yelling, degrading or saying anything that makes a resident feel bad about self and stated examples of physical abuse would include anything that was unwanted or aggressive. The DON stated she had not seen video from electronic monitoring in room. She stated the Administrator has started an internal investigation on 8/7/2026. The DON also stated she filed a grievance on behalf of Resident #68 today. The DON stated, after viewing the video from 8/6/26 times tamped 10:02, stated the MA-A had poor customer service and was inappropriate but not abusive. The DON also stated after video ended MA-A may have come back to the room with attempt to administer medications. The DON stated she understood why the resident was left to wonder if the pills were replaced. The DON stated the incident could have been avoided by leaving the room before offering the medication. In an interview on 8/7/2026 at 5:40pm, the Administrator stated he was notified on 8/7/26 at 2:24 pm about an alleged incident occurring on 8/6/26. He stated an internal investigation was immediately started. MA-A was suspended pending investigation. He stated as part of the investigation, Resident #68 was interviewed and unable to answer specific questions and denied abuse. He stated he contacted Resident #68's Representative, and she stated she was busy and unable to talk with him at the time he called. The Administrator stated interviews were conducted with residents in surrounding area and no concerns identified by several residents. The Administrator stated he had an interview with MA-A. She reported to the Administrator, attempts to give meds were refused. The Administrator stated he interviewed LVN-B, only aware of refusal, but denies knowledge of an incident. He stated he had interviews with other staff including ADON and all denied any knowledge of the incident on 8/6/26. At the time of this interview the internal investigation is ongoing. The Administrator stated his expectation of staff was to always report any abuse, neglect or exploitation. He gave examples of verbal abuse as staff speaking to residents in a derogatory way or using profanity toward a resident. He stated examples of physical abuse would include putting hands on resident in any way other than to provide care. He stated anytime a resident is upset or mad, he expected staff to provide redirection and notify charge, DON or ADMN. The ADMN stated he had previously had conversations with Resident #68 and Resident #68's Representative in past related concerns of staff. Care plan meetings have been held and resolutions have been attempted. Resident has history of making things up caused difficulty knowing what is true or accurate. After viewing video provided by resident family date 8/6/2026 timestamped at 10:02am he stated the interaction could have been handled differently. He stated, it's not abuse, not even close to it. MA-A could have responded differently. We want to be patient and respectful. He stated staff interactions need to be improved, that bad days are contagious. The ADMN stated in-services are provided on a regular basis to address abuse and neglect. He stated he intends to provide an in-service about the expectation for staff to provide respectful communication throughout the entire interaction with residents. After seeing video, he does not feel like a self-report will be needed. Record review of facility document titled Resident Rights, not dated, states [in part]: Policy Statement: Employees shall treat all residents with kindness, respect and dignity.Policy Interpretation and Implementation:Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident to:A dignified existence;Be treated with respect, kindness and dignity;

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 1 resident (Resident #39) reviewed for incontinent care. The facility failed to ensure CNA-E performed proper peri-care (incontinent care) for Resident #39. This failure could place residents at-risk for urinary tract infection due to improper care practices.Findings Included:Record review of Resident #39's electronic face sheet, accessed 08/06/26, revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses including kidney disease, anxiety, and depression.Record review of Resident #39's Quarterly MDS assessment, dated 07/09/26, revealed a BIMS score of 09 which indicated moderately impaired cognition. Section H revealed the resident was always incontinent of bladder and frequently incontinent of bowel. Record review of Resident #39's care plan, initiated 11/06/24, revealed: bowel/bladder incontinence. Interventions: check for incontinent episode during rounds, change promptly and apply a protective skin barrier. During an observation on 08/05/2026 at 10:50 AM, CNA-E performed peri-care on Resident #39. CNA-E entered the room with no hand washing or hand sanitation. CNA-E donned 2 sets of gloves. CNA-E unfastened the brief. She wiped down the right groin, folded the wipe and wiped the lower abdominal fold, folded the wipe and wiped down the left groin and discarded the wipe in the trash can. CNA-E turned the resident over and wiped buttocks which contained bowel movement, folded the wipe and wiped more bowel movement, folded the wipe and wiped more bowel movement and discarded wipe in the trash can. CNA-E grabbed a new wipe and wiped buttocks, folded wipe and wiped buttocks, and then folded wipe and wiped buttocks and discarded wipe in the trash can. CNA-E did not change gloves or perform hand hygiene; CNA-E applied a new clean brief. CNA-E removed gloves, removed trash bag from trash can and exited room with no hand hygiene. During an interview on 08/06/2026 at 10:23 AM, CNA-E stated she was nervous because she was being watched. She stated she should have washed her hands prior to beginning incontinent care. She stated she had not completed any skills checkoffs or competencies for the facility. She stated she was not aware that she needed to change gloves or sanitize her hands in between dirty to clean. She stated not performing proper hand hygiene could have led to urinary tract infection. During an Interview on 08/06/2026 at 11:15 AM, the ADON-Q stated CNA-E should have washed her hands prior to performing incontinent care, when going from dirty to clean, and when done with the task. She stated she felt it was ok to fold the wipe and use again and that she was unsure what the policy said. She stated all CNAs are in-serviced and perform competency checkoffs when they are hired, and they receive handwashing in-service at least every 3-4 months. She stated not following proper infection control techniques when performing incontinent care would lead to urinary tract infections. During an interview on 08/06/2026 at 11:22 AM, the DON stated that all CNAs perform annual competencies for incontinent care. She was not able to locate or provide any evidence of competencies. She stated hand hygiene was important and should be done prior to beginning and when completed. She stated double gloves could be worn and the one pair removed when going from dirty to clean and that the CNA should have removed the gloves in the middle of the procedure. She stated that improper incontinent care would lead to urinary tract infections. Record review of the facility's policy titled Incontinent Care- With or Without Catheter, not dated, revealed in part: It is the policy of this center to provide incontinent care to residents in a manner which provides privacy, promotes dignity and ensures no cross contamination: Procedure.Wash hands. Wear gloves and follow Standard Precautions.Female: Cleanse the peri area with wipes going front to back/clean to dirty. Separate the labia (clean to dirty). Use a new wipe with each stroke. Wipe one side, wipe the other side, wipe down the center and then once from hip bone.Discard soiled gloves, sanitize hands. Re-glove prior to touching clean linens/adult brief.

Based on observation, interview, and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan and the residents' goals and preferences for 1 (Resident #44) of 3 residents reviewed for IV therapy. The facility failed to provide adequate maintenance of the PICC (central catheter) line for Resident #44 by not performing a dressing change from 07/17/26 until 08/04/26. This failure could place residents at risk for infection and/or deterioration in their condition.Findings included: Record review of Resident #44's electronic face sheet, accessed 08/06/26, revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses including sepsis (infection of the blood), abscess of liver, and Cholecystitis (inflammation of the gallbladder). Record review of Resident #44's Quarterly MDS Assessment, dated 07/23/26, revealed a BIMS score of 00 which indicated severe cognition impairment. Further review revealed Section O revealed resident received IV medications. Record review of Resident #44's Comprehensive Care plan, last reviewed 08/06/26, revealed no evidence of the resident receiving IV antibiotic therapy or having a PICC line. During an observation on 08/04/2026 at 10:30 AM, Resident #44 was in bed. Observation of the PICC line revealed the dressing was dated 07/17/26. The dressing was dry and intact with no redness noted to the insertion site. Record review of Resident #44's electronic physicians orders, accessed 08/06/20026, revealed no evidence of an order for PICC line placement or dressing changes. Physician's orders revealed: (Ceftriaxone Sodium (antibiotic) Injection Solution Reconstituted 1 GM give 2 grams intravenously one time a day with a start date 08/04/26 and end date 08/14/26. Record review of Resident #44's MAR and TAR, from 07/17/26 to 08/04/26, revealed no evidence of PICC line dressing change being performed. Record review of Resident #44's electronic nurses notes, from 07/17/26 to 08/04/26, revealed no evidence of PICC line dressing change being performed. During an interview on 08/06/2026 at 11:15 AM, ADON-Q stated all nurses could administer IV medications and could perform central line dressing changes. She stated they were trained and checked off by the facility. She stated PICC line dressings must be changed every 7 days and as needed. She stated the residents must have a physician's order. She stated it was her responsibility to ensure that all the correct physicians' orders were entered for a resident with a PICC line. She stated not changing the dressing weekly could have led to severe infection. She stated she felt that since the dressing was clean and dry and there was no redness that there was no harm. During an interview on 08/06/2026 at 11:22 AM, the DON stated nurses could administer IV medications and could perform central line dressing changes. She stated they were trained and checked off by the facility. She stated PICC line dressings must be changed every 7 days and as needed. She stated the residents must have a physician's order. She stated not changing the dressing weekly could have led to severe infection. She stated she felt that since the dressing was clean and dry and there was no redness that there was no harm. The DON was unable to provide any proof of IV training or checkoffs for the nurses. During an interview on 08/06/2026 at 11:30 AM, LVN-B stated she did perform central line dressing changes. She stated she did not receive any special IV training and had never been checked off on the procedure. She stated she had not changed Resident #44's dressing. She stated all residents with a central line should have an order to change the dressing every 7 days. She stated she felt that since the dressing was clean and dry and there was no redness that there was no harm. She stated not performing dressing changes could have led to infection.Record review of the facility's policy titled, Central Venous Catheter Dressing Changes, revised April2025, revealed in part: Purpose: The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings.General Guidelines.5. Change dressings at least every 5-7 days as needed.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident consistent with the residents rights and that included measurable objectives and time frames to meet, attain, or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 19 residents (Residents #44) reviewed for care plans. The facility failed to ensure Resident #44 had a care plan in place for receiving IV antibiotic therapy or having a PICC line. This failure could place residents at risk of not receiving individualized care and services to meet their needs. Findings included: Record review of Resident #44's electronic face sheet, accessed 08/06/26, revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses including sepsis (infection of the blood), abscess of liver, and Cholecystitis (inflammation of the gallbladder). Record review of Resident #44's Quarterly MDS Assessment, dated 07/23/26, revealed a BIMS score of 00 which indicated severe cognition impairment. Further review revealed Section O revealed resident received IV medications. Record review of Resident #44's Comprehensive Care plan, last revised 08/06/26, revealed no evidence of the resident receiving IV antibiotic therapy or having a PICC line. During an observation on 08/04/2026 at 10:30 AM, Resident #44 was in bed. Observation of the PICC line revealed the dressing was dated 07/17/26. The dressing was dry and intact with no redness noted to the insertion site. Record review of Resident #44's electronic physicians orders, accessed 08/06/2026, revealed no evidence of an order for PICC line placement or dressing changes. Physician's orders revealed: (Ceftriaxone Sodium (antibiotic) Injection Solution Reconstituted 1 GM give 2 grams intravenously one time a day with a start date 08/04/26 and end date 08/14/26. During an interview on 08/06/2026 at 11:15 AM, ADON-Q stated it was her responsibility to update care plans. She stated the antibiotics and PICC line should have been addressed on the care plan. She stated the resident was admitted on a weekend and somehow it was just missed. She stated she did not feel there was a negative effect. During an interview on 08/06/2026 at 11:22 AM, the DON stated the antibiotics and PICC line should have been addressed on the care plan. She stated it was her reasonability to ensure that the nurses and the ADON updated and completed care plans. She stated the negative effect would be that residents would not receive the care they needed. Record review of the facility policy titled, Care Plans, Comprehensive Person-Centered , revised March 2022, revealed, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 7. The comprehensive, person-centered care plan: b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview and record review the facility failed to ensure adequate equipment to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 2 of 21 residents (Resident # 37 and Resident #66) residing in the facility. The facility failed to provide a working communication system that was easily at reach that would allow Resident # 37 and Resident #66 the ability to safely call for staff assistance. The failure had the potential to place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living.Findings included: Record review Resident #37's face sheet dated 8/7/2026 revealed Resident#37 was a [AGE] year old male, who was admitted to facility on 11/7/2024 with a secondary admission on [DATE]. Resident #37's diagnoses included: Cerebral aneurysm (a weak bulging spot on an artery wall in the brain that fills with blood), Seizures, Dementia with agitation, Depression, Bipolar disorder (mental health condition that causes extreme shifts in mood, energy, activity levels and concentration), hypertension, Cognitive communication deficit (difficulty communicating caused by disrupted thinking skills), Hemiplegia and Hemiparesis following Cerebral Infarction (neurological condition involving one side of the body following a stroke), and Parkinsonism (movement disorder causing slow movement, muscle stiffness and tremors). Record review of Resident #37's care plan revised on 7/13/2026 reflected a focus related to Falls had intervention dated 1/16/2025 Ensure call light is in reach- answer promptly. Record review of Resident #37's Quarterly MDS completed on 7/9/2026 indicated resident BIMS of 00 (Severe cognitive impairment). MDS indicates resident had no behaviors consistent with delusions or hallucinations. Decreased range of motion to upper and lower extremities, dependence on wheelchair for mobility. Required partial to moderate assistance with eating and oral care, max assistance required for all other ADLs. He was incontinent of bowel and bladder. Occupational and speech therapy services were being provided. In an observation on 8/4/2026 at 9:45am Resident #37 was lying in bed. The call light cord was observed to be in a basket of toiletry items on nightstand. The cord was damaged condition. The outer protective insulation of the cord appeared torn with the wiring exposed. The cord was severed and was not functional or within reach of resident #37. In an observation on 8/5/2026 at 6:40am Resident # 37 was lying in his bed with the call light cord observed in same damaged manner as observed on 8/4/2026. In an interview on 8/4/2026 at 6:45am, MA-A stated she was unable to recall answering a call light for Resident # 37.She stated all residents' call lights were to be within reach while in bed. She stated before leaving any resident's room, she checked to see if the call light was within the resident's reach. In an interview on 8/6/2026 at 4:20pm the DON reported her expectation was for all residents to have a call light in reach. She stated all employees had the responsibility to ensure the call light was in reach and in working condition. She stated if a call light was not working properly, staff would need to notify maintenance and provide the residents with a bell to use for needs. She stated even if Resident #37 is non-verbal, his call light should have been in working order and within his reach. She also stated she was unsure how or when the damage to Resident #37's call light occurred. She stated a negative outcome of a resident not having a functioning call light in reach could delay a response in providing care or attending to resident needs. In an interview on 8/6/2026 at 4:20pm the ADMN stated his expectation was for all residents to have access to their call light. He was unaware of Resident #37's call light being broken until the maintenance employee told him about it. He stated the call light was immediately repaired once facility was aware it was damaged. During an observation and interview on 08/05/2026 at 10:16 a.m., Resident #66 was lying in his bed. He stated he did not use the call light. Observed the push light attached to his right side of the bed and the end was not connected to the call system on the wall, it was unable to be used. He did not push the call light when asked if he could. During an observation on 08/05/2026 at 12:09 p.m., Resident #66 was not in his room. The call light continued to not be connected to the call system on the wall. During an interview on 08/06/2026 at 4:20 p.m., CNA-P stated she worked on the hall that Resident #66 resided in. She stated Resident #66 would not use the call light but should have access to a working call light. She stated if she had noticed the call light not being connected to the wall she would have notified the maintenance department. She stated she would check that the call light was in reach but did not check that it was connected to the wall. During an interview on 08/06/2026 at 4:30 p.m., the DON stated she expected residents to have a working call light in reach. She stated all staff that go into the resident rooms were responsible for making sure that the call lights were in working order. She stated if the call light was not in working order, she expected the resident to have a bell to notify staff that the resident needed assistance. She stated she believed Resident #66 could utilize the call light. She stated the negative outcome of not having access to the call light would be that the residents would not get help when needed. During an interview on 08/06/2026 at 4:35 p.m., the ADMN stated he was not aware of the call lights not being in working order prior to today. He stated the call lights had been fixed today, after he had been notified of them not being in working order. He stated he did not know if the maintenance department provided routine checks to ensure call lights were in working order. He stated he expected all residents to have access to working call lights in reach. He did not voice any negative outcome of the call lights not working when asked. Review of document titled Call light use dated on 2/17/2020 stated [in part]:PolicyIt is the policy of this center to ensure residents have a call light within reach that they are physically able to access and that they have been instructed on its use.EQUIPMENTBedside call light in functioning order.Emergency call light in functioning order.PROCEDURE12. Be sure call lights are placed near the resident, never on the floor or bedside stand.

Based on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for of 17 of 17 staff (Admin, DON, Social Worker, Activity Director, Director of Food Services, Director of Therapy, Housekeeping, Wound Care Nurse, RN H, RN D, LVN B, LVN C, LVN E, CNA I, CMA A, CNA F, CNA G) reviewed for Quality Assurance and Performance Improvement training. The facility failed to ensure the Admn, DON, SW, Activity Director, DM, Director of Therapy, Hskpg, WC Nurse, RN H, RN D, LVN B, LVN C, LVN E, CNA I, CMA A, CNA F, CNA G)were trained in Quality Assurance and Performance Improvement. This failure could place residents at risk of receiving care from incompetent/untrained staff and not receiving quality care from facility staff. Based on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for of 17 of 17 staff (Admn, DOR, Hskping, W C Nurse, RN H, RN D, LVN B, LVN C, LVN E, CNA I, CMA A, CNA F, CNA G) reviewed for Quality Assurance and Performance Improvement training. The facility failed to ensure the Admn, DON, SW, Activity Director, DM, Director of Therapy, Hskpg, WC Nurse, RN H, RN D, LVN B, LVN C, LVN E, CNA I, CMA A, CNA F, CNA G)were trained in Quality Assurance and Performance Improvement. This failure could place residents at risk of receiving care from incompetent/untrained staff and not receiving Quality care from facility staff. Findings included: Record review of the Administrators' personnel files revealed a hire date of 8/13/25 and no evidence of QAPI training. Record review of RN D's personnel files revealed a hire date of 1/3/24 and no evidence QAPI training.Record review of LVN-B employment file revealed hire date of 8/16/2019 with no evidence of QAPI training Record review of LVN-C employment file revealed hire date of 12/6/2023 with no evidence of completion of QAPI training. Record review of the DON's personnel files revealed a hire date of 3/19/23 and no evidence of QAPI training. Record review of RN H's personnel files revealed a hire date of 2/28/25 and no evidence of QAPItrainingRecord review of the AD personnel files revealed a hire date of 11/30/20 QAPI training Record review of CNA I's personnel files revealed a hire date of 10/14/25 and no evidence of QAPI training. Record review of MA A''s personnel files revealed a hire date of 5/15/24 and no evidence of QAPI training. Record review of CNA F's personnel files revealed a hire date of 3/19/26 and no evidence of QAPI training. Record review of CNA G's personnel files revealed hire date of 3/26/26 and no evidence of QAPI training. Record review of the SW's personnel files revealed a hire date of 8/27/25 and no evidence of QAPI training. Record review of DM's personnel files revealed a hire date of 11/18/24 and no evidence of QAPI training. Record review of Director of Therapy personnel files revealed hire date of 6/15/2022 and no evidence of QAPI training. Record review of the Housekeeper's personnel files revealed hire date of 10/2023 and no evidence of QAPI training. Record review of the WC Nurse's personnel files revealed hire date of 10/2/225 and no evidence of QAPI training. During an interview on 8/7/26 at 11:09 AM HR assistant stated she was continuing to work on personnel files which were requested via email from the administrator on 8/6/26 at 10:21a.m. and she still did not have a file for two staff that transferred from another facility (RN H & LVN C). She stated she could not call the other facility due to the facility had been sold and they would not provide her with any information. She stated she could not find a file for CNA I and could not provide an explanation for why the file was not in the facility. She stated the prior HR director had been responsible for the employee files and training, but she was no longer at the facility and could not be reached for assistance.During an interview on 8/7/26 at 1:45 PM the administrator stated that he had been assistant administrator prior to The sale of the facility to another company. He stated he had nothing to do with employee files during the time that he was in the position of assistant administrator. He stated he did not know why employees had not received the training required and he would see that they did receive all training going forward. He stated he would continue to assist the Assistant HR person to locate the missing training and files. He stated he did not realize that there was a problem with employee training and personnel files until he was told by the HR Assistant today. He stated as administrator he was responsible for oversight of the entire building and resident care. Record review of the facility assessment dated April of 2026 contained the following information which addressed training : Provide a link to all staff training and competencies needed by type of staff. Consider If It would be helpful to Indicate which competencies are reviewed at the time the staff member Is hired and how often they are reviewed after that. Required In-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aids but must be no less than 12 hours per year.Address areas of weakness as determined In nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff.Record review of the Policy Provided by Administrator Titled Competency of Nursing Staff dated revised 2017 revealed in part: Policy StatementAll nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law.In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: participate in a facility-specific, competency-based staff development and training program; and demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.Policy Interpretation and ImplementationThe staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents.

Based on record reviews and interviews, the facility failed to include effective communications as mandatory training for direct care staff reviewed for of 17 of 17 staff (Admin, DON, SW, AD , DFS, DOR, Hskp, WC Nurse, RN H, RN D, LVN B, LVN C, LVN E, CNA I, CMA A, CNA F, CNA G) reviewed for communication training. The facility failed to ensure the Admin, DON, SW, AD , DFS, DOR, HSKP, WC Nurse, RN H, RN D, LVN B, LVN C, LVN E, CNA I, CMA A, CNA F, CNA G) This failure could place residents at risk of receiving care from incompetent/untrained staff and not having their communication needs met.Findings included:*Record review of RN H's personnel files revealed hire date of 2/28/25 and no evidence of communicationtraining Record review of LVN C's personnel files revealed hire date of 12/6/23 and no evidence of communicationtraining Record review of CNA I's personnel files revealed hire date of 10/14/25 and no evidence of communicationtraining Record review of CMA A''s personnel files revealed hire date of 5/15/24and no evidence of communicationtraining Record review of CNA F's personnel files revealed hire date of 3/19/26/ and no evidence of communicationTraining. Record review of CNA G's personnel files revealed hire date of 3/26/26 and no evidence of Communication training. Record review of the DON's personnel files revealed hire date of 3/19/26 and no evidence of Communication training. Record review of the SW's personnel files revealed a hire date of 8/27/25 and no evidence of Communication training Record review of The DM personnel files revealed hire date of 11/18/24 and no evidence of Communication training. Record review of DOR personnel files revealed hire date of 6/15/2022 and no evidence of Communication, training. Record review of Housekeeper's personnel files revealed hire date of 10/5/2023 and no evidence of Communication, , training. Record review of the WC Nurse's personnel files revealed hire date of 10/2/25 and no evidence of Communication, training. During an interview on 8/7/26 at 11:09 AM HR assistant stated she was continuing to work on personnel files which were requested via email from the administrator on 8/6/26 at 10:21a.m. and she still did not have a file for two staff that transferred from another facility (RN H & LVN C). She stated she could not call the other facility due to the facility had been sold and they would not provide her with any information. She stated she could not find a file for CNA I and could not provide an explanation for why the file was not in the facility. She stated the prior HR director had been responsible for the employee files and training, but she was no longer at the facility and could not be reached for assistance. During an interview on 8/7/26 at 1:45 PM the administrator stated that he had been assistant administrator prior to The sale of the facility to another company. He stated he had nothing to do with employee files during the time that he was in the position of assistant administrator. He stated he did not know why employees had not received the training required and he would see that they did receive all training going forward. He stated he would continue to assist the Assistant HR person to locate the missing training and files. He stated he did not realize that there was a problem with employee training and personnel files until he was told by the HR Assistant today. He stated as administrator he was responsible for the buildings function.Record review of the Facility assessment dated April of 2026 contained the following information which addressed training : Provide a link to all staff training and competencies needed by type of staff. Consider If It would be helpful to Indicate which competencies are reviewed at the time the staff member Is hired and how often they are reviewed after that. Consider the following training topics (not an inclusive list): Communication-effective communications for direct care staffRequired In-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aids but must be no less than 12 hours per year.For nurse aides providing services to Individuals with cognitive Impairments, also address the care of the cognitively Impaired. Record review of the Policy Provided by Administrator Titled Competency of Nursing Staff dated revised 2017 revealed in part: Policy StatementAll nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law.In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: participate in a facility-specific, competency-based staff development and training program; and demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.Policy Interpretation and ImplementationThe staff development and training program is created by the nursing leadership, with input from the medical director, and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents.The following factors are considered in the creation of the competency-based staff development and training program: an evaluation of the current program to ensure basic nursing competencies; Any gaps in education or training that may be contributing to poor outcomes; specialized skills or training needed based on the resident population; a method to track, assess, plan, implement and evaluate the effectiveness of training; and a method to evaluate critical thinking skills and management of care in complex environments with multiple interruptions. The facility assessment includes an evaluation of the staff competencies that are necessary to provide the level and types of care specific to the resident population. Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as:Communication.

Based on interview and record review, the facility, with a capacity of more than 120 beds, failed to employ a qualified social worker on a full-time basis for 1 of 1 facility reviewed for qualified staffing. The facility failed to ensure they had a full-time licensed Social Worker since 08/27/2025. This failure could affect all residents of the facility by placing them at increased risk of psychosocial decline and poor quality of life. Findings included:During an interview on 08/07/2026 at 6:20 p.m., the SSA stated that she is not a licensed social worker and that she is working towards licensure. She stated that she receives virtual guidance from another social worker outside of the facility. During an interview on 08/07/2026 at 6:30 p.m., the ADMN stated he did not have a licensed social worker, and he only has the SSA who has been working at the facility. He did not state an expectation or negative outcome[KS87.1]. He stated that the new company is going to allow the hiring of a licensed social worker.Record review of the job description for Social Worker, no date listed with SSA signature, reflected The Licensed Social Worker is responsible for providing social and emotional support to residents and their families.Record review of the Social Work Application for employed SSA, dated 08/18/25 reflected SSA started working at the facility on 08/27/25 and it was written on the application the facility was aware she did not have her license as it states, no license yet.Record review of Form 3740 titled Bed Classification dated 08/05/2026 revealed the facility had a licensed capacity of 138 resident beds.

Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 (Resident #3) of 8 residents reviewed for pharmaceutical services. The facility failed to ensure Resident #3 received Clonazepam 0.5 mg and Phenobarbital 32.4 mg, both medications ordered for seizures, as ordered as evidenced by gaps in administrations on 11/1/25-11/3/25, 11/10/25 and 11/18/25. This failure could place the residents at risk of not receiving medications as ordered by the physician and risk of seizures (sudden surge of abnormal electrical activity in the brain that can cause changes in behavior, awareness, or muscle control).Findings included:Record review of Resident #3's face sheet dated 6/11/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including acute respiratory failure (when the lungs fail to deliver enough oxygen to the blood or cannot remove carbon dioxide effectively which impairs organ function and potentially cause life-threatening complications) and other seizures (sudden surge of abnormal electrical activity in the brain that can cause changes in behavior, awareness, or muscle control). Record review of Resident #3's admission MDS dated [DATE], section C (Cognitive Patterns) revealed a BIMS could not be conducted as Resident #3 is rarely or never understood. Section I (Active Diagnoses) revealed Resident #3 had an active diagnosis of a seizure disorder or epilepsy. Record review of Resident #3's Order Summary Report dated 6/9/26 revealed physician's order for Clonazepam oral tablet 0.5 mg with instructions to give 1 tablet via peg tube two times a day for anticonvulsant (antiseizure medication) with start date of 10/2/25 and Phenobarbital oral tablet 32.4 mg with instructions to give 1.5 tablets two times a day with start dates of 10/7/25.Record review of Resident #3's care plan dated 6/11/26 revealed focus that Resident #3 was at risk for increased episodes of seizure activity with intervention dated 10/17/25 to give medication per order. Record review of Resident #3's November 2025 MAR revealed Clonazepam 0.5 mg tablet with instructions to give 1 tablet every morning and at bedtime was documented with chart code 9 for 11/2/25 at 8 a.m. and 8 p.m., 11/3/25 at 8 a.m. and 8 p.m. and 11/9/25 at 8 p.m. MAR also revealed Phenobarbital oral tablet 32.4 mg with instructions to give 1.5 tablet every morning and at bedtime was documented as 9 for dates 11/1/25 at 8 p.m., 11/2/25 at 8 a.m. and 8 p.m., 11/3/25 at 8 a.m. and 8 p.m., and 11/18/25 at 8 p.m. Chart codes on the MAR revealed 9 meant other/see progress notes.Record review of Resident #3 progress note dated 11/2/25 at 1:53 a.m. written by LVN D revealed note awaiting delivery from pharmacy- medication has been reordered for phenobarbital oral tablet 32.4 mg with instructions to give 1.5 tablet every morning and at bedtime. Record review of Resident #3's progress note dated 11/2/25 at 9:14 a.m. written by LVN B revealed note on order for clonazepam oral tablet 0.5 mg with instructions to give 1 tablet every morning and at bedtime. Record review of Resident #3's progress note dated 11/2/25 at 9:15 a.m. written by LVN B revealed note on order for phenobarbital oral tablet 32.4 mg with instructions to give 1.5 tablet every morning and at bedtime. Record review of Resident #3's progress note dated 11/2/25 at 10:03 p.m. written by LVN B revealed note on order for clonazepam oral tablet 0.5 mg with instructions to give 1 tablet every morning and at bedtime. Record review of Resident #3's progress note dated 11/2/25 at 10:09 p.m. written by LVN B revealed note on order for phenobarbital oral tablet 32.4 mg with instructions to give 1.5 tablet every morning and at bedtime. Record review of Resident #3's progress note dated 11/3/25 at 7:50 a.m. written by LVN B revealed note on order for clonazepam oral tablet 0.5 mg with instructions to give 1 tablet every morning and at bedtime.Record review of Resident #3's progress note dated 11/3/25 at 7:50 a.m. written by LVN B revealed note on order for phenobarbital oral tablet 32.4 mg with instructions to give 1.5 tablet every morning and at bedtime. Record review of Resident #3's progress note dated 11/3/25 at 9:08 p.m. written by LVN C revealed note on order for clonazepam oral tablet 0.5 mg with instructions to give 1 tablet every morning and at bedtime. Record review of Resident #3's progress note dated 11/3/25 at 9:09 p.m. written by LVN C revealed note on order for phenobarbital oral tablet 32.4 mg with instructions to give 1.5 tablet every morning and at bedtime. Record review of Resident #3's progress note dated 11/4/25 at 1:14 a.m. written by LVN C revealed Called on-call due to the patient continuously jerking, 2 episodes of vomiting, and needing a script for the patient's Clonazepam and Phenobarbital. The script was placed while on the phone. Order for one time dose of Clonazepam was given but was unable to pull it from the automated medication dispensing system due to the other nurses not having access. Family member was informed and left the facility to go get the patient's medication from home.Record review of Resident #3's progress note dated 11/10/25 at 4:02 a.m. written by LVN D revealed note awaiting delivery from pharmacy. Writer unable to pull medication from automated medication dispensing system for clonazepam oral tablet 0.5 mg with instructions to give 1 tablet every morning and at bedtime.Record review of Resident #3's progress note dated 11/18/25 at 9:28 p.m. written by LVN G revealed note pending pharmacy delivery for phenobarbital oral tablet 32.4 mg with instructions to give 1.5 tablet every morning and at bedtime. Record review of Resident #3's SNF Follow Up dated 11/5/25 written by MD B did not reveal any documentation that Resident #3 had a history of seizure-like movements related to missed doses of clonazepam but did have a past medical history of a seizure disorder. Record review of Resident #3's progress note dated 11/10/25 at 11:08 a.m. by LVN E revealed Called pharmacy regarding resident's Clonazepam. Advised by pharmacy medication partially filled and remaining will be sent on next pharmacy run.Record review of Resident #3's progress note dated 11/10/25 at 6:09 p.m. by LVN E revealed Called pharmacy regarding resident's Clonazepam and Phenobarbital as medication called in by MD. Both medications will arrive on midnight run.Record review of Resident #3's SNF Follow Up dated 11/15/25 written by Nurse Practitioner A revealed Resident #3 had a history of seizure-like movement related to missed doses of clonazepam and past medical history of a seizure disorder. List of medications included clonazepam 0.5 mg tablet with instructions to take 1 tablet every 12 hours. Review of systems revealed no seizures. Record review of Resident #3's SNF Follow Up dated 11/20/25 written by MD B revealed Resident #3 had a history of seizure-like movement related to missed doses of clonazepam and past medical history of a seizure disorder. List of medications included clonazepam 0.5 mg tablet with instructions to take 1 tablet every 12 hours. Review of systems revealed no seizures. Record review of intake investigation worksheet #1058998 dated 12/30/25 revealed concern from Resident #3's family member that Resident #3 had run out of clonazepam for three days which caused her to have an increase in seizures and tremors. During interview on 6/11/26 at 10:29 a.m., the Assistant Administrator said he did not have a phone number for MD B, Nurse Practitioner A, LVN B, LVN C or LVN E. The Assistant Administrator said he obtained MD B and Nurse Practitioner A's phone numbers from the electronic medical record and there was no longer any contact information listed in the electronic medical record and MD B and Nurse Practitioner A no longer worked at the facility.During interview on 6/11/26 at 11:06 a.m., LVN F said if a resident did not have their scheduled medications, she would call the pharmacy right away and call the doctor because they have to put the medication on hold. LVN F said the facility pharmacy could do what was called a hot shot where they have a local pharmacy bring a couple of pills until the medication could be delivered. LVN F said it was not good and would be a major issue if a resident did not have their seizure medication for two days and they should be on top of that. LVN F said they always tell the medication technician to let them know when the resident was down to seven days on their medications. LVN F said the facility had an automated medication dispensing system and more general medications could be obtained but they may not be able to get more specialized medications and they would have to let the pharmacy know to bring out the medication. LVN F said she had not had any problems with residents not receiving their prescription medications. During interview on 6/11/26 at 12:44 a.m., the Assistant Administrator said they keep employee information on a year to year basis and did not have employees' information that no longer worked at the facility.During interview on 6/11/26 at 2:20 p.m., LVN A denied any problems with residents' medications not being refilled or not being available and that the facility had had a good supply. Surveyor attempted to contact LVN D on 6/11/26 at 2:33 a.m. via phone but there was no answer. Surveyor left message with request to call surveyor but no response.Surveyor attempted to contact MD B on 6/11/26 at 2:37 a.m. via phone, but there was no answer. Surveyor left message with request to call surveyor but no response.During observation on 6/11/26 at 2:45 p.m. of the facility's automated medication dispensing system revealed an attached list of medications that could be obtained that included Clonazepam 0.5 mg tablet. During interview on 6/11/26 at 1:12 p.m., MA A denied any problems running out of residents' medications as the facility used blister packs, so they did not have problems with the medications running out. MA A said if they did have a challenge, they called the pharmacy and got it worked out. MA A said she did not have access to the pyxis machine and the nurses had access and it was mainly used for as needed medications. During interview on 6/11/26 at 2:20 p.m., LVN A denied any problems with residents' medications not being refilled or not being available and said they had had a good supply. On 6/11/26 at 2:37 p.m., surveyor attempted to contact MD B by leaving a voice message but did not receive a return call.During interview on 6/11/26 at 2:48 p.m., the DON said since she had been at the facility in March 2026 they had educated the nursing staff via in-services the staff about medication availability. The DON said if they needed to use an outside medication they could. The DON said the pharmacy facility had been good since she had been at the facility and had no issues and nothing that they were not able to resolve quickly. The DON said they were able to obtain missing medications or STAT drops from the automated medication dispensing system. The DON said if a seizure medication was not available to a resident it could increase the resident's chances of having a seizure. The DON said if the facility was out of a medication like a seizure medication, she had instructed staff to call the physician and get an order to hold the medication or to get a new order and then they could proceed that way.During interview on 6/11/26 at 3:32 p.m., the DON said they had to get the medications from the pharmacy when the resident gets to the facility. The DON said that they did a run in the morning or a run in the evening, so it depends on what time the resident gets in the facility. The DON said that they did not have a pharmacy onsite and if they had a late admission then they would not have the medications available right away. The DON said regarding a current resident they try not to run out of medications but if they get in a position then they called the pharmacy and asked to STAT a medication or they had to wait until the next drop as well. The DON said they did have the ability to ask the pharmacy for a STAT drop and that took around 4-6 hours. The DON said sometimes there were availability issues with the pharmacy but she had not had any problems since she had been at the facility. The DON said if they were not able to obtain a medication then they call the physician and ask if the resident could be put on something else. The DON said regarding Resident #3 if she was already on two other medications then she would be able to hold over until they got another script. The DON said she could not speak to Resident #3's situation of not getting the Clonazepam on 11/2-11/3/25 except what happened in the notes, and she did not see any kind of seizure activity or anything like that.During interview on 6/18/26 at 2:12 p.m., MD A said Resident #3 was not his patient but was transferred to MD B. Regarding the missing medications for Resident #3, MD A said they did not have at least one of the medications in stock as they were on back order or maybe both of the medications. MD A said Resident #3's family member had a supply at home and the facility needed to approve the medication while the back order was filled and then they could go back to the pharmacy supply. MD A said clonazepam was an antianxiety disorder that was used for a panic disorder but phenobarbital would be the main medication for seizures. MD A said clonazepam would not be used to treat acute seizures and the seizure medication Resident #3 would have been on was the phenobarbital. MD A said Resident #3 did not have any seizure events that he was aware of. MD A said it did happen that residents needed medications that were on back order and there were medications that they could use in their place if residents were having symptoms. MD A said shaking was not necessarily a seizure symptom. MD A said you would have to know what the resident's phenobarbital level was in their blood and if the level was below the range they would be at risk for missing doses. MD A said if the resident was getting the medication regularly missed doses would not put them at a significant risk because the medication level would not drop off quickly. MD A said he would not know for sure the effects of missing doses of phenobarbital because you would need to know what the level was but should not have been a significant event. MD A said Resident #3 had grand mal seizures which would cause the resident to stiffen up or become frothy in the mouth and that was his understanding of what kind of seizures Resident #3 had. MD A said it would be very hard to say what was the cause of the shaking Resident #3 was having that was documented in the progress notes.During interview on 6/30/26 at 1:15 p.m., LVN B said when he ran out of the clonazepam Resident #3's family member gave them some from the home supply and they checked with doctor regarding this. LVN B said there was never an issue with both medications referring to the Clonazepam and Phenobarbital. LVN B said sometimes if they ran out on the weekend, they let Resident #3's family member know and they had her own supply. LVN B said on order from the progress notes meant that they reordered the medication and was waiting for it to come in and then they resumed the medication administration. LVN B said he could not remember a time frame of how long it was until Resident #3's family member [NAME] in the medications. LVN B said he never witnessed Resident #3 having any tremors or seizures. During interview on 6/30/26 at 1:34 p.m., LVN D said they tried to stay on top of having scheduled and as needed medications, but she could not remember Resident #3 being out of any medication that she needed. Surveyor read note written by LVN D on 11/10/26 at 4:02 a.m. that read write unable to pull medication from automated medication dispensing system and LVN D said that would mean the medication was not available in the automated medication dispensing system. LVN D said she did not remember Resident #3 having any problems with tremors or seizures under her watch. LVN D said if they were out of a medication like the clonazepam and phenobarbital which were considered to be narcotics, they would reach out to the provider and let them know the narcotic needed to be called in or let them know we need a triplicate which was a prescription which was then faxed to pharmacy. On 6/30/26 at 1:48 p.m., surveyor attempted to contact LVN G by leaving a voice message but did not receive a return call.Record review of facility's policy Administering Medications dated quarter 3 2018 revealed Medications must be administered in accordance with the orders, including any required time frame.

Based on observations, interviews, and record review, the facility failed to ensure each resident was free from abuse, neglect and exploitation for 2 of 5 (Resident #1 and CR#2) residents reviewed for abuse. The facility failed to ensure Resident #1 was free from sexual abuse when CR #2 told Resident #1 to hold his (CR#2's) penis and touch his body on 3/14/2025. The noncompliance was identified as Past Non-Compliance. The PNC IJ began on 03/14/2025 and ended on 3/17/2025. The facility corrected the noncompliance before the survey began. This failure placed all residents in the facility at risk of abuse and neglect that could result in emotional and mental trauma. Findings included: Record review of Resident #1's admission face sheet dated 4/8/2025 revealed he was a [AGE] year-old male, who admitted to the facility on [DATE] with primary diagnoses of cerebral palsy (disorder of movement and muscle tone), lobar pneumonia (a type of pneumonia that affects and inflames one or more lung lobes), acute respiratory failure with hypoxia (a serious condition where the lungs fail to adequately oxygenate the blood leading to low oxygen levels, epilepsy (nerve activity in the brain causing seizure), muscular atrophy(a condition that causes the muscles to lose mass and strength), asthma (condition where the airways become inflamed), muscle wasting (loss of muscle mass and strength), and intellectual disabilities (significant limitations in both intellectual functioning and adaptive behavior). Record review of Resident #1's Admission MDS assessment dated [DATE] revealed he has a BIMS score of 8 indicating he was moderately impaired for cognition; For behavior he was coded as having no behavior. For ADL activities he was dependent on staff for toileting, shower/bathe, lower body dressing, putting on and taking off shoes and personal hygiene, he was partial/moderate assist for eating, and required substantial/maximal assistance for oral hygiene and upper body dress. The resident was coded as always incontinent of bowel and bladder. Record review of Resident #1's care plan revised 01/21/2025 revealed the following areas of concern: COGNITIVE IMPAIRMENT: Resident #1's has impaired cognition r/t Congenital Mental Retardation, and is at risk for further decline and injury. o Resident #1's needs will be met and dignity maintained over the next 90 days. o Allow time for tasks and responses o Explain all procedures using terms/gestures the resident can understand o Involve in care to maintain or increase level of independence o Praise for tasks that the resident completes o Repeat information PRN Record review of Resident #1's care plan revised 01/29/2024 revealed the following areas of concern: Record review of nurse's notes 3/15/2025 at 9:30pm COMMUNICATION- with Resident Assistant Administrator was physically in room. Resident In bed comfortably, stated that he feels safe and not upset about situation that occurred earlier in the day. Supportive Care Psychologist will see him 3/16/2025. 3/15/2025 4:06 Incident Note: Resident informed this writer that he had been touched all over his body by another resident. Also states that he was asked to touch the other resident's private parts after the resident came into his room. Resident immediately taken to room and head-to-toe assessment performed without any significant findings. Enhanced supervision began with the alleged perpetrator for resident's safety. Police department, MD and family notified. Observation on 3/17/2025 at 9:25am Resident #1 observed in a low bed. He appeared to have limited ROM. A camera was observed in the room and the resident did not have a roommate. In an interview on 3/17/2025 at 9:25am Resident #1 said CR #2 told him to touch him everywhere. He said he wanted him to touch his crack, his butt, his behind and he did, but he didn't want to touch CR #2's private body parts. He said he told Activity Director A CR #2 wanted him to touch him all over and making him do bad things by touching him. He said Activity Director A told him CR #2 should not have told him to do that, and he (Resident #1) did not do anything wrong. In an interview on 3/17/2025 at 1:13pm Resident #1's family member said CR #2 was not Resident #1's roommate. She said she had video evidence on her computer from the camera past Friday. The camera was accidently moved or disconnected on Saturday, and she thought something happened on Saturday but there was no video evidence. She said Resident #1 reported it to Activity Director A. She said she was not aware until she was told on Saturday. She said she felt the facility responded appropriately. I don't think this was an easy thing to deal with and they reacted in a few hours. They called at 4 pm on Saturday and when she got to the facility there was an officer at the facility. In an interview on 3/17/2025 at 2:15pm the Assistant Administrator said on Saturday afternoon, the 15th of March 2025, Activity Director A witnessed CR #2-wheeling Resident #1 back to his room and Resident #1 was calling CR #2 'Daddy. Activity Director A told Resident #1 not to call CR #2 daddy because he was not his father. After the meal, CR #2 wheeled Resident #1 to his room, then came back about an hour later to Bingo. She said she was surprised because Resident #1 did not like Bingo. When Resident #1 got to the table he told Activity Director A that CR #2 (Daddy) made me touch his private parts and I didn't like it. The Administrator said, Resident #1 was usually truthful when he spoke. She called the supervisor over and got statements from the CNA, 2 charge nurses, and Activity Director A. She said both residents were immediately placed on enhanced supervision, she reported the incident to both families, and she called the police. She said Resident #1's family was here when the police arrived. She said no camera footage found on Saturday because the camera was unplugged, the camera footage was from Friday. She said Resident #1 did not have a roommate, both residents were living on separate halls. She said CR #2 was a new admit, he was admitted a few days before the incident. She said he would wander down different halls. She said CR #2 was ambulatory, very friendly, and did not exhibit any behaviors that indicated aggression or sexual behavior. She said CR #2 complained of headache, and CR#2's behaviors of acting drowsy etc. during the interview. She said she called CR #2's family and she was told to send him to the hospital. She said CR #2 was sent to the hospital on Saturday on 3/15/2025 at 9:30 pm. Record review of CR #2's admission face sheet dated 3/20/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and was discharged on [DATE] to a local hospital. His diagnoses included chronic kidney disease (inability to filter waste and excess fluid from the blood), type II diabetes (high blood sugar), altered mental status (a state where a person's alertness and awareness are changed), dementia (memory loss), hypertension (high blood pressure), and hyperlipidemia (high fat in blood). Record review of CR#2's care plan dated 3/13/2025 revealed the following: CR#2 was at risk of elopement, risk/wanderer r/t, resident wanders aimlessly. -wanders from hall to hall throughout the day. - safety will be maintained through the review date. - will not leave facility unattended through the review date. - was Assess for fall risk. o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: o 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. o Monitor for fatigue and weight loss. o Monitor location. Document wandering behavior and attempted diversional In an interview on 3/17/2025 at 2:33pm CNA A said she was in-serviced that morning on stopping abuse. She said if she witnessed abuse to report it to the DON and let everyone know. CNA A was able to verbalize understanding of the different forms of abuse. In an interview on 3/17/2025 at 1:35 CNA B said she was in-serviced on the different forms of abuse. If abuse was witnessed between two residents, she was to separate the residents and report to the charge nurse immediately. CNA B was able to verbalize understanding of the different forms of abuse and training. In an interview on 3/17/2025 at 1:45pm CNA C said she was in-serviced on abuse/neglect and if she witnessed any resident-to-resident abuse she would separate the residents, call the charge nurse, and report it to the Administrator. She said she did not know much about the two residents because she normally did not work the halls the residents were on. In an interview on 3/17/2025 at 1:48 pm Resident #4 said he had no problems with any staff or residents. He said if he was abused, he would tell the people at the front desk. He was never abused by any staff or residents. In an interview on 3/17/2025 at 1:48 pm Resident #5 said she had no problems with any staff or residents. She said she was treated well by the staff. She said no resident came to her room. She said if she was abused, she would report it to the charge nurse. In an interview on 3/17/2025 at 1:50 pm Resident #6 said he had no problems with staff or residents. He said the staff treatment was good and he had no problems with other residents. He said if he was abused, he would tell the nurse. In an interview on 3/17/2025 at 1:53pm Resident#7 said he had no problems with other residents. He said if he was abused, he would report it to the charge nurse. In an interview on 3/17/2025 at 1:50pm LVN F said he was recently in-serviced on abuse and neglect, resident rights, and resident to resident abuse. He said if he witnessed resident to resident abuse, he would separate the residents, make sure they were safe, and notify the Administrator. He said no one has reported abuse to him. In an interview on 3/17/2025 at 1:52pm LVN G said she was in-serviced recently on abuse/neglect, resident rights, enhanced supervision, and resident to resident abuse. She said if she witnessed resident to resident abuse she would separate them, monitor them. She said she would interview the staff and residents to find out was going on and she would report to the Administrator or the DON. In an interview on 04/04/2025 at 1:13 pm Activity Director A said CR #2 was pushing Resident #1's wheelchair to the dining room. She said she asked CR #2 if he was going to play bingo and he wheeled Resident #1 back to his room. She said prior to the incident, she heard Resident #1 calling CR #2 daddy when they were in activities. She said she told Resident #1 not to call CR #2 daddy because he was not his daddy. She said after the meal, on 3/15/2025 she noticed CR #2 taking Resident #1 back to Resident #1's room. She said about an hour later they came to bingo, and she was surprised because Resident #1 did not like bingo. Activity Director A said when they got to the table, Resident #1 told her Daddy made me touch his private parts and all over his body and he did not like it. She said she looked for the Weekend Supervisor and told her. She said Resident #1 did not seem afraid, but he looked uncomfortable. In an interview with the Weekend Supervisor on 4/4/2025 at 3:00pm she said she was working the day the incident took place. She said Activity Director A took Resident #1 to her and said Resident #1 told her CR #2 had him touched his private parts and other parts of his body. She said she took Resident #1 to his room and did a head-to-toe evaluation and there were no marks or bruises. She said CR #2 was also evaluated and there were no marks or bruises. She said when she interviewed CR #2, he denied at first that he had Resident #1 touch his private parts but later said Resident #1 only touched his private parts one time. She said they started to monitor both residents in their different rooms. She said CR #2 started complaining of a headache and said he wanted to go to the hospital, and he was later transferred to the hospital. Interview on 4/4/2025 at 3:20pm with the Administrator revealed Activity Director A told her Resident #1 told her CR #2 had him to do something he did not want to do. She said Activity Director A told her that Resident#1 came to her and told CR #2 (Daddy) let him touch his private part, and he did not like it. She said Resident #1 was brought back to his room, head to toe assessment done and enhanced supervision and monitoring started. CR #2 was brought to his room and a head to toe assessment done and enhanced supervision and monitoring put in place. She said she immediately launched an investigation. She said after the assessment CR#2 started complaining of a headache and said he wanted to go to the hospital. She said Resident#1 and CR #2 were not roommates but were meeting at lunch. She said CR #2 would push Resident #1's wheelchair to his room and he never displayed any inappropriate behaviors. She said they were thinking of elopement as CR #2, wandered in the facility, so being inappropriate was a surprise for them. He said they were always redirecting him because he at times was confused and walked up and down the hallway. She said there was no witness to the inappropriate touching but Resident #1 said CR #2 let him touch his body part. The Administrator said during the interview CR #2 first said Resident #1 fell and he picked him up and might have touched his bottom in the process. She said at that point she knew CR #2 was not telling the truth. She said if Resident #1 fell CR #2 could not pick him up by himself. She continued to ask him questions and he finally said that he let him touch his private part, but he only did it once. She said CR #2's family was notified, and permission given for the resident to be sent to the hospital. She said he was discharged to the hospital and would not be readmitted to the facility. She said in-services were done on abuse/neglect, enhanced supervision, and resident rights. Observation on 4/4/2025 at 12:20pm Resident #1 was observed in bed, he was alert and oriented with some confusion. He was clean and groomed with no offensive odor. The call light was observed to be within reached. No visible marks or bruises noted. CR #2 was not interviewed on 4/4/2025 because he was not at the facility. He was sent to the hospital and did not return. In an interview with Resident #1 on 4/4/2025 at 12:20pm, Resident #1 said he was treated well at the facility. He stated CR #2 abused him. He was asked at that time, what CR #2 did. He said CR #2 made him touch his private body parts all over and he did not like it. He said the man who touched him was living in another room. He stated he did not have a roommate. In a telephone interview with Resident #1's family on 04/04/2025 at 2:00pm she said the family was notified of the abuse regarding Resident #1 and CR #2. She said she was satisfied with the fact it was addressed in a timely manner. She said by the time she arrived, the police was in the building and the investigation was in progress. In an interview on 04/04/2025 at 12:17pm Medication Aide H said she had been working at the facility for about a year and she said she was trained on abuse, neglect, resident to resident abuse, and resident rights. She said if she witnessed two residents fighting, she would separate them and call the nurse. She said she would report any abuse or neglect to the DON, and the Administrator. In an interview on 04/04/2025 at 3:15pm Medication Aide L said she had been working at the facility for the last [AGE] years. She said she was trained on abuse, neglect, resident to resident abuse, and resident rights. She said if she witnessed two residents in a fight or any other altercation, she would separate them and call the nurse. She said she would report any abuse to the nurses, the DON, and the Administrator. In an interview on 04/04/2025 at 2:17pm CNA K said she was trained on abuse and neglect. She said she had never seen anyone being abusive to Resident#1. She said they were trained on not having residents pushing residents, resident to resident abuse, and resident rights. In an interview on 04/04/2025 at 3:40 pm RN E said she had been working at the facility for almost one year and she was recently trained on abuse, neglect, resident to resident abuse, and resident rights. She said if she witnessed two residents in a fight or other altercation, she would separate them, call the nurse, and notify the family. She said she would report any form of abuse to the nurses, the DON, and the Administrator. On 04/08/2025 at 2:50pm, the facility's Administrator, DON, and Regional Nurse were notified of the past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the Administrator on 04/08/2025 at 2:58 p.m. In an interview on 04/08/2025 at 3:50pm CNA I said she had been working at the facility for the last three weeks. She said she was trained on abuse, neglect, resident to resident abuse, resident rights, and residents who wandered in other resident's room. She said if she witnessed two residents in a fight, she would separate them and call the nurse. She said she would report any abuse to the nurses, the DON, and the Administrator. In an interview on 04/08/2025 at 4:04pm Medication Aide H said she was in-serviced on abuse and neglect, resident to resident abuse, and resident rights. She said if she witnessed resident to resident abuse, she would separate them and call the nurse. She said if she witnessed abuse, she would report it to the nurse and the administrator. In an interview on 4/08/2025 at 4:10pm CNA J said he was in-serviced recently on abuse and neglect, resident rights, and resident to resident abuse. He said if he witnessed resident to resident abuse he would separate them, call the nurse, and report the incident to the charge nurse and administrator. Record review of Resident #1's clinical records revealed that the resident was seen by psychiatric services on 3/18/2025 and they would be following the resident. Further review revealed Resident #1 said he felt safe at the facility. Record review of the in-service dated 3/15/2025 revealed all staff were in-serviced on abuse and neglect, reporting of abuse and neglect, signs of abuse and neglect, exploitation , enhanced supervision, resident rights safety, and supervision to prevent abuse and neglect of resident. Staff sign in sheets were also reviewed. Record review revealed safe survey was done with residents on 3/15/2025 and residents verbalized that they felt safe at the facility. Interviews were conducted with facility staff, and they confirmed they were in-serviced. Staff were able to recall the incident that triggered the in-serviced. Record review of the facility's document date 07/17/2021 titled, Abuse read in part . POLICY It is the policy of this center to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. DEFINITIONS Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The noncompliance was identified as Past Non-Compliance. The IJ began on 03/14/2025 and ended on 04/08/2025. The facility corrected the noncompliance before the survey began.

Based on observation, interview and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing care to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 8 of 10 residents (Resident #34, Resident #65, Resident #87, Resident #91, Resident #19, Resident #41, Resident #50 and Resident #59) reviewed for sufficient staffing. -The facility failed to ensure there were sufficient staff per the facility assessment, and failed to provide care for residents including blood pressure and blood sugar monitoring, medicaiton administration, repositioning, and incontinent care. - Resident #34, Resident #65, Resident #87, and Resident #91 did not receive their morning and/or afternoon medications. -The facility failed to provide ADL care to residents with bowel/bladder incontinence during the night shift (11pm-7am) on 4/21/24 and 4/22/24. An Immediate Jeopardy (IJ) was identified on 04/24/24. The IJ template was provided to the facility on [DATE] at 5:35 p.m. While the IJ was removed on 04/28/24 at 12:35 p.m., the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that was not immediate jeopardy, because all staff had not been trained on medication administration and chain of command. These failures could place residents at risk of their needs not being met, injury, skin breakdown, low self-esteem, depression, embarrassment, and psychological harm. Findings included: Record review of the Facility Assessment Tool updated 04/24/2024 revealed the average daily census was 94 residents. The facility had 18 residents with behavioral needs, 11 residents required injections. Tracheostomy care 18 residents and ventilator or Respirator 7 residents. The facility residents break down of ADL care was 32 dependent on bathing, 30 dependent on bed mobility, 20 dependent on eating, 25 dependent on personal hygiene, 24 dependent on toilet use, 26 dependent on transfer. The average number suggested for licensed nurses providing direct care was 5 licensed nurses (Days & Evening), 4 licensed nurses (Nights). Nurse Aides was 7 CNAs on Days and Evenings, 2 Restorative CNA split shift, 7 CNA/CMAs (Days & Evenings), 8 CNAs on Nights. Record review of facility map revealed [NAME] zone 1 was room [ROOM NUMBER] through 112, Dove zone 2 was114 through 125, Flamingo zone 5 was 126 through 137, Swan zone 6 was 139 through 150, South east wing zone 11 was 201 through 206, and south west wing zone 12 was 207 through 224. Record review of the facility resident roster dated 04/23/24 revealed [NAME] station rooms 101-112, revealed 17 residents, Dove station rooms [PHONE NUMBER] revealed 13 residents, Flamingo station rooms 126-137 revealed 16 residents, Swan station rooms 138-149 revealed 17 residents and South station rooms 201-224 revealed 33. Resident #34 Record review of the Admission Record for Resident #34 (dated 04/25/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, cerebral palsy (a group of movement disorders), type 2 diabetes mellitus, gastrostomy status (has feeding tube), and epilepsy (seizure disorder). Record review of the MDS (ARD 04/11/24) for Resident #34 revealed she had a BIMS score of 0/15, indicative of severe cognitive impairment. Record review of the Care Plan (revised 03/30/24) for Resident #34 revealed she was receiving anticoagulant therapy (Eliquis) and was at risk for increased bleeding or bruising. One of the Interventions read Give medications as ordered. The Care Plan reflected Resident #34 had diabetes. Corresponding Interventions were to monitor blood glucose levels as ordered, and to give medications as ordered. Record review of the April 2024 Order Summary Report for Resident #34 revealed she was to receive Eliquis (anticoagulant) 5 mg twice daily for prevention of pulmonary embolism (blood clot in an artery of the lung). The orders reflected she was to have her blood glucose checked every six hours, with insulin to be administered per sliding scale. The orders reflected Metoprolol Tartrate (Toprol) tablet, 12.5 mg was to be administered twice daily for high blood pressure. The orders reflected the Toprol was to be held if the resident's systolic blood pressure was less than 100 mmhg. The orders reflected Trileptal Oral suspension (300 mg/5 ml) 10 ml was to be administered twice daily for epilepsy. Record review of the April 2024 MAR/TAR for Resident #34 revealed the following medications were not administered on 04/22/24 at 9:00 a.m.: -Eliquis 5 mg -Toprol 12.5 mg (blood pressure not documented) -Trileptal Oral suspension (300 mg/5 ml) 10 ml Resident #34's blood glucose levels were not checked at noon or 6:00 p.m. No sliding scale insulin was administered. Record review of the April 2024 Order Summary report revealed Resident #34 was to receive the following Fiasp (100 u/ml) insulin amounts based on her blood glucose level: -150 - 200 mg/dl administer 2 units -201 - 250 mg/dl administer 4 units -251 - 300 mg/dl administer 6 units -301 - 350 mg/dl administer 8 units -351 - 400 mg/dl administer 10 units If Resident #34's blood glucose level was greater than 400 mg/dl, the nurse was to administer 12 units and notify the NP. Observation on 04/23/24 at 9:00 a.m. revealed Resident #34 was in her room, lying in bed. She did not respond to a verbal greeting. She was receiving enteral nutrition via her g-tube. Resident #65 Record review of the Admission Record for Resident #65 (dated 04/25/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus, schizophrenia, seizures, stage 4 pressure ulcer of the sacrum, and atherosclerotic heart disease of coronary artery without angina pectoris (chest pain). The resident had a gastrostomy tube (g-tube) for nutrition and medications. Record review of the MDS (ARD 01/24/24) revealed she had memory deficits and moderately impaired cognition . Record review of the April 2024 Order Summary Report for Resident #65 revealed she was to receive the IV antibiotic Ertapenem Sodium Solution reconstituted 1 gm for an infection of the pressure ulcer of her sacrum. The orders also reflected Resident #65 was to have her blood glucose checked at 8:00 a.m., and Glargine insulin (100units/ml) 40 units administered. The orders reflected she was to have her blood glucose checked every six hours, with insulin to be administered per sliding scale, and she was to receive Levetiracetam solution (100 mg/ml) 5 ml twice daily for seizures, Oxcarbazepine 300 mg twice daily for seizures, and Haldol 2 mg twice daily for schizophrenia. Record review of the April 2024 MAR for Resident #65 revealed the following medications with corresponding times were not administered on 04/22/2024: -IV Ertapenem Sodium Solution reconstituted 1 gm scheduled for 8:00 a.m. -Haldol 2 mg scheduled for 8:00 a.m. -Levetiracetam solution (100 mg/ml) 5 ml scheduled for 9:00 a.m. -Oxcarbazepine 300 mg scheduled for 9:00 a.m. Resident #65's blood glucose was not checked as ordered on 04/22/2024 at 8:00 a.m. and 40 units of Insulin Glargine was not given. Resident #65's blood glucose was not checked as ordered at 6:00 a.m., noon, or 6:00 p.m. on 04/22/2024, and sliding-scale insulin was not given. Record review of the April 2024 Order Summary report revealed Resident #65 was to receive the following Lispro (200 u/ml) insulin amounts based on her blood glucose level: -150 - 200 mg/dl administer 2 units -201 - 250 mg/dl administer 4 units -251 - 300 mg/dl administer 6 units -301 - 350 mg/dl administer 8 units -351 - 400 mg/dl administer 10 units If Resident #65's blood glucose level was greater than 400 mg/dl, the nurse was to administer 12 units and notify the physician. Observation and interview on 04/23/24 at 9:13 a.m. revealed Resident #65 was in her room, sitting in her wheelchair. She said she had received her medications today but was unable to recall yesterday (04/22/24). Resident #87 Record review of the Admission Record for Resident #87 (dated 04/24/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus, atrial fibrillation, congestive heart failure, hypertension, and history of pulmonary embolism (obstruction of the pulmonary artery by a blood clot or other foreign matter). Record review of the MDS (ARD 03/25/24) revealed she scored 0 of 15 on the BIMS, indicative of severely impaired cognition . Record review of the April 2024 Order Summary Report for Resident #87 revealed she was to receive Apixaban (blood thinner/anticoagulant) 5 mg twice daily to prevent blood clots, Metoprolol Tartrate 12.5 mg twice daily for blood pressure, Amiodarone 200 mg for atrial fibrillation, and she was to have her blood glucose checked before meals, with insulin to be administered per sliding scale. Resident #87 was to recieve Mtotoprolol Tartrate 12.5 mg., which had blood pressure parameters instructing to hold the medication if the resident's systolic blood pressure was less than 100 mmHg. Record review of Resident #87's April 2024 MAR revealed she was not administered the 9:00 a.m. doses of Apixaban 5 mg, Amiodarone 200 mg, or the Metoprolol Tartrate 12.5 mg. on 04/22/24. Resident #87's blood pressure was not documented as been checked. Resident #87's blood glucose was not checked as ordered at 11:00 a.m. and 4:00 p.m. on 04/22/2024 and sliding-scale insulin was not administered. Record review of the April 2024 Order Summary report revealed Resident #87 was to receive the following Lispro insulin (100 u/ml) sliding scale amounts based on her blood glucose level: -150 - 200 mg/dl administer 1 unit -201 - 250 mg/dl administer 2 units -251 - 300 mg/dl administer 3 units -301 - 350 mg/dl administer 4 units -351 - 400 mg/dl administer 5 units If Resident #87's blood glucose level was greater than 400 mg/dl, the nurse was to administer 6 units and notify the NP. Resident #91 Record review of the Admission Record for Resident #91 (dated 04/24/24) revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, diabetes mellitus, combined systolic and diastolic congestive heart failure, and long-term use of anticoagulants. Record review of the MDS (ARD 04/08/24) revealed Resident #91 scored 15 of 15 on the BIMS, indicative of intact cognition . Record review of the April 2024 Order Summary Report for Resident #91 revealed he had a LVAD (left ventricular assist device). A LVAD is a mechanical pump that is implanted in the chest to assist the resident's heart to pump blood. The orders read, in part, .Please place parameters to hold for SBP less than 110 and hr [heart rate] less than 60 on bp [blood pressure] meds . Record review Resident #91's Care Plan (initiated 04/10/24) revealed, in part, ._____ [Resident #91] requires the use of an LVAD r/t Cardiomyopathy [disorder of the heart muscle], Acute/Chronic CHF, . An 'Intervention' was for the resident to receive all medications as ordered. Record review of the April 2024 MAR for Resident #91, for Monday 04/22/24, revealed he was not administered Coumadin (blood thinner/anticoagulant) 3 mg at 5:00 p.m. as ordered. The resident was to have a PT/INR lab drawn to monitor the Coumadin. The lab was not initialed as drawn. The MAR revealed his blood glucose was not checked as ordered at 7:00 a.m. or 11:00 a.m. and sliding-scale insulin was not given. The resident was not administered Hydralazine HCl (for high blood pressure) 50 mg at 6:00 a.m. or 2:00 p.m. The resident's blood pressure was not documented for 6:00 a.m. or 2:00 p.m. Resident #91 was not administered Carvedilol (for CHF) 6.25 mg at 9:00 a.m. Observation on 04/23/24 at 3:00 p.m. revealed there were three nurses on the South Hall. In an interview on 04/23/24 at 3:30 p.m., RN M revealed the nurses on the South Hall work 12-hour shifts, from 7:00 a.m. to 7:00 p.m. She said the South Hall was usually divided for three nurses; South 1 was from room [ROOM NUMBER] to room [ROOM NUMBER]. South 2 was from room [ROOM NUMBER] to room [ROOM NUMBER]. South 3 was from room [ROOM NUMBER] to room [ROOM NUMBER]. RN M said she worked on 04/22/24, and there were two nurses. RN M said LVN N was assigned to South 1, and she was assigned South 2. She said there was supposed to be a third nurse, but one had called off. She said she and LVN N did not redistribute care of the South 3 residents because there were two admissions. She said since they were short-handed, they did not complete the medication administration. RN M presented a text dated 04/22/24 at 11:00 a.m. to the DON that reflected she informed the DON there was no nurse for South 3. The DON replied that South 3 should be divided between the two nurses. RN M had responded that she could not handle the additional residents. RN M said neither the DON, ADON, or any other nurses came in to assist. In an interview via telephone on 04/23/24 at 3:50 p.m. LVN N said she worked on 04/22/24 on the South Hall. She said she worked on South 1 and RN M worked on South 2. She said they did not notice until 11:00 a.m. that there was no third nurse. In an interview on 04/23/24 at 4:05 p.m., the DON said there had been some issues with staffing. She said there were three nurses scheduled for the South Hall on 04/22/24, but one had called off. She said the hall should have been split between the two nurses. She said she was responsible for finding replacement staffing. She said the nurse who canceled texted her at 4:22 a.m. and she did not see it until 6:50 a.m. She said she called the facility and told a nurse to adjust the schedule but did not recall who she spoke with. She said 'WNBI' should have been scribed next to the name of the nurse who called off. She said she found out fifteen minutes ago that residents missed their medications on 04/22/24 . In an interview on 04/23/24 at 4:20 p.m., the Administrator said a staffing coordinator had recently resigned, so the DON was currently responsible for staffing. She said the two nurses should have split the hall on 04/22/24. She said she was at the facility from 8:00 a.m. to 6:00 p.m., and no one informed her they were 'struggling' on the South Hall. She said she was not aware residents missed their medications. In an interview on 04/23/24 at 4:40 p.m., the DON said that if a resident missed a dose of Coumadin (Resident #91) the PT/INR lab result could change. It would place the resident at higher risk for blood clots. She said if a resident missed a dose of Levetiracetam and/or Oxcarbazepine (Resident #65) they would be at greater risk for seizures. She said she had not informed the doctor because NP Q was at the facility on 04/22/24. In an interview on 04/23/24 at 4:55 p.m., RN M said NP Q was at the facility on 04/22/24. She said she told NP Q they were short of staff, but did not tell the NP that residents missed medications. She said she had not spoken with the NP or physician regarding the medications. In an interview on 04/24/24 at 9:35 a.m., the Corporate RN said she called the physician and received orders to monitor the residents. She said RN M should have divided the residents between her and LVN N. She said she provided 1:1 education for RN M, and that she would be making a referral to the Board of Nursing. In an interview on 04/24/24 at 11:50 a.m., NP Q said she was not made aware the residents missed their medications on 04/22/24 until yesterday (04/23/24). She said she was told only the evening medications were missed. The surveyor informed her that residents missed their morning medications as well. She said the resident on Coumadin would need to have his next PT/INR lab watched. She said the facility would need to make sure vital signs and blood sugars were monitored. She said a missed dose of Keppra (Levetiracetam) or Oxcarbazepine would make the resident more prone to have a seizure, but missing a dose would probably not cause a seizure. She said Resident #91 was in the transitioning phase of attaining a therapeutic range for Coumadin, and he was not there yet. Missing the dose was a setback. She said Resident #91 has a LVAD device, and if he had a clot, it could be fatal. Resident#19 Record review of the admission sheet (undated) for Resident #19 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning), other abnormalities of gait and mobility (weakness of the hip and lower extremity muscles commonly cause gait disturbances) and other lack of coordination (impaired balance or coordination). Record review of Resident #19's Quarterly MDS, dated [DATE], revealed she had a BIMS score of 12 out of 15, indicative of moderately impaired cognitively. She required partial/moderate assistance from staff with toileting hygiene, shower/bathe, upper/lower body dressing and personal hygiene. Further review of section H0300 and H0400 coded always incontinent of bladder and bowel. Record review of Resident #19's care plan, initiated 01/27/2023 and revised on 02/21/2023 revealed the following: Focus: ADL FUNCTIONAL DEFICITS: [Resident#19] is at risk for decline in ADL functions and injury r/t age related osteoporosis Polyosteoarthritis abnormalities of gait mobility malaise lack of coordination muscle wasting. Goal: [Resident#19] will be well dressed, groomed, clean, odor free and will have no decline in ADL functioning over the next 90 days. Target Date: 02/14/2024. Interventions: Toileting: Provide extensive assistance of 2 persons for toileting Observation and interview on 04/23/24 at 9:32 a.m., revealed Resident #19 was sitting on the side of the bed. The fitted sheet and the towel used as a draw sheet were soaking wet. Resident #19 mumbled for about 5 minutes while being interviewed and could not respond appropriately to the questions asked. In an interview on 04/23/24 at 10:54 a.m., CNA I said she came to work late at 7:45 a.m, and did not have a chance to change residents from last night (4/22/24) because she was busy passing out breakfast trays. Resident #41 Record review of the admission sheet (undated) for Resident #41 revealed a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included sleep terrors (episodes of screaming, intense fear, and flailing while still asleep, often paired with sleepwalking) and restless legs syndrome (a condition characterized by a nearly irresistible urge to move the legs, typically in the evenings). Record review of Resident #41's Quarterly MDS, dated [DATE], revealed he had a BIMS score of 15 out of 15, indicative of intact cognitively. He required partial/moderate assistance from staff with toileting hygiene, shower/bathe, upper/lower body dressing and personal hygiene. Further review of section H0300 and H0400 coded always incontinent of bladder and bowel. Record review of Resident #41's care plan, initiated 08/09/2022 and revised on 04/03/2023 revealed the following: Focus: ADL FUNCTIONAL DEFICITS: [Resident#41] is at risk for decline in ADL functions and injury r/t Parkinson disease, Restless Leg syndrome, Muscle weakness, repeated falls, Unwitnessed fall-3/31/23 per resident Goal: [Resident#41] will be well dressed, groomed, clean, odor free and will have no decline in ADL functioning over the next 90 days. Target Date: 05/04/2024 Interventions: Toileting: Provide extensive assistance of 2 persons for toileting. In an interview on 4/23/24 at 9:23 a.m., Resident #41 said there was no CNA last night (4/22/24) and the night before (4/21/24) on 11-7am shift. He said he was incontinent of bowel and bladder. He said his bed had been soaking wet when morning shift CNA changed him. He said, I can have skin breakdown and pressure ulcer from laying in urine. Resident #50 Record review of the admission sheet (undated) for Resident #50 revealed an [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body), congestive heart failure(a chronic condition in which the heart doesn't pump blood as well as it should) and functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord). Record review of Resident #50's Quarterly MDS, dated [DATE], revealed he had a BIMS score of 15 out of 15, indicative of intact cognitively. He required Substantial/maximal assistance from staff with toileting hygiene, shower/bathe, upper/lower body dressing and personal hygiene. Further review of section H0300 and H0400 coded always incontinent of bladder and bowel. Record review of Resident #50's care plan, initiated 04/21/2023 and revised on 05/29/2023 revealed the following: Focus: ADL FUNCTIONAL DEFICITS: [Resident#50] is at risk for decline in ADL functions and injury r/t resp failure. Goal: [Resident#50] will be well dressed, groomed, clean, odor free and will have no decline in ADL functioning over the next 90days. Interventions: Toileting: Provide total assistance of (1) person(s) for toileting In an interview on 4/23/24 at 9:28 a.m., Resident #50 said there was no can last night (4/22/24) and the night before (4/21/24) on 11-7 a.m. shift. He said he had a bowel movement around 10 p.m. and he pressed his call light. He said no one came to the room to change him till 8 a.m. the next day (4/23/24). He said he had a heart attack in 2005 and knows the symptoms. He said, what if I was having a heart attack; nobody came to check on me. In an interview on 4/23/24 at 9:50 a.m., LVN C said she was the nurse for Swan Hall. She said she received a report from the night nurse that Swan Hall did not have a CNA on 4/21/24 during the 11-7 a.m. shift and a CNA left at 3 am on 4/22/24 during the 11-7 am shift. When asked if the DON or the Administrator were notified. LVN C said the management was aware of short staffing with CNAs calling in last minute or no show. She said she was trying to help CNA I change residents from last night along with doing her assigned duties. In an interview on 4/24/24 at 9:01 a.m., Resident #50 said there was no CNA this morning (4/24/24). He said, I have a bowel movement and need to be changed. In an interview on 4/24/24 at 9:07 a.m., with LVN C, this surveyor notified the Nurse in charge of Swan Hall that Resident #50 was requesting to be changed. LVN C said Resident #50 told her he needed to be changed but she was in the middle of passing meds and there was no CNA on the hall. Resident #59 Record review of the admission sheet (undated) for Resident #59 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord). Record review of Resident #59's Quarterly MDS, dated [DATE], revealed she had a BIMS score of 15 out of 15, indicative of intact cognitively. She was dependent on staff with toileting hygiene, shower/bathe, upper/lower body dressing and personal hygiene. Further review of section H coded having indwelling catheter and section H0400 coded always incontinent of bowel. Record review of Resident #59's care plan, initiated 02/24/2023 and revised on 03/07/2023 revealed the following: Focus: ADL FUNCTIONAL DEFICITS [Resident #59] is at risk for decline in ADL functions and injury r/t Quadriplegia Max assist to 1-2 persons with ADL'S W/C mobility. Goal: [Resident #59] will be well dressed, groomed, clean, odor free and will have no decline in ADL functioning over the next 90 days. Interventions: Toileting: Provide extensive assistance of 1 person for toileting. Observation and interview on 4/23/24 at 11:35 a.m., Resident #59's hair was oily, and she had dry flaky skin. She had food stains on her shirt. Her nails were about 3/4-inch-long with brown substance in between. Resident #59 said she had not received a shower in 6 days due to short staff. She said she required 2 people assist with showers. She said the facility was short staffed especially during the 11-7 am shift. She said she had to call the fire department to come turn and reposition her. She said the Administrator was aware of her missing showers. Resident #59 showed this Surveyor the text she had sent to the Administrator. Record review and interview on 4/24/24 at 2:14 p.m., with ADON A this surveyor request ADLs/shower sheets for Resident #59 for the month of April 2024. ADON A returned after few minutes and said she was unable to find the shower sheets for the Resident #59. In an interview on 4/24/24 at 1:05 p.m., the Administrator said Resident #59 had texted her regarding not receiving showers. The Administrator said, I made sure she received a shower yesterday (4/23/24). In an interview on 4/24/24 at 11:10 a.m., during a confidential resident group meeting 11 out of 11 residents complained about short staffing, not getting changed, nor receiving showers on their assigned days. In an interview on 4/24/24 at 1:05 p.m., the Administrator said staffing was determined by skill level of the hall. There were 5 CNAs (7-3pm), 4 CNAs (3-11pm) and 4 CNAs night shift (11-7am). She said she found out on Monday morning (4/21/24) that there was no CNAs during the night shift. She said the facility did not use agency staff that was corporate decision. She said the risk of staff shortage was high risk fall, residents not taken care of. She said nurses were allowing CNAs to leave. She said she came to the facility at night and the CNAs were scheduled but she was unable to find them. The Administrator said she was new and was trying to hire more staff. In an interview on 04/24/24 at 1:22 p.m., the DON said she was unaware the facility was short staffed on 4/21/24 and 4/22/24 during 11pm-7am shift. She said if CNA was late or no show the charge nurse needed to notify her by calling the staffing phone. She said she had the staffing phone, but she did not receive any calls. In an interview on 04/25/2024 at 4:10 p.m., with Cook A, she said the facility used disposable dishes and plasticware a lot last week for the resident's for some lunches, but mostly for their dinners. She said she had worked 11 days straight because the kitchen staff was short and they were unable to wash dishes to reuse again for the residents. Record review of facility's Staffing policy dated (Revised October 2017) revealed read in part: .Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation: 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident ' s plan of care . It was determined an Immediate Jeopardy (IJ) existed on 04/24/24 at 5:35 p.m., the Administrator was notified and the IJ template was provided. The following Plan of Removal was submitted by the facility was accepted on 04/25/26 at 6:47 p.m. and indicated the following: _____ [Facility name] Plan of Removal Immediate Jeopardy On 04/24/2024 the HHSC Health and Human Services Commission surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy of resident health and safety. The notification of Immediate Jeopardy states as follows: F725 - Sufficient Nursing Staffing: The facility failed to a). ensure there were sufficient staff per the facility assessment; b). the facility failed to provide sufficient nursing staffing to ensure residents received their medications; and c). the facility failed to provide ADL care to residents with bowel/bladder incontinence during the night shift (11 pm - 7 am). All facility residents have the potential to be affected by deficient practice. 1). Action: Medication Error Reports were completed for R#91, R#65, R#87, R#34, and R#37 were assessed for adverse events. There were no adverse events observed. The assessment results were shared with the nurse practitioner, and facility staff consulted the nurse practitioner to address the care needs of residents identified in the identified deficient practice. The Nurse Practitioner gave instructions to monitor residents' vital signs, including blood sugar, for residents as ordered and to call for concerns. An audit was completed to determine if other residents missed medications due to staffing shortages; a Medication Error Report will be completed, residents assessed, and medical provider notification will be completed for those resident identified and interventions as per medical provider instructions. Start Date: 04/24/2024 Completion Date: 04/24/2024 Responsible: Director of Nursing 2). Action: Skin checks were completed for R#19, R#41, R#50, and R#59. No skin breakdown and/or pressure ulcers were assessed. The facility's Chief Nursing Officer (CNO) completed Safe Surveys with cognitively intact facility residents; survey questions included the following questions: Do you feel there is sufficient staffing to meet your needs?; Do you receive your medication timely?; Does staff answer call lights timely? Do the employees appropriately help you with activities of daily living?; Does the facility help you feel safe and secure in your home?; Do you feel comfortable reporting any concerns to the proper staff member?; Do you have any concerns to report at this time? All facility residents verbalized they felt safe; no change in demeanor was observed in cognitively impaired residents. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Director of Nursing and Chief Nursing Officer 3). Action: The facility Administrator reviewed the Facility Assessment as it relates to staffing needs for medication administration and direct care. The facility Assessment has been updated. Comprehension will be assessed via completing the staffing matrix to demonstrate an understanding of minimum staffing needs. The staffing matrix will be reviewed daily by the facility administrator and nursing director during the Monday- Friday morning meeting for actual and potential needs; and by the Weekend Supervisor on Saturdays and Sundays. The facility Administrator will provide additional education as deemed necessary to maintain ongoing compliance. Compliance checks will be completed during the monthly Quality Assurance and Performance Improvement (QAPI) process. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Administrator 4). Action: Additionally, the Director of Nursing educated nursing staff (Licensed Nurses (RNs/LVNs), Certified Medication Aides (CMAs), and Certified Nursing Assistants (CNAs) on duty on the facility policy as it relates to a). Supporting Activities of Daily Living (ADLs) and b). Peri Care. The Director of Nursing emphasized the importance of timely response to 1). Residents call for assistance, 2). Provision of assistance with ADLS to include turning and repositioning, timely incontinent care, and showering per facility-established showering schedule to ensure residents are provided with care, treatment, and services as appropriate to maintain good personal hygiene and to prevent skin irritation. Licensed Nurses (RNs/LVNs) not on duty during [TRUNCATED]

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including dispensing and administering of all drugs and biologicals, to meet the needs of 4 residents (Residents #34, #65, #87, and #91) of 10 residents reviewed for medication administration. -Facility staff did not redistribute assignments of residents when one of three nurses assigned to the South Hall called off from her shift. -Resident #34, Resident #65, and Resident #87 did not have their blood glucose levels checked as ordered, which determined if sliding scale insulin was to be administered on 04/22/24. -Resident #34, Resident #65, Resident #87, and Resident #91 did not receive their morning and/or afternoon medications as ordered by their physician on 04/22/24. -Resident #34, Resident #65, and Resident #87 had parameters for administering blood pressure medications. Blood pressures were not documented, and the blood pressure medications were not administered. -Missed medications included, but were not limited to, insulin, anticoagulants (blood thinners), and one IV antibiotic. -The DON was not aware of the residents missing their medications prior to surveyor notification. -The Physician was not notified until after the surveyor notified the DON. An Immediate Jeopardy (IJ) was identified on 04/24/24. The IJ template was provided to the facility on [DATE] at 5:35 p.m. While the IJ was removed on 04/28/24 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy, because all staff had not been trained on medication administration and chain of command. The failure could place the residents at risk for not having their medication needs met as ordered by their physician. Missed insulin could result in the resident becoming hyperglycemic (high blood sugar). Missed anticoagulants could result in blood clots, which could be fatal for Resident #91, who had a LVAD (left ventricle assist device). Missed antibiotics could result in a resident's infection not healing, or the resident becoming septic Findings include: Resident #34 Record review of the Admission Record for Resident #34 (dated 04/25/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, cerebral palsy (a group of movement disorders), type 2 diabetes mellitus, gastrostomy status (has feeding tube), and epilepsy (seizure disorder). Record review of the MDS (ARD 04/11/24) for Resident #34 revealed she had a BIMS score of 0/15, indicative of severe cognitive impairment. Record review of the Care Plan (revised 03/30/24) for Resident #34 revealed she was receiving anticoagulant therapy (Eliquis) and was at risk for increased bleeding or bruising. One of the Interventions read Give medications as ordered. The Care Plan reflected Resident #34 had diabetes. Corresponding Interventions were to monitor blood glucose levels as ordered, and to give medications as ordered. Record review of the April 2024 Order Summary Report for Resident #34 revealed she was to receive Eliquis (anticoagulant) 5 mg twice daily for prevention of pulmonary embolism (blood clot in an artery of the lung). The orders reflected she was to have her blood glucose checked every six hours, with insulin to be administered per sliding scale. The orders reflected Metoprolol Tartrate (Toprol) tablet, 12.5 mg was to be administered twice daily for high blood pressure. The orders reflected the Toprol was to be held if the resident's systolic blood pressure was less than 100 mmhg. The orders reflected Trileptal Oral suspension (300 mg/5 ml) 10 ml was to be administered twice daily for epilepsy. Record review of the April 2024 MAR/TAR for Resident #34 revealed the following medications were not administered on 04/22/24 at 9:00 a.m.: -Eliquis 5 mg -Toprol 12.5 mg (blood pressure not documented) -Trileptal Oral suspension (300 mg/5 ml) 10 ml Resident #34's blood glucose levels were not checked at noon or 6:00 p.m. No sliding scale insulin was administered. Record review of the April 2024 Order Summary report revealed Resident #34 was to receive the following Fiasp (100 u/ml) insulin amounts based on her blood glucose level: -150 - 200 mg/dl administer 2 units -201 - 250 mg/dl administer 4 units -251 - 300 mg/dl administer 6 units -301 - 350 mg/dl administer 8 units -351 - 400 mg/dl administer 10 units If Resident #34's blood glucose level was greater than 400 mg/dl, the nurse was to administer 12 units and notify the NP. Observation on 04/23/24 at 9:00 a.m. revealed Resident #34 was in her room, lying in bed. She did not respond to a verbal greeting. She was receiving enteral nutrition via her g-tube. Resident #65 Record review of the Admission Record for Resident #65 (dated 04/25/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus, schizophrenia, seizures, stage 4 pressure ulcer of the sacrum, and atherosclerotic heart disease of coronary artery without angina pectoris (chest pain). The resident had a gastrostomy tube (g-tube) for nutrition and medications. Record review of the MDS (ARD 01/24/24) revealed she had memory deficits and moderately impaired cognition . Record review of the April 2024 Order Summary Report for Resident #65 revealed she was to receive the IV antibiotic Ertapenem Sodium Solution reconstituted 1 gm for an infection of the pressure ulcer of her sacrum. The orders also reflected Resident #65 was to have her blood glucose checked at 8:00 a.m., and Glargine insulin (100units/ml) 40 units administered. The orders reflected she was to have her blood glucose checked every six hours, with insulin to be administered per sliding scale, and she was to receive Levetiracetam solution (100 mg/ml) 5 ml twice daily for seizures, Oxcarbazepine 300 mg twice daily for seizures, and Haldol 2 mg twice daily for schizophrenia. Record review of the April 2024 MAR for Resident #65 revealed the following medications with corresponding times were not administered on 04/22/2024: -IV Ertapenem Sodium Solution reconstituted 1 gm scheduled for 8:00 a.m. -Haldol 2 mg scheduled for 8:00 a.m. -Levetiracetam solution (100 mg/ml) 5 ml scheduled for 9:00 a.m. -Oxcarbazepine 300 mg scheduled for 9:00 a.m. Resident #65's blood glucose was not checked as ordered on 04/22/2024 at 8:00 a.m. and 40 units of Insulin Glargine was not given. Resident #65's blood glucose was not checked as ordered at 6:00 a.m., noon, or 6:00 p.m. on 04/22/2024, and sliding-scale insulin was not given. Record review of the April 2024 Order Summary report revealed Resident #65 was to receive the following Lispro (200 u/ml) insulin amounts based on her blood glucose level: -150 - 200 mg/dl administer 2 units -201 - 250 mg/dl administer 4 units -251 - 300 mg/dl administer 6 units -301 - 350 mg/dl administer 8 units -351 - 400 mg/dl administer 10 units If Resident #65's blood glucose level was greater than 400 mg/dl, the nurse was to administer 12 units and notify the physician. Observation and interview on 04/23/24 at 9:13 a.m. revealed Resident #65 was in her room, sitting in her wheelchair. She said she had received her medications today but was unable to recall yesterday (04/22/24). Resident #87 Record review of the Admission Record for Resident #87 (dated 04/24/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus, atrial fibrillation, congestive heart failure, hypertension, and history of pulmonary embolism (obstruction of the pulmonary artery by a blood clot or other foreign matter). Record review of the MDS (ARD 03/25/24) revealed she scored 0 of 15 on the BIMS, indicative of severely impaired cognition . Record review of the April 2024 Order Summary Report for Resident #87 revealed she was to receive Apixaban (blood thinner/anticoagulant) 5 mg twice daily to prevent blood clots, Metoprolol Tartrate 12.5 mg twice daily for blood pressure, Amiodarone 200 mg for atrial fibrillation, and she was to have her blood glucose checked before meals, with insulin to be administered per sliding scale. Resident #87 was to recieve Mtotoprolol Tartrate 12.5 mg., which had blood pressure parameters instructing to hold the medication if the resident's systolic blood pressure was less than 100 mmHg. Record review of Resident #87's April 2024 MAR revealed she was not administered the 9:00 a.m. doses of Apixaban 5 mg, Amiodarone 200 mg, or the Metoprolol Tartrate 12.5 mg. on 04/22/24. Resident #87's blood pressure was not documented as been checked. Resident #87's blood glucose was not checked as ordered at 11:00 a.m. and 4:00 p.m. on 04/22/2024 and sliding-scale insulin was not administered. Record review of the April 2024 Order Summary report revealed Resident #87 was to receive the following Lispro insulin (100 u/ml) sliding scale amounts based on her blood glucose level: -150 - 200 mg/dl administer 1 unit -201 - 250 mg/dl administer 2 units -251 - 300 mg/dl administer 3 units -301 - 350 mg/dl administer 4 units -351 - 400 mg/dl administer 5 units If Resident #87's blood glucose level was greater than 400 mg/dl, the nurse was to administer 6 units and notify the NP. Resident #91 Record review of the Admission Record for Resident #91 (dated 04/24/24) revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, diabetes mellitus, combined systolic and diastolic congestive heart failure, and long-term use of anticoagulants. Record review of the MDS (ARD 04/08/24) revealed Resident #91 scored 15 of 15 on the BIMS, indicative of intact cognition . Record review of the April 2024 Order Summary Report for Resident #91 revealed he had a LVAD (left ventricular assist device). A LVAD is a mechanical pump that is implanted in the chest to assist the resident's heart to pump blood. The orders read, in part, .Please place parameters to hold for SBP less than 110 and hr [heart rate] less than 60 on bp [blood pressure] meds . Record review Resident #91's Care Plan (initiated 04/10/24) revealed, in part, ._____ [Resident #91] requires the use of an LVAD r/t Cardiomyopathy [disorder of the heart muscle], Acute/Chronic CHF, . An 'Intervention' was for the resident to receive all medications as ordered. Record review of the April 2024 MAR for Resident #91, for Monday 04/22/24, revealed he was not administered Coumadin (blood thinner/anticoagulant) 3 mg at 5:00 p.m. as ordered. The resident was to have a PT/INR lab drawn to monitor the Coumadin. The lab was not initialed as drawn. The MAR revealed his blood glucose was not checked as ordered at 7:00 a.m. or 11:00 a.m. and sliding-scale insulin was not given. The resident was not administered Hydralazine HCl (for high blood pressure) 50 mg at 6:00 a.m. or 2:00 p.m. The resident's blood pressure was not documented for 6:00 a.m. or 2:00 p.m. Resident #91 was not administered Carvedilol (for CHF) 6.25 mg at 9:00 a.m. Observation on 04/23/24 at 3:00 p.m. revealed there were three nurses on the South Hall. In an interview on 04/23/24 at 3:30 p.m. RN M revealed the nurses on the South Hall work 12 hour shifts, from 7:00 a.m. to 7:00 p.m. She said the South Hall was usually divided for three nurses; South 1 was from room [ROOM NUMBER] to room [ROOM NUMBER]. South 2 was from room [ROOM NUMBER] to room [ROOM NUMBER]. South 3 was from room [ROOM NUMBER] to room [ROOM NUMBER]. RN M said she worked on 04/22/24, and there were two nurses. RN M said LVN N was assigned to South 1, and she was assigned South 2. She said there was supposed to be a third nurse, but one had called off. She said she and LVN N did not redistribute care of the South 3 residents because there were two admissions. She said since they were short-handed, they did not complete the medication administration. RN M presented a text dated 04/22/24 at 11:00 a.m. to the DON that reflected she informed the DON there was no nurse for South 3. The DON replied that South 3 should be divided between the two nurses. RN M had responded that she could not handle the additional residents. RN M said neither the DON, ADON, or any other nurses came in to assist. In an interview via telephone on 04/23/24 at 3:50 p.m. LVN N said she worked on 04/22/24 on the South Hall. She said she worked on South 1 and RN M worked on South 2. She said they did not notice until 11:00 a.m. that there was no third nurse. In an interview on 04/23/24 at 4:05 p.m., the DON said there has been some issues with staffing. She said there were three nurses scheduled for the South Hall on 04/22/24, but one had called off. She said the hall should have been split between the two nurses. She said she was responsible for finding replacement staffing. She said the nurse who canceled texted her at 4:22 a.m. and she did not see it until 6:50 a.m. She said she called the facility and told a nurse to adjust the schedule but did not recall who she spoke with. She said 'WNBI' should have been scribed next to the name of the nurse who called off. She said she found out fifteen minutes ago that residents missed their medications on 04/22/24. In an interview on 04/23/24 at 4:20 p.m. the Administrator said a staffing coordinator had recently resigned, so the DON was currently responsible for staffing. She said the two nurses should have split the hall on 04/22/24. She said she was at the facility from 8:00 a.m. to 6:00 p.m., and no one informed her they were 'struggling' on the South Hall. She said she was not aware residents missed their medications. In an interview on 04/23/24 at 4:40 p.m. the DON said that if a resident missed a dose of Coumadin (Resident #91) the PT/INR lab result could change. It would place the resident at higher risk for blood clots. She said if a resident missed a dose of Levetiracetam and/or Oxcarbazepine (Resident #65) they would be at greater risk for seizures. She said she has not informed the doctor because NP Q was at the facility on 04/22/24. In an interview on 04/23/24 at 4:55 p.m. RN M said NP Q was at the facility on 04/22/24. She said she told NP Q they were short of staff, but did not tell the NP that residents missed medications. She said she has not spoken with the NP or physician regarding the medications. In an interview on 04/24/24 at 9:35 a.m. the Corporate RN said she called the physician and received orders to monitor the residents. She said RN M should have divided the residents between her and LVN N. In an interview on 04/24/24 at 11:50 a.m., NP Q said she was not made aware the residents missed their medications on 04/22/24 until yesterday (04/23/24). She said she was told only the evening medications were missed. The surveyor informed her that residents missed their morning medications as well. She said the resident on Coumadin would need to have his next PT/INR lab watched. She said the facility would need to make sure vital signs and blood sugars were monitored. She said a missed dose of Keppra (Levetiracetam) or Oxcarbazepine would make the resident more prone to have a seizure, but missing a dose would probably not cause a seizure. She said Resident #91 was in the transitioning phase of attaining a therapeutic range for Coumadin, and he was not there yet. Missing the dose was a setback. She said Resident #91 has a LVAD device, and if he had a clot, it could be fatal . It was determined an Immediate Jeopardy (IJ) existed on 04/24/24 at 5:35 p.m. The Administrator was notified at that time. The Administrator was provided with the IJ template on 04/24/24 at 5:35 p.m. The following Plan of Removal submitted by the facility was accepted on 04/25/26 at 6:47 p.m.: _____[Facility Name] Plan of Removal Immediate Jeopardy On 04/24/2024 the HHSC Health and Human Services Commission surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy of resident health and safety. The notification of Immediate Jeopardy states as follows: F755 - Pharmaceutical Services: The facility failed to administer medications (Coumadin, Insulin, and Seizure medications) to 5 residents residing in South Hall 3. All facility residents have the potential to be affected by deficient practice. 1). Action: Medication Error Reports were completed for R#91, R#65, R#87, R#34, and R#37 were assessed for adverse events. There were no adverse events observed. The assessment results were shared with the nurse practitioner, and facility staff consulted the nurse practitioner to address the care needs of residents identified in the identified deficient practice. The Nurse Practitioner gave instructions to monitor residents' vital signs, including blood sugar, for residents as ordered and to call for concerns. An audit was completed to determine if other residents missed medications due to staffing shortages; a Medication Error Report will be completed, residents assessed, and medical provider notification will be completed for those resident identified and interventions as per medical provider instructions. Start Date: 04/24/2024 Completion Date: 04/24/2024 Responsible: Director of Nursing 2). Action: The Chief Nursing Officer (CNO) reviewed facility policy related to Staffing on 04/24/2024; no revisions were deemed necessary. As such, The CNO educated the facility Administrator and Director of Nursing on the facility policy as it relates to Staffing, which reads Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Emphasis was placed on the need to ensure the facility had a sufficient number of Licensed Nurses (RNs/LVNs), Certified Medication Aides (CMAs), and Certified Nursing Assistants (CNAs) available 24 hours a day to provide direct resident care services and the need to ensure staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. The mode of education was a memo in the form of a copy of the policy and procedure and occurred in a face-to-face meeting on 04/24/2024. Comprehension was assessed via the teach-back methods and a one-sentence summary of actions to be taken in the event of staff shortages on 04/25/2024. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Chief Nursing Officer 3). Action: The facility Administrator and Director of Nursing educated the facility staff on duty of the facility Chain of Command when presented with staffing challenges. A copy of the facility Chain of Command - Organizational Chart - was posted on the employee bulletin board. The facility Leadership Team - Administrator and the Director of Nursing - directed the facility Licensed Nurses (RNs/LVNs) to contact the on-call staffing phone within the first fifteen (15) minutes of the start of each shift when call-ins and no-calls/no-shows were noted so that additional staff could be called to ensure sufficient number of Licensed nurses and certified nursing assistants available to provide direct resident care services and the need to ensure staffing numbers and the skill requirements of direct care staff as determined by the needs of the residents based on each resident's plan of care. If at any time a Licensed Nurses (RNs/LVNs) or Certified Medication Aide (CMAs) feel they cannot administer mediations as prescribed, he/she should follow the Chain of Command - contact the Assistance Director of nursing and then the Director of Nursing for assistance and further direction. Licensed Nurses (RNs/LVNs) will not be allowed to return to work until they receive this in-service. Licensed Nurses (RNs/LVNs) who do not physically attend the in-service training in person will be in-serviced via phone. During the in-service training and phone in-service, there will be a discussion (Question and Answering) to ensure understanding and competency. A post-test will measure learning. A demonstrable competency of 90% accuracy must be demonstrated before the start of their next shift.; those scoring less than 90% will receive immediate reeducation before being allowed to work. The mode of education was a memo in the form of a copy of the policy and procedure, which occurred in a face-to-face meeting that started on 04/24/2024. The education was added as part of the orientation for ongoing training of new hires, agency, and PRN (as needed) staff through a combination of employee training, employee monitoring, and reporting processes. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Administrator and Director of Nursing 4). Action: The facility Administrator reviewed the Facility Assessment as it relates to staffing needs for medication administration and direct care. The facility Assessment has been updated. Comprehension will be assessed via completing the staffing matrix to demonstrate an understanding of minimum staffing needs. The staffing matrix will be reviewed daily by the facility administrator and nursing director during the Monday- Friday morning meeting for actual and potential needs; and by the Weekend Supervisor on Saturdays and Sundays. The facility Administrator will provide additional education as deemed necessary to maintain ongoing compliance. Compliance checks will be completed during the monthly Quality Assurance and Performance Improvement (QAPI) process. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Administrator 5) Action: The facility Administrator Contracted with a Supplemental Staffing agency to provide Licensed Nurses (RNs/LVNs), Certified Medication Aides (CMAs), and Certified Nursing Assistants (CNAs) to ensure a contingency staffing plan is in place when the facility has call-ins and no-call/no-shows, and the facility staff cannot cover sufficient staffing needs. The facility Administrator educated the Director of Nursing on the need to call and request supplemental staff when there are call-ins and/or no-call/no-shows to ensure a sufficient number of Licensed Nurses RNs/LVNs), Certified Medication Aides (CMAs), Certified Nursing Assistants (CNAs) available 24 hours a day to provide direct resident care services - medication administration. The mode of education was in the form of a memo indicating when supplemental staffing should be requested. Comprehension will be assessed via completing the staffing matrix to demonstrate an understanding of minimum staffing needs. The staffing matrix will be reviewed daily by the facility administrator and nursing director during the Monday- Friday morning meeting for actual and potential needs; and by the Weekend Supervisor on Saturdays and Sundays. The facility Administrator will provide additional education as deemed necessary to maintain ongoing compliance. Compliance checks will be completed during the monthly Quality Assurance and Performance Improvement (QAPI) process. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Administrator and Director of Nursing 6). Action: The Chief Nursing Officer (CNO) educated the facility Director of Nursing on the facility policy and procedure as it relates to Administering Medications, which reads, Medications shall be administered in a safe and timely manner, and as prescribed. The emphasis was stressed that medication must be administered in accordance with the required time frame - within one (1) hour of their prescribed time. If a medication is not given at the prescribed time, the medical provider (Physician/Nurse Practitioner/Physician Assistant) must be contacted and consulted for further directions. The mode of education was a memo in the form of a copy of the policy and procedure, which occurred in a face-to-face meeting on 04/24/2024. Comprehension was assessed via the teach-back methods on 04/25/2024 Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Chief Nursing Officer 7). Action: The facility Director of Nursing educated Licensed Nurses (RNs/LVNs) and Certified Medication Aides (CMAs) on the facility policy and procedure as it relates to Administering Medications, which reads, Medications shall be administered in a safe and timely manner, and as prescribed. The emphasis was stressed that medication must be administered in accordance with the required time frame - within one (1) hour of their prescribed time. If a medication is not given at the prescribed time, the medical provider (Physician/Nurse Practitioner/Physician Assistant) must be contacted and consulted for further directions. The mode of education was a memo in the form of a copy of the policy and procedure and occurred in a face-to-face meeting on 04/24/2024 and 04/25/2024. Licensed Nurses (RNs/LVNs) and Certified Medication Aides (CMAs) not present will be in-serviced via phone. During the face-to-face in-service training and phone in-service, there will be a discussion (Question and Answering) to ensure understanding and competency. A post-test will measure learning. All nurses in-serviced, face-to-face or over the phone will not be allowed to work until they complete the post-test and demonstrate competency. A demonstrable competency of 90% accuracy must be demonstrated before the start of their next shift.; those scoring less than 90% will receive immediate reeducation before being allowed to work. The mode of education was a memo in the form of a copy of the policy and procedure, which occurred in a face-to-face meeting started on 04/24/2024. The education is added as part of the orientation for ongoing training of new hires, agency, and PRN (as needed) staff through a combination of employee training, employee monitoring, and reporting processes. Contact the Physician. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Director of Nursing and Facility Administrator 8). Action: The Director of Nursing (DON) will review the Point of Care (PCC) Medication Administration Dashboard daily Monday - Friday and the Weekend Supervisor on Saturdays and Sundays to ensure Licensed Nurses (RNs/LVNs) and Certified Medication Aides (CMAs) have administered and documented medication administration timely and proper notification of medical providers have been completed when any deviation from the facility policy and procedures. Discrepancies noted during reviews will be immediately addressed. Progressive disciplinary actions, which include additional training and leading to termination, will be taken as deemed appropriate. The facility administrator will review the QA audit tool on a weekly basis to ensure that the nurse managers (DON and Weekend Supervisor) follow the correction plan for four weeks. reviewed monthly during the QAPI meetings for the next three (3) months and will be ongoing as needed. Meeting minutes will be taken and maintained for twelve (12) months. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Director of Nursing, Weekend Supervisor and Facility Administrator 9). Action: The facility Administrator conducted an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) to discuss the deficient practice identified and to review the Plan of Removal (POR) was completed on 04/25/2024 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Action items will be reviewed monthly during the QAPI meetings for the next three (3) months and will be ongoing as needed. Meeting minutes will be taken and maintained for twelve (12) months. Start Date: 04/25/2024 Completion Date: 04/25/2024 Responsible: Facility Administrator Surveyors monitored the Plan of Removal for effectiveness as follows: On 04/26/24 the facility was monitored. Not all staff had been in-serviced. In an interview on 04/27/24 at 9:45 a.m. LVN O said she was assigned to South 1 Rooms 201 to 209. She said she still had three residents to give medications to in room [ROOM NUMBER] A and B, and room [ROOM NUMBER]. In an interview on 04/27/24 at 09:51 a.m. RN P said she was with a staffing agency. She said she was assigned Rooms 210 to 214. In an interview on 04/27/24 at 09:55 a.m. LVN R said he had one more resident to administer medications to, but would be finished on time. In an interview on 04/27/24 at 10:15 a.m., RN S said he was finished with the morning medication administration for the Flamingo Hall. In an interview on 04/27/24 at 10:17 a.m. LVN T said she had completed the morning medication pass for Swan Hall and Dove Hall. In an interview on 04/27/24 at 10:19 a.m. MA U said she has been in-serviced regarding medication administration and Chain of Command. She said if medications were going to be late she was to tell the charge nurse. Record review 'spot checks' of the MARs for each hall were conducted. Three random residents from each hall were reviewed. There were no concerns for the following halls: [NAME] Hall, Dove Hall, Flamingo Hall, Swan Hall, South 2 Hall, and South 3 Hall. Three residents on South 1 had their medications administered late. In an interview on 04/27/24 at 11:30 a.m. the DON was asked if any medications were administered late. She said she would check. At 1:31 p.m. she said three residents' medications were late, and the physician had been notified. In an interview on 04/27/2024 at 1:31 p.m. the DON said she had provided in-services for the agency nurses and the staff who came in today. She said the book (envelope) was at the north nurses' station. On 04/27/24 at 1:36 p.m. the surveyor picked up the two manila envelopes at the north nurses' station labelled in-service. Copies of the staff attendance sheet were made at that time. Record review of the envelopes revealed one contained in-service training for medication administration, protocol for calling off a shift, Physician notification for missed/late medications, chain of command, and general staffing policy review. Observation and interview on 04/28/24 at 6:40 a.m. revealed LVN Z and LVN L were at the north nurses' station. Both nurses said they had the in-services. Both nurses were able to explain what the in-services were about. In an interview on 04/28/24 at 7:25 a.m. LVN K said she had the in-services on Thursday. She was able to tell what the in-services were about. In an interview on 04/28/24 at 7:41 a.m. RN S said the north was short two CNAs. He said the nurses and the MA would fill in. In an interview on 04/28/24 at 10:05 a.m. LVN R said he had the in-services. He was able to tell what the in-services were about. In an interview on 04/28/24 at 10:10 a.m. LVN O said she has had the in-services. She was able to tell what the in-services were about. Record review of the binder entitled State Workbook 2024 Binder for POR revealed the following: Medication error reports for the four residents were completed. Safe Survey Questionnaires for all halls were completed. In-services for: Med Administration - Nurses, MA Notify MD - Nurses, MA Attendance/call off - all staff Chain of Command - all staff Staffing - Nursing mgt and Administrator A/N - all staff Contacting Administrator and/or DON - all staff Facility Assessment Tool updated 2 Staff agency contracts EMR Audit sheet - up to date Review of the binder revealed the facility was effectively implimenting the components of the POR. Record review of an Agency contract revealed the facility had contracted with the agency to provide nurses in case of staffing shortages. The contract was signed on 04/25/24. An Immediate Jeopardy (IJ) was identified on 04/24/24 [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure 4 residents (Residents #34, #65, #87, and #91) of 10 residents reviewed for medication administration were free of significant medication errors. -Resident #91 did not receive Coumadin (anticoagulant) as ordered by the physician in the afternoon of 04/22/24, placing him at risk for a blood clot. -Resident #34, Resident #65, and Resident #87 did not have their blood glucose levels checked as ordered, which determined if sliding scale insulin was to be administered on 04/22/24. -Resident #34 did not receive Metoprolol Tartrate (for high blood pressure) as ordered by the physician, and her blood sugar was not checked, resulting in not having blood sugar levels to determine amounts of insulin to be administered. -Resident #65 did not receive a dose of IV antibiotic for a sacral pressure ulcer infection. -Resident #87 did not receive Metoprolol Tartrate as ordered by the physician, and her blood sugar was not checked, resulting in not having blood sugar levels to determine amounts of insulin to be administered. -Missed medications included, but were not limited to, insulin, anticoagulants (blood thinners), and one IV antibiotic. -The DON was not aware of the residents missing their medications prior to surveyor notification. -The Physician was not notified until after the surveyor notified the DON. An Immediate Jeopardy (IJ) was identified on 04/24/24. The IJ template was provided to the facility on [DATE] at 5:35 p.m. While the IJ was removed on 04/28/24 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy, because all staff had not been trained on medication administration and chain of command. The failure placed the residents at higher risk for hyperglycemia (high blood sugar), blood clots, and sepsis. In an interveiw with the NP revealed a blood clot could be fatal for Resident #91. Findings include: Resident #34 Record review of the Admission Record for Resident #34 (dated 04/25/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, cerebral palsy (a group of movement disorders), type 2 diabetes mellitus, gastrostomy status (has feeding tube), and epilepsy (seizure disorder). Record review of the MDS (ARD 04/11/24) for Resident #34 revealed she had a BIMS score of 0/15, indicative of severe cognitive impairment. Record review of the Care Plan (revised 03/30/24) for Resident #34 revealed she was receiving anticoagulant therapy (Eliquis) and was at risk for increased bleeding or bruising. One of the Interventions read Give medications as ordered. The Care Plan reflected Resident #34 had diabetes. Corresponding Interventions were to monitor blood glucose levels as ordered, and to give medications as ordered. Record review of the April 2024 Order Summary Report for Resident #34 revealed she was to receive Eliquis (anticoagulant) 5 mg twice daily for prevention of pulmonary embolism (blood clot in an artery of the lung). The orders reflected she was to have her blood glucose checked every six hours, with insulin to be administered per sliding scale. The orders reflected Metoprolol Tartrate (Toprol) tablet, 12.5 mg was to be administered twice daily for high blood pressure. The Metoprolol Tartrate was to be held if the resident's systolic blood pressure was less than 100 mmHg. The orders reflected Trileptal Oral suspension (300 mg/5 ml) 10 ml was to be administered twice daily for epilepsy. Record review of the April 2024 MAR/TAR for Resident #34 revealed the following medications were not administered on 04/22/24 at 9:00 a.m.: -Eliquis 5 mg -Toprol 12.5 mg (blood pressure was not documented) -Trileptal Oral suspension (300 mg/5 ml) 10 ml Resident #34's blood glucose levels were not checked at noon or 6:00 p.m. No sliding scale insulin was administered. Record review of the April 2024 Order Summary report revealed Resident #34 was to receive the following Fiasp (100 u/ml) insulin amounts based on her blood glucose level: -150 - 200 mg/dl administer 2 units -201 - 250 mg/dl administer 4 units -251 - 300 mg/dl administer 6 units -301 - 350 mg/dl administer 8 units -351 - 400 mg/dl administer 10 units If Resident #34's blood glucose level was greater than 400 mg/dl, the nurse was to administer 12 units and notify the NP. Observation on 04/23/24 at 9:00 a.m. revealed Resident #34 was in her room, lying in bed. She did not respond to a verbal greeting. She was receiving enteral nutrition via her g-tube. Resident #65 Record review of the Admission Record for Resident #65 (dated 04/25/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus, schizophrenia, seizures, stage 4 pressure ulcer of the sacrum, and atherosclerotic heart disease of coronary artery without angina pectoris (chest pain). The resident had a gastrostomy tube (g-tube) for nutrition and medications. Record review of the MDS (ARD 01/24/24) revealed she had memory deficits and moderately impaired cognition . Record review of the April 2024 Order Summary Report for Resident #65 revealed she was to receive the IV antibiotic Ertapenem Sodium Solution reconstituted 1 gm for an infection of the pressure ulcer of her sacrum. The orders also reflected Resident #65 was to have her blood glucose checked at 8:00 a.m., and Glargine insulin (100units/ml) 40 units administered. The orders reflected she was to have her blood glucose checked every six hours, with insulin to be administered per sliding scale, and she was to receive Levetiracetam solution (100 mg/ml) 5 ml twice daily for seizures, Oxcarbazepine 300 mg twice daily for seizures, and Haldol 2 mg twice daily for schizophrenia. Record review of the April 2024 MAR for Resident #65 revealed the following medications with corresponding times were not administered on 04/22/2024: -IV Ertapenem Sodium Solution reconstituted 1 gm scheduled for 8:00 a.m. -Haldol 2 mg scheduled for 8:00 a.m. -Levetiracetam solution (100 mg/ml) 5 ml scheduled for 9:00 a.m. -Oxcarbazepine 300 mg scheduled for 9:00 a.m. Resident #65's blood glucose was not checked as ordered on 04/22/2024 at 8:00 a.m. and 40 units of Insulin Glargine was not given. Resident #65's blood glucose was not checked as ordered at 6:00 a.m., noon, or 6:00 p.m. on 04/22/2024, and sliding-scale insulin was not given. Record review of the April 2024 Order Summary report revealed Resident #65 was to receive the following Lispro (200 u/ml) insulin amounts based on her blood glucose level: -150 - 200 mg/dl administer 2 units -201 - 250 mg/dl administer 4 units -251 - 300 mg/dl administer 6 units -301 - 350 mg/dl administer 8 units -351 - 400 mg/dl administer 10 units If Resident #65's blood glucose level was greater than 400 mg/dl, the nurse was to administer 12 units and notify the physician. Observation and interview on 04/23/24 at 9:13 a.m. revealed Resident #65 was in her room, sitting in her wheelchair. She said she had received her medications today but was unable to recall yesterday (04/22/24). Resident #87 Record review of the Admission Record for Resident #87 (dated 04/24/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus, atrial fibrillation, congestive heart failure, hypertension, and history of pulmonary embolism (obstruction of the pulmonary artery by a blood clot or other foreign matter). Record review of the MDS (ARD 03/25/24) revealed she scored 0 of 15 on the BIMS, indicative of severely impaired cognition . Record review of the April 2024 Order Summary Report for Resident #87 revealed she was to receive Apixaban (blood thinner/anticoagulant) 5 mg twice daily to prevent blood clots, Metoprolol Tartrate 12.5 mg twice daily for blood pressure, Amiodarone 200 mg for atrial fibrillation. The Metoprolol Tartrate was to be held if the resident's systolic blood pressure was less than 100 mmHg. She was to have her blood glucose checked before meals, with insulin to be administered per sliding scale. Record review of Resident #87's April 2024 MAR revealed she was not administered the 9:00 a.m. doses of Apixaban 5 mg, Amiodarone 200 mg, or the Metoprolol Tartrate 12.5 mg. on 04/22/24. Her blood pressure was not documented as been checked. Resident #87's blood glucose was not checked as ordered at 11:00 a.m. and 4:00 p.m. on 04/22/2024 and sliding-scale insulin was not administered. Record review of the April 2024 Order Summary report revealed Resident #87 was to receive the following Lispro insulin (100 u/ml) sliding scale amounts based on her blood glucose level: -150 - 200 mg/dl administer 1 unit -201 - 250 mg/dl administer 2 units -251 - 300 mg/dl administer 3 units -301 - 350 mg/dl administer 4 units -351 - 400 mg/dl administer 5 units If Resident #87's blood glucose level was greater than 400 mg/dl, the nurse was to administer 6 units and notify the NP. Resident #91 Record review of the Admission Record for Resident #91 (dated 04/24/24) revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, diabetes mellitus, combined systolic and diastolic congestive heart failure, and long-term use of anticoagulants. Record review of the MDS (ARD 04/08/24) revealed Resident #91 scored 15 of 15 on the BIMS, indicative of intact cognition . Record review of the April 2024 Order Summary Report for Resident #91 revealed he had a LVAD (left ventricular assist device). A LVAD is a mechanical pump that is implanted in the chest to assist the resident's heart to pump blood. The orders read, in part, .Please place parameters to hold for SBP less than 110 and hr [heart rate] less than 60 on bp [blood pressure] meds . Record review Resident #91's Care Plan (initiated 04/10/24) revealed, in part, ._____ [Resident #91] requires the use of an LVAD r/t Cardiomyopathy [disorder of the heart muscle], Acute/Chronic CHF, . An 'Intervention' was for the resident to receive all medications as ordered. Record review of the April 2024 MAR for Resident #91, for Monday 04/22/24, revealed he was not administered Coumadin (blood thinner/anticoagulant) 3 mg at 5:00 p.m. as ordered. The resident was to have a PT/INR lab drawn to monitor the Coumadin. The lab was not initialed as drawn. The MAR revealed his blood glucose was not checked as ordered at 7:00 a.m. or 11:00 a.m. and sliding-scale insulin was not given. The resident was not administered Hydralazine HCl (for high blood pressure) 50 mg at 6:00 a.m. or 2:00 p.m. Resident #91's blood pressure was not documented for either dose. Resident #91 was not administered Carvedilol (for CHF) 6.25 mg at 9:00 a.m. Observation on 04/23/24 at 3:00 p.m. revealed there were three nurses on the South Hall. In an interview on 04/23/24 at 3:30 p.m. RN M revealed the nurses on the South Hall work 12 hour shifts, from 7:00 a.m. to 7:00 p.m. She said the South Hall was usually divided for three nurses; South 1 was from room [ROOM NUMBER] to room [ROOM NUMBER]. South 2 was from room [ROOM NUMBER] to room [ROOM NUMBER]. South 3 was from room [ROOM NUMBER] to room [ROOM NUMBER]. RN M said she worked on 04/22/24, and there were two nurses. RN M said LVN N was assigned to South 1, and she was assigned South 2. She said there was supposed to be a third nurse, but one had called off. She said she and LVN N did not redistribute care of the South 3 residents because there were two admissions. She said since they were short-handed, they did not complete the medication administration. RN M presented a text dated 04/22/24 at 11:00 a.m. to the DON that reflected she informed the DON there was no nurse for South 3. The DON replied that South 3 should be divided between the two nurses. RN M had responded that she could not handle the additional residents. RN M said neither the DON, ADON, or any other nurses came in to assist. In an interview via telephone on 04/23/24 at 3:50 p.m. LVN N said she worked on 04/22/24 on the South Hall. She said she worked on South 1 and RN M worked on South 2. She said they did not notice until 11:00 a.m. that there was no third nurse. In an interview on 04/23/24 at 4:05 p.m., the DON said there has been some issues with staffing. She said there were three nurses scheduled for the South Hall on 04/22/24, but one had called off. She said the hall should have been split between the two nurses. She said she was responsible for finding replacement staffing. She said the nurse who canceled texted her at 4:22 a.m. and she did not see it until 6:50 a.m. She said she called the facility and told a nurse to adjust the schedule but did not recall who she spoke with. She said 'WNBI' should have been scribed next to the name of the nurse who called off. She said she found out fifteen minutes ago that residents missed their medications on 04/22/24. In an interview on 04/23/24 at 4:20 p.m. the Administrator said a staffing coordinator had recently resigned, so the DON was currently responsible for staffing. She said the two nurses should have split the hall on 04/22/24. She said she was at the facility from 8:00 a.m. to 6:00 p.m., and no one informed her they were 'struggling' on the South Hall. She said she was not aware residents missed their medications. In an interview on 04/23/24 at 4:40 p.m. the DON said that if a resident missed a dose of Coumadin (Resident #91) the PT/INR lab result could change. It would place the resident at higher risk for blood clots. She said if a resident missed a dose of Levetiracetam and/or Oxcarbazepine (Resident #65) they would be at greater risk for seizures. She said she has not informed the doctor because NP Q was at the facility on 04/22/24. In an interview on 04/23/24 at 4:55 p.m. RN M said NP Q was at the facility on 04/22/24. She said she told NP Q they were short of staff, but did not tell the NP that residents missed medications. She said she has not spoken with the NP or physician regarding the medications. In an interview on 04/24/24 at 9:35 a.m. the Corporate RN said she called the physician and received orders to monitor the residents. She said RN M should have divided the residents between her and LVN N. In an interview on 04/24/24 at 11:50 a.m., NP Q said she was not made aware the residents missed their medications on 04/22/24 until yesterday (04/23/24). She said she was told only the evening medications were missed. The surveyor informed her that residents missed their morning medications as well. She said the resident on Coumadin would need to have his next PT/INR lab watched. She said the facility would need to make sure vital signs and blood sugars were monitored. She said a missed dose of Keppra (Levetiracetam) or Oxcarbazepine would make the resident more prone to have a seizure, but missing a dose would probably not cause a seizure. She said Resident #91 was in the transitioning phase of attaining a therapeutic range for Coumadin, and he was not there yet. Missing the dose was a setback. She said Resident #91 has a LVAD device, and if he had a clot, it could be fatal . It was determined an Immediate Jeopardy (IJ) existed on 04/24/24 at 5:35 p.m. The Administrator was notified at that time. The Administrator was provided with the IJ template on 04/24/24 at 5:35 p.m. The following Plan of Removal submitted by the facility was accepted on 04/25/26 at 6:47 p.m.: _____[Facility Name] Plan of Removal Immediate Jeopardy On 04/24/2024 the HHSC Health and Human Services Commission surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy of resident health and safety. The notification of Immediate Jeopardy states as follows: F755 - Pharmaceutical Services: The facility failed to administer medications (Coumadin, Insulin, and Seizure medications) to 5 residents residing in South Hall 3. All facility residents have the potential to be affected by deficient practice. 1). Action: Medication Error Reports were completed for R#91, R#65, R#87, R#34, and R#37 were assessed for adverse events. There were no adverse events observed. The assessment results were shared with the nurse practitioner, and facility staff consulted the nurse practitioner to address the care needs of residents identified in the identified deficient practice. The Nurse Practitioner gave instructions to monitor residents' vital signs, including blood sugar, for residents as ordered and to call for concerns. An audit was completed to determine if other residents missed medications due to staffing shortages; a Medication Error Report will be completed, residents assessed, and medical provider notification will be completed for those resident identified and interventions as per medical provider instructions. Start Date: 04/24/2024 Completion Date: 04/24/2024 Responsible: Director of Nursing 2). Action: The Chief Nursing Officer (CNO) reviewed facility policy related to Staffing on 04/24/2024; no revisions were deemed necessary. As such, The CNO educated the facility Administrator and Director of Nursing on the facility policy as it relates to Staffing, which reads Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Emphasis was placed on the need to ensure the facility had a sufficient number of Licensed Nurses (RNs/LVNs), Certified Medication Aides (CMAs), and Certified Nursing Assistants (CNAs) available 24 hours a day to provide direct resident care services and the need to ensure staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. The mode of education was a memo in the form of a copy of the policy and procedure and occurred in a face-to-face meeting on 04/24/2024. Comprehension was assessed via the teach-back methods and a one-sentence summary of actions to be taken in the event of staff shortages on 04/25/2024. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Chief Nursing Officer 3). Action: The facility Administrator and Director of Nursing educated the facility staff on duty of the facility Chain of Command when presented with staffing challenges. A copy of the facility Chain of Command - Organizational Chart - was posted on the employee bulletin board. The facility Leadership Team - Administrator and the Director of Nursing - directed the facility Licensed Nurses (RNs/LVNs) to contact the on-call staffing phone within the first fifteen (15) minutes of the start of each shift when call-ins and no-calls/no-shows were noted so that additional staff could be called to ensure sufficient number of Licensed nurses and certified nursing assistants available to provide direct resident care services and the need to ensure staffing numbers and the skill requirements of direct care staff as determined by the needs of the residents based on each resident's plan of care. If at any time a Licensed Nurses (RNs/LVNs) or Certified Medication Aide (CMAs) feel they cannot administer mediations as prescribed, he/she should follow the Chain of Command - contact the Assistance Director of nursing and then the Director of Nursing for assistance and further direction. Licensed Nurses (RNs/LVNs) will not be allowed to return to work until they receive this in-service. Licensed Nurses (RNs/LVNs) who do not physically attend the in-service training in person will be in-serviced via phone. During the in-service training and phone in-service, there will be a discussion (Question and Answering) to ensure understanding and competency. A post-test will measure learning. A demonstrable competency of 90% accuracy must be demonstrated before the start of their next shift.; those scoring less than 90% will receive immediate reeducation before being allowed to work. The mode of education was a memo in the form of a copy of the policy and procedure, which occurred in a face-to-face meeting that started on 04/24/2024. The education was added as part of the orientation for ongoing training of new hires, agency, and PRN (as needed) staff through a combination of employee training, employee monitoring, and reporting processes. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Administrator and Director of Nursing 4). Action: The facility Administrator reviewed the Facility Assessment as it relates to staffing needs for medication administration and direct care. The facility Assessment has been updated. Comprehension will be assessed via completing the staffing matrix to demonstrate an understanding of minimum staffing needs. The staffing matrix will be reviewed daily by the facility administrator and nursing director during the Monday- Friday morning meeting for actual and potential needs; and by the Weekend Supervisor on Saturdays and Sundays. The facility Administrator will provide additional education as deemed necessary to maintain ongoing compliance. Compliance checks will be completed during the monthly Quality Assurance and Performance Improvement (QAPI) process. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Administrator 5) Action: The facility Administrator Contracted with a Supplemental Staffing agency to provide Licensed Nurses (RNs/LVNs), Certified Medication Aides (CMAs), and Certified Nursing Assistants (CNAs) to ensure a contingency staffing plan is in place when the facility has call-ins and no-call/no-shows, and the facility staff cannot cover sufficient staffing needs. The facility Administrator educated the Director of Nursing on the need to call and request supplemental staff when there are call-ins and/or no-call/no-shows to ensure a sufficient number of Licensed Nurses RNs/LVNs), Certified Medication Aides (CMAs), Certified Nursing Assistants (CNAs) available 24 hours a day to provide direct resident care services - medication administration. The mode of education was in the form of a memo indicating when supplemental staffing should be requested. Comprehension will be assessed via completing the staffing matrix to demonstrate an understanding of minimum staffing needs. The staffing matrix will be reviewed daily by the facility administrator and nursing director during the Monday- Friday morning meeting for actual and potential needs; and by the Weekend Supervisor on Saturdays and Sundays. The facility Administrator will provide additional education as deemed necessary to maintain ongoing compliance. Compliance checks will be completed during the monthly Quality Assurance and Performance Improvement (QAPI) process. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Administrator and Director of Nursing 6). Action: The Chief Nursing Officer (CNO) educated the facility Director of Nursing on the facility policy and procedure as it relates to Administering Medications, which reads, Medications shall be administered in a safe and timely manner, and as prescribed. The emphasis was stressed that medication must be administered in accordance with the required time frame - within one (1) hour of their prescribed time. If a medication is not given at the prescribed time, the medical provider (Physician/Nurse Practitioner/Physician Assistant) must be contacted and consulted for further directions. The mode of education was a memo in the form of a copy of the policy and procedure, which occurred in a face-to-face meeting on 04/24/2024. Comprehension was assessed via the teach-back methods on 04/25/2024 Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Chief Nursing Officer 7). Action: The facility Director of Nursing educated Licensed Nurses (RNs/LVNs) and Certified Medication Aides (CMAs) on the facility policy and procedure as it relates to Administering Medications, which reads, Medications shall be administered in a safe and timely manner, and as prescribed. The emphasis was stressed that medication must be administered in accordance with the required time frame - within one (1) hour of their prescribed time. If a medication is not given at the prescribed time, the medical provider (Physician/Nurse Practitioner/Physician Assistant) must be contacted and consulted for further directions. The mode of education was a memo in the form of a copy of the policy and procedure and occurred in a face-to-face meeting on 04/24/2024 and 04/25/2024. Licensed Nurses (RNs/LVNs) and Certified Medication Aides (CMAs) not present will be in-serviced via phone. During the face-to-face in-service training and phone in-service, there will be a discussion (Question and Answering) to ensure understanding and competency. A post-test will measure learning. All nurses in-serviced, face-to-face or over the phone will not be allowed to work until they complete the post-test and demonstrate competency. A demonstrable competency of 90% accuracy must be demonstrated before the start of their next shift.; those scoring less than 90% will receive immediate reeducation before being allowed to work. The mode of education was a memo in the form of a copy of the policy and procedure, which occurred in a face-to-face meeting started on 04/24/2024. The education is added as part of the orientation for ongoing training of new hires, agency, and PRN (as needed) staff through a combination of employee training, employee monitoring, and reporting processes. Contact the Physician. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Director of Nursing and Facility Administrator 8). Action: The Director of Nursing (DON) will review the Point of Care (PCC) Medication Administration Dashboard daily Monday - Friday and the Weekend Supervisor on Saturdays and Sundays to ensure Licensed Nurses (RNs/LVNs) and Certified Medication Aides (CMAs) have administered and documented medication administration timely and proper notification of medical providers have been completed when any deviation from the facility policy and procedures. Discrepancies noted during reviews will be immediately addressed. Progressive disciplinary actions, which include additional training and leading to termination, will be taken as deemed appropriate. The facility administrator will review the QA audit tool on a weekly basis to ensure that the nurse managers (DON and Weekend Supervisor) follow the correction plan for four weeks. reviewed monthly during the QAPI meetings for the next three (3) months and will be ongoing as needed. Meeting minutes will be taken and maintained for twelve (12) months. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Director of Nursing, Weekend Supervisor and Facility Administrator 9). Action: The facility Administrator conducted an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) to discuss the deficient practice identified and to review the Plan of Removal (POR) was completed on 04/25/2024 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Action items will be reviewed monthly during the QAPI meetings for the next three (3) months and will be ongoing as needed. Meeting minutes will be taken and maintained for twelve (12) months. Start Date: 04/25/2024 Completion Date: 04/25/2024 Responsible: Facility Administrator Surveyors monitored the Plan of Removal for effectiveness as follows: On 04/26/24 the facility was monitored. Not all staff had been in-serviced. In an interview on 04/27/24 at 9:45 a.m. LVN O said she was assigned to South 1 Rooms 201 to 209. She said she still had three residents to give medications to in room [ROOM NUMBER] A and B, and room [ROOM NUMBER]. In an interview on 04/27/24 at 09:51 a.m. RN P said she was with a staffing agency. She said she was assigned Rooms 210 to 214. In an interview on 04/27/24 at 09:55 a.m. LVN R said he had one more resident to administer medications to, but would be finished on time. In an interview on 04/27/24 at 10:15 a.m., RN S said he was finished with the morning medication administration for the Flamingo Hall. In an interview on 04/27/24 at 10:17 a.m. LVN T said she had completed the morning medication pass for Swan Hall and Dove Hall. In an interview on 04/27/24 at 10:19 a.m. MA U said she has been in-serviced regarding medication administration and Chain of Command. She said if medications were going to be late she was to tell the charge nurse. Record review 'spot checks' of the MARs for each hall were conducted. Three random residents from each hall were reviewed. There were no concerns for the following halls: [NAME] Hall, Dove Hall, Flamingo Hall, Swan Hall, South 2 Hall, and South 3 Hall. Three residents on South 1 had their medications administered late. In an interview on 04/27/24 at 11:30 a.m. the DON was asked if any medications were administered late. She said she would check. At 1:31 p.m. she said three residents' medications were late, and the physician had been notified. In an interview on 04/27/2024 at 1:31 p.m. the DON said she had provided in-services for the agency nurses and the staff who came in today. She said the book (envelope) was at the north nurses' station. On 04/27/24 at 1:36 p.m. the surveyor picked up the two manila envelopes at the north nurses' station labelled in-service. Copies of the staff attendance sheet were made at that time. Record review of the envelopes revealed one contained in-service training for medication administration, protocol for calling off a shift, Physician notification for missed/late medications, chain of command, and general staffing policy review. Observation and interview on 04/28/24 at 6:40 a.m. revealed LVN Z and LVN L were at the north nurses' station. Both nurses said they had the in-services. Both nurses were able to explain what the in-services were about. In an interview on 04/28/24 at 7:25 a.m. LVN K said she had the in-services on Thursday. She was able to tell what the in-services were about. In an interview on 04/28/24 at 7:41 a.m. RN S said the north was short two CNAs. He said the nurses and the MA would fill in. In an interview on 04/28/24 at 10:05 a.m. LVN R said he had the in-services. He was able to tell what the in-services were about. In an interview on 04/28/24 at 10:10 a.m. LVN O said she has had the in-services. She was able to tell what the in-services were about. Record review of the binder entitled State Workbook 2024 Binder for POR revealed the following: Medication error reports for the four residents were completed. Safe Survey Questionnaires for all halls were completed. In-services for: Med Administration - Nurses, MA Notify MD - Nurses, MA Attendance/call off - all staff Chain of Command - all staff Staffing - Nursing mgt and Administrator A/N - all staff Contacting Administrator and/or DON - all staff Facility Assessment Tool updated 2 Staff agency contracts EMR Audit sheet - up to date Review of the binder revealed the facility was effectively implimenting the components of the POR. Record review of an Agency contract revealed the facility had contracted with the agency to provide nurses in case of staffing shortages. The contract was signed on 04/25/24. An Immediate Jeopardy (IJ) was identified on 04/24/24. The IJ template was provided to the facility on [DATE] at 5:35 p.m. While the IJ was removed on 04/28/24 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm t [TRUNCATED]

Based on interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent falls for 1 (CR#1) of six residents reviewed for accidents, hazards, and supervision. - The facility failed to provide adequate supervision and proper bed mobility for CR#1 when the facility wound care doctor and wound care nurse failed to supervise resident while doing wound care causing CR#1 to fall from the bed and hit her head on [DATE] and be rushed to the hospital and life flighted to another local hospital by helicopter for an emergency procedure. -The facility failed to care plan and put additional services in place for CR #1 when she had her 1st fall on [DATE].CR #1 had a 2nd fall on [DATE] causing her additional pain and suffering. An Immediate Jeopardy (IJ) was identified on [DATE] at 2:39 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of pattern as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents who are totally dependent on Staff for activities of daily living, supervision, and bed mobility at risk of not being adequately supervised, no adequate intervention, improper bed mobility, worsening of existing wounds, decline in quality of care, experiencing pain and death. Findings include: CR #1 Record review of CR #1's face sheet revealed original admitted to facility was [DATE] and was admitted on [DATE] and she died on [DATE]. Resident was diagnosed with pressure ulcer of sacral region, hypertension (high blood pressure), acute kidney failure (kidneys unable to filter waste products from the blood), anemia (a disorder in which red blood cells are destroyed faster than they can be made), end stage renal disease (kidneys stop functioning permanently leading to the need for dialysis or a kidney transplant to maintain life), legal blindness, hearing loss, major depressive disorder, seizures (a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness) and insomnia (a sleep disorder characterized by difficulty falling asleep, or staying asleep). Record review of CR #1's undated care plan revealed resident was at risk for falls and injuries dated [DATE] and the interventions were to anticipate needs, provide prompt assistance, assure lighting is adequate and areas are free of clutter, encourage resident to ask for assistance of staff, encourage socialization and activity attendance as tolerated, ensure call light is in reach and answer promptly, therapy to screen resident and to evaluate/treat as indicated, and send to ER for evaluation on [DATE]. Record review of CR #1's undated care plan did not reveal any additional significant interventions after fall on [DATE] and [DATE]. Record review of CR #1's MDS signed on [DATE] revealed resident had a BIMS Summary score of 0 meaning severe cognitive impairment and she was dependent on staff and the helper does all of the effort. CR #1's bed mobility, transfer, walking, dressing, eating and/or swallowing score was 0 for the number of days restorative programs were performed. CR #1 did not have use of bed rails, trunk and limb restraint and no bed or chair alarms were used. Record review of Admission/Readmission Tool effective date [DATE] revealed most recent admission [DATE] admitted from hospital with admitting diagnosis of fall, resident bedbound, bed mobility and transfers were total assistance and required 2-person assistance. Record review of CR #1's Side Rail Safety Evaluation effective date [DATE] revealed CR#1 requesting to have side rails raised while in bed for either comfort or safety, no cognitive impairments or change in level of consciousness, visually impaired, resident no able to get in and out of bed unassisted in a safe manner, has a history of falls, resident does not experience difficult with balance or trunk control, no reason to believe the resident may attempt to climb over the rails, rails are not being used as a restraint to prevent from getting out of bed, no diagnosis of seizures or experienced seizures in last 90 days, resident takes medication that would require safety precautions, resident able to demonstrate safe technique when using the side rail for positioning and mobility. Record review of CR #1's Local Hospital emergency room Records dated 7 /,d+[DATE] revealed, Call log 2:41 p.m., transfer center [DATE] at 2:53 p.m. and [DATE] at 3:14 p.m. Patient [CR#1] accepted to local hospital Neuro ICU .Chief complaint from nursing facility fall forward hitting face on floor while doing therapy. Patient [CR#1] awake and alert x3, Contusions to face, no altered level of consciousness per nursing home. Pain to left side of face, tenderness, pattern constant, confused times 4, distance of fall ,d+[DATE] feet from bed, hard floor, accidental, left face Trauma Secondary Assessment: Head/Neck general findings: Hematoma, swelling, abrasion, left upper and right upper extremity decreased motor function and left and right lower extremity decreased motor function, Trauma documentation respiratory rate ,d+[DATE] breaths per minute, Glasgow coma scale revised score 12. Neurological Assessment: not oriented to situation, not oriented to time, consciousness level: Alert, history of blindness in right and left eye, neurovascular check was poor 2 in all areas. Reexamination /Reevaluation : .interpretation of capillary transit time heterogeneity (CTH), patient has diffuse vasogenic edema results from disruption of the blood-brain barrier, allowing protein-rich fluid to accumulate in the extracellular space and hydrocephalus (a neurological disorder caused by an abnormal buildup of cerebrospinal fluid in the ventricles (cavities) deep within the brain) .Procedure; Critical Care Time: [40 ] minutes. The patient presents with an illness or injury that acutely impaired one or more vital organ systems. There was a high probability of imminent or life-threatening deterioration in the patient's condition during their evaluation in the ED. This is the total time spent evaluating, coordinating, managing, and providing care to the critical patient, as well as time spent in documenting such activities. This time is exclusive of time required to perform procedures required during patient management. Impression and Plan Diagnosis Vasogenic brain edema Working, Medical) Hydrocephalus, Working, Medical) Hypertensive emergency, Working, Medical) Accidental fall, Working, Medical) Plan Condition: Critical. Disposition: Transfer to other location: Time: [DATE] 3:12 p.m., Facility name: local hospital neuro ICU accepted by: Doctor. Transfer on [DATE] at 3:59 p.m.: Reason for transfer: higher level of care. Service Needed: Neurosurgery, patient in system to another local Hospital, condition on Transfer: Stable, Transported: ID bands in place, on Cardiac monitor, via helicopter. Record review of Local Hospital emergency room Records dated [DATE] at 6:59 a.m. revealed: Check in time [DATE] at 8:46 p.m., Chief complaint: Patient from Nursing home fall out of bed per staff at around 4:30 p.m., Patient was found on the floor by staff, no visible injuries, patient on hospice at this time and is DNR, family wanted patient checked out- no thinners, patient at baseline mentation. Trauma scores: Respiratory Rate: ,d+[DATE] breaths per minute, systolic blood pressure is greater than 89, Glasgow Coma Revised Score: 12, Mechanism of injury: fall from bed, distance of fall: ,d+[DATE] feet, fall impact: hard floor. Diagnosis from visit: fall, head injury and hyperkalemia. Medical history: blindness, hypertension, seizures, vasogenic brain edema and acquired hydrocephalus, aphasia at baseline, Posterior reversible encephalopathy syndrome, healthcare associated pneumonia, and chronic arterial ischemic cerebrovascular accident (stroke). Record review of facility incidents from [DATE] to [DATE] dated [DATE] revealed CR #1's fall was not listed. Record review of CR #1's progress notes dated [DATE] at 12:05 p.m. revealed, at 11:10 a.m., during rounds with NP, treatment nurse reports that resident [CR#1] fell off bed and hit head on nightstand. Resident [cr#1] is immediately assessed, bruising noted to left eyes .Resident [CR#1] denies pain and due to dx of legal blindness, resident only reports that she fell out of bed and hit head. Resident denies pain at this time. Alert and oriented x 3. 11:16 a.m. NP orders to send resident out via emergency transport. 911 called at 11:18 a.m. and arrived at 11:22 a.m. Resident [CR#1] is transported to local hospital via stretcher 11:29 a.m. [CR#1's family member] is contacted at approximately 11:30 a.m. of condition and transfer to hospital for CT scan. During this time [CR#1's family member] states while crying, I am looking at recording, oh my god, whoever is in white coat is just standing there not holding mom to make sure she does not fall. this nurse apologizes for any wrong doings on that person behalf. Don, ADON, administrator made aware. Record review of CR#1's progress notes dated [DATE] at 6:49 p.m., written by RN B for Admit/Readmit resident returned to the facility from local hospital at 3:40 pm. She arrived on a stretcher with 2 EMS attendants. She is Alert and oriented x3 and legally blind. She receives Hemodialysis (a treatment to filter wastes and water from your blood) in house Monday thru Friday through her right. subclavian access. She was placed in a new bed with air mattress and ,d+[DATE] side rails for safety. Fall precautions are in place. Bed in low position and call light in reach. In an interview on [DATE] at 10:25 a.m. with CR #1's family member she stated she had 2 videos' where the facility dropped CR #1. CR #1's family member stated she did not want to disclose the video's. She stated the first time the facility dropped CR#1 was when they were doing wound care and the Wound Care Nurse saw CR#1 was hanging off the side of the bed and the Wound Care Doctor walked away from CR#1 while CR#1 did not have bed railing. She stated the Wound Care Nurse turned around to do something and CR#1 fell out of the bed on [DATE]. CR#1's family member stated CR#1 was sent to the emergency room at a local hospital and they life flighted her to another local hospital because there was swelling on CR#1's brain and they needed a surgeon. CR#1's family member stated the incident was not investigated by the State. CR#1's family member stated when CR#1 was readmitted to the facility she requested the facility to give CR#1 a bed with rails and they said they did not have a bed with rails. CR#1's family member stated CR#1 was blind, could not feed herself, bed bound and CR#1 scoots. CR#1's family member stated the facility always had CR#1 up way to high. CR#1's family member stated for the last fall on [DATE] CR#1 was sitting way to high up in the bed and at this time CR#1 could not speak and the staff that was in the room left with CR#1 sitting all the way up like she was sitting upright in a recliner and CR#1 fell . She stated she had a number for a can and 2 days prior to her mom's last falling CR#1 was about to fall and CR#1's family member called the CNA, and she heard the CNA by phone drop what she was doing and ran to CR#1 and CR#1 was already hanging from the bed. CR#1's family member said then 2 days after that CR#1 was on the floor and during shift change an aide (unknown name) came in and found CR#1 on the floor. In an interview on [DATE] at 12:20 p.m. with the Administrator she stated she received a call from the facility staff saying CR#1 fell out of bed on [DATE] and that CR#1's family was at the facility, and they were threatening the nurse saying that if the nurse walked in the room, they (CR#1's family) would end up in jail. The police were in the building, and they had the nurse in a room by herself for her protection until CR#1's family left the building. The Administrator stated CR#1's family wanted CR#1 sent to the hospital even though she was hospice. She stated the nurse called hospice and let them know they were sending CR#1 out the hospital to be checked out. The facility nurse called the CR#1's family too. The Administrator stated CR#1 went to the hospital on [DATE] and they sent her right back. The Administrator stated on Sunday,[DATE] she came to look at CR#1 and CR#1 looked bad, but CR#1 was in isolation because she had Candida auris. The Administrator stated she moved CR#1 to a private room so the family could visit, and that nurse would not have to interact with the family. The Administrator stated she saw CR#1's family again on Monday, [DATE] and CR#1's family stated they had it on camera that CR#1 edged herself out and fell out the bed. The Administrator stated the facility nurse was agency and she asked for the nurse not to return. She stated CR#1 passed away on Monday, [DATE]. In an interview on [DATE] at 12:58 p.m., CNA A stated CR#1 was blind, and CNA A would sit with CR#1 to feed her. CNA A always wanted more food, went to dialysis every other day, then every day. CNA A stated they always had to watch CR#1 and she would scratch her face, slide and would be in the bed sideways. She stated CR#1 went to the hospital on [DATE] and when she came CR#1 was not talking anymore and then she started talking again. CNA A stated on Saturday, [DATE] there was a facility function, and she brought her kids to introduce her to CR#1 and she went to check on her and found CR#1 slouched over and CNA A laid CR#1's head back a little more and repositioned her and left to do the facility function. CNA A stated she heard a few hours after she left the facility CR#1 fell . CNA A stated she did not know how CR#1 fell out of the bed. In an interview on [DATE] at 1:10 p.m. with LVN B she stated on [DATE] she is an agency nurse went on break and came back and the shift was changing with the CNAs. She stated a CNA (unknown name) was doing rounds and the CNA found CR#1 on the floor and another nurse (unknown name) on South Hall responded to the fall initially and was assessing CR#1. LVN B stated she had to get her equipment and when she walked in CR#1's room the facility staff had CR#1 on the floor in supine position (face up) and they lifted her up in the bed. LVN B stated the facility staff stated CR#1 did not have injury. LVN B stated she did vitals ,d+[DATE] on most of CR#1's fingers and LVN B put the oxygen on CR#1 and monitored her. LVN B stated she made sure CR#1's oxygen came back with 97 to 98. LVN B stated she called the on-call number for hospice and said CR#1 fell and she did the vitals and Hospice said they would send out a nurse to assess CR#1 and LVN B told Hospice CR#1 needed oxygen and that she needed a concentrator in her room. LVN B stated she called CR#1's family and said CR#1 had a fall and said she had the vitals. LVN B stated CR#1's family member started yelling saying that's why she wanted side rails on CR#1's bed and CR#1's family member hung up the phone and both CR#1's family members walked in and one of them stormed past LVN B and the other family member came towards her and a cop came in and said he was here to investigate. LVN B stated the police officer asked her about how CR#1 fell out the bed and CR#1 was alert but was not verbal. LVN B stated CR#1's family member stated LVN B better not be out here because she is going to jail today so the police officer put her in a room and the whole time CR#1's family member was threatening LVN B. LVN B stated the vitals were supposed to be taken for neuro checks, but she could not do them. LVN B stated she contacted the ADON and DON and told them and they contacted the Administrator and CR#1's family was escorted out. LVN B stated CR#1's family was upset CR#1 was not sent out to the hospital. LVN B stated the only time they send hospice patients out is because of broken bones and there was nothing she could send CR#1 out for, and she needed a Doctor's order. LVN B stated she talked to the Administrator and was told to send CR#1 out to the hospital because the family requested it. LVN B stated this all happened at 430 p.m. and by 5 p.m. she was already in contact with CR#1's family and hospice was documenting everything. She stated by 7 pm the Administrator said go ahead and send CR#1 out based on the family's request. LVN B stated when the police asked CR#1's family to see the video he said, it looked like CR#1 just popped out of bed. LVN B stated only 18 minutes had gone by since the time CR#1 hit the floor to the time they saw her do vitals. LVN B stated when she saw the video, CR#1 had just popped out the bed. LVN B stated the first text went out at 4:05 p.m. and CR#1's vitals were in progress. LVN B stated maybe hospice can get bolsters for CR#1 and the DON said the facility could not do rails. LVN B stated she was not able to do neuros at that time due to CR#1's family threatening her. She stated when she got in CR#1's room, the bed was medium low, but the bed was flat and that it may have been a 30-degree angle if that. LVN B stated she did not understand how CR#1 fell out the bed. LVN B stated she knew the CNA's were doing rounds, but she does not know how long it had been since someone went to check on CR#1. In a record review and interview on [DATE] at 1:50 p.m., the DON stated she saw the video of CR#1's fall on [DATE] and it looked like CR#1 plopped out of the bed and before the fall, CR#1 was declining she refused to eat and refused dialysis. The DON stated she was not here in July when CR#1 fell and did not come to the facility until the end of August so she could not say what happened with the fall in July. Record review of CR#1's hospital notes revealed CR#1 was in the hospital from ,d+[DATE]-[DATE] for the fall. The DON stated the hospital discharge note says CR#1 had brain swelling (hydrocephalus) and she needed an LP (Lumbar puncture) procedure. The DON stated she probably would have reported the incident to the State. In an interview on [DATE] at 2:15 p.m. with the Administrator she stated the Wound Care Doctor saw CR#1 falling and she stepped back and put her hands in the air and let CR#1 fall when the wound care nurse walked away. The Administrator stated she fired the Wound Care Doctor that day and she did not return to the facility. In an interview on [DATE] at 2:27 p.m. with the NP she stated when CR#1 was taken out in July for a fall CR#1 had sent her for a head CT. She stated the CT was negative and LP is lumbar puncture. The NP stated the CT was negative with no bleed on her brain. CR#1's hospital diagnosis was Hydrocephalus and metabolic encephalopathy. In an interview on [DATE] at 11:24 a.m. with the Wound Care Nurse he stated on [DATE] the Wound Care Doctor CR#1 on her side. The Wound Care Nurse stated when he entered CR#1's room CR#1 was laying on her right side facing the window and the Wound Care Doctor was standing on the left side of CR#1's bed at the foot of the bed facing CR#1. He stated he did wound care set up and CR#1's wound was already exposed because the Wound Care Doctor had already removed the other dressing. He stated he had to throw something into the trash, so he turned away from CR#1 to throw the trash away. The Wound Care Nurse stated when he turned, he could hear CR#1 starting to roll over and when he turned around CR#1 had already fallen from the bed and the Wound Care Doctor was still facing the patient at the foot of the bed. He stated it looked like the Wound Care Doctor just stood there and watched CR#1 fall. He stated he could not remember what she said, but he was very panicked and assessed CR#1 and called for a CNA to help to pick CR#1 up and placed her back in bed. The Wound Care Nurse stated CR#1 hollered out Awhh or Ouch. He stated the Wound Care Doctor saw CR#1 hit her head on the nightstand. The Wound Care Nurse stated CR#1 was taken out to the hospital by 911. The Wound Care Nurse stated he assessed CR#1 and so did the nurse on the floor (unknown name). He stated CR#1 did not have any visible injuries and no bleeding. In an interview on [DATE] with CNA B she stated on [DATE] she heard a loud crash while she was in the next room giving someone a bath, so she stopped what she was doing and came to assist CR#1. She stated she was agency staff and when she came into CR#1's room there were 2 people (Wound Care Doctor and Wound Care Nurse) in the room with CR#1 and CR#1 was on the floor. CNA B stated CR#1 was on the floor on the side of the bed and there was a nightstand on the side of the bed, and she did help to put CR#1 back in the bed. CNA B stated the Wound Care Nurse and Wound Care Doctor were just looking at CR#1 and no one was saying anything, and she guessed CR#1 had already been assessed. CNA B stated they used a draw sheet under CR#1 rolled her from side to side and lifted CR#1 up and after that CNA B left the room. In an interview on [DATE] at 11:38 a.m. with the Wound Care Doctor she stated she went in to take care of CR#1 and she had requested several times that the facility get a bed that will keep CR#1 from falling. The Wound Care Doctor stated she asked for rails several times. She stated she told the Wound Care Nurse that was working with her, and the Administrator and the Administrator said that those kinds of beds were not allowed but she saw other patients with beds like that. The Wound Care Doctor stated the Wound Care Nurse put the patient (CR #1) in a position where CR#1 could be taken care of. She stated when she came into the room CR#1 fell . The Wound Care Doctor stated the Wound Care Nurse went to call for help and she got a CNA, but she called her, and she lifted CR#1 and the CNA lifted CR#1 in the bed and they took her blood pressure and stood by her until the ambulance came. She stated CR#1 was taken to the ambulance immediately. The Wound Care Doctor stated she did not turn CR#1 and that the Wound Care Nurse turned CR#1 and went out to get the medicine to treat CR#1. The Wound Care Doctor stated the Wound Care Nurse went out of the room and CR#1 fell . She stated she went in with the Wound Care Nurse and, they turned CR#1, and the Wound Care Nurse went out to get CR#1's medicine. She stated no one assisted the Wound Care Nurse in turning CR#1 because CR#1 was very small. She stated she did not remember who removed the bandages. The Wound Care Doctor stated when CR#1 fell she was leaving the room, but she heard CR#1 fall so she turned to see what the noise was, and she had fallen. The Wound Care Doctor stated she called the NP to come and get CR#1. The Wound Care Doctor stated she did not see CR#1 going down, she just heard the noise of something hitting the floor. She stated CR#1 was turned to her side and CR#1's face was toward the right side facing the window. The Wound Care Doctor stated she was headed to the door, but this was a vague memory and she thought she was going to check on the Wound Care Nurse outside. She stated she did not remember bolsters or pillows around CR#1, and she did not think CR#1 had a fall mat. The Wound Care Doctor stated she did not remember how high CR#1's bed was. She stated she had not touched CR#1 at all and did not even do her wound that day. The Wound Care Doctor left the facility afterwards. She stated she was hired as a consulting physician and the facility asked for her training when hired as a consulting physician. She stated she knew what to do when a resident falls because doctors are trained in positioning residents. The Wound Care Doctor stated the facility asked for her medical training, but those trainings come with wound care. She stated the Administrator told her she did not want her to work at the facility and she agreed that she did not want to work at the facility. She stated the Wound Care Nurse was not in the room at all and neither was she stated no one was in the room with CR#1. The Wound Care Doctor stated she did not remember if CR#1 was at the edge of the bed. In an interview on [DATE] at 12:04 p.m. with the Administrator she stated because The Wound Care Doctor is a doctor the facility did not do training with them. She stated the facility got the doctor's license and their credentialing packet and that includes board certifications, etc. In an interview on [DATE] at 12:18 p.m. with the Wound Care Nurse he stated when he walked in CR#1's room CR#1 was already on her side and the dressing was already removed and the Wound Care Doctor was standing at the foot of the bed facing CR#1. He stated he was not there because he was gathering wound care supplies at the cart, so the Wound Care Doctor went ahead to inspect the wound. He stated the Wound Care Doctor had already looked at CR#1's wound and he was going to perform the wound care and move on to the next patient. The Wound Care Nurse stated CR#1 was laying on her right side facing the window and the brief was open and the dressing was removed, and the wound care doctor was standing at the foot of the bed facing CR#1. He stated CR#1's bed was not very high like maybe up to his elbow. The Wound Care Nurse stated CR#1 did not have a fall mat, he could not remember if CR#1 had rails or not when the incident occurred. He stated CR#1's head was on a pillow; she was laying on her side and the blankets were pulled back. He stated there were no bolsters or additional pillows for positioning. The Wound Care Nurse stated he started performing the wound care and he had his left hand on CR#1 to stabilize her and he was using his right hand to clean the wound with the gauze and he went to turn to throw the gauze away and he heard CR#1 begin to fall and the blankets were rustling and he turned and CR#1 was already on the ground and started screaming OW. He stated once he was in the room, he did not have to leave the room to do anything. The Wound Care Nurse stated after he cleaned CR#1's wound he took his hand off CR#1 and turned to his side to throw trash away and he could hear CR#1 falling. The Wound Care Nurse stated the Wound Care Doctor was standing at the side foot of CR#1's bed facing CR#1 and the Wound Care Doctor could have reached out to touch CR#1 if she wanted to. He stated he walked around CR#1's bed to assess CR#1 and the Wound Care Doctor went to get a CNA to assist with getting CR#1 into the bed. He stated they got CR#1 assessed and got her in the bed and the Wound Care Doctor talked to the NP. In an interview on [DATE] at 12:56 p.m. with the NP she stated the Wound Care Doctor walked down the hall with the Wound Care Nurse and the Wound Care Doctor said CR#1 would need a head CT and she said yeah she fell , hit her head and needs a head CT. The NP stated CR#1 was very confused and she sent CR#1 to the hospital right away 911 because CR#1 had a head strike. She stated she did not know the events that occurred. The NP stated CR#1's family came to her and said they saw the Wound Care Doctor in CR#1's room and the Wound Care Doctor put her hands up when CR#1 fell . The NP stated the Wound Care Doctor did not tell her what happened, but she found it odd that she did not tell the NP what happened. The NP stated the next day the Wound Care Doctor no longer worked at the facility. She stated the Wound Care Doctor specifically told her that CR#1 would need a head CT and the Wound Care nurse was standing right next to her when she said it. She stated she was a NP, and she was a bedside nurse before becoming a physician, and as a bedside nurse and was a CNA first so she has a clear understanding of bedside care. The NP stated the Medical Doctors have a vast knowledge of the body with [AGE] years of intense study, but their bedside manner is more like studying the disease. She stated she did not feel like Doctors [NAME] in on when they care for the patient like studying you should watch this position and do that. The NP stated in reference to wound care they are not trained specifically for bedside positioning. The NP stated CR#1 had no herniation syndrome and there were superficial injuries in the left occipital region without underlying fracture. In an observation on [DATE] at 2:10 p.m. of wound care with the Wound Care Nurse revealed the Wound Care Nurse raised the random resident's bed to a high position. The Wound Care Nurse turned the resident using the bedsheet and turned the resident to his side and said he should stay on his side and told him to stay that way until he came back with the wound supplies. Observation revealed the Resident was left holding on to a grab bar on the wall. The resident said alright and asked the Wound Care Nurse did he park way out in the parking lot. Observation revealed the Wound Care Nurse did not bolster or use any kind of support for the resident to prevent him from falling. Observation revealed the Wound Care Nurse left the room and went to gather all of his wound care supplies while the resident was left holding on to the grab bar and his bed was positioned up high with no support around him. The Wound care nurse came back into the room and told the resident he needed to wash his hands and grab some gloves and the resident asked him why he had to wash his hands first if he was going to get gloves. The Wound Care Nurse left the resident to wash his hands and get gloves and he was observed leaving the room again to go back to his supply cart. Observation of the Resident appeared he got tired of holding the grab bar on the wall and he let go of the bar and whispered, oh boy and grabbed the bar back again. The Wound Care Nurse was observed going back outside of the residents room again to the wound cart and came back into the room. The wound care nurse was observed performing wound care and the Resident asked him how long did he have to lay like this. The Wound Care Nurse told the resident not too much longer and he continued with wound care. Observation revealed once the Wound Care Nurse finished wound care, he left the resident in the same position and went to wash his hands and the resident asked the Wound Care Nurse if he could turn back and the Wound Care Nurse said yes, and the resident said the Wound Care Nurse did not tell him he could. Resident was observed turning himself and the Wound Care Nurse brought the bed in low position to the floor and raised the resident's head. The Resident was observed to have upper rails on his bed. In an interview on [DATE] at 11:15 a.m. with the ADON she stated the MDS Nurse does the comprehensive care plans, but nursing will do care plans. The ADON stated they had a care plan meeting with CR#1's family and the SW, DON, ADON, Administrator and NP were there. She stated they talked about CR#1's medical condition. She stated CR#1 was able to make her own decisions and if she did not want to do dialysis she did not have to. She stated the MDS nurse only came to the facility 2 or 3 times a week and she was here yesterday. The ADON stated whenever there is an incident or accident the DON and ADON take care of the care plan. She stated they ask daily about falls in standup and they have a sheet where they have to write down the falls and talk about the interventions and it gets care planned by the ADON or DON. The ADON stated CR#1 was sent out to the hospital on [DATE] so it would not have been care planned until she returned back from the hospital. She stated they talked about the [DATE] fall and they talked about it in the morning meeting on Monday, [DATE]. She stated the DON was going to care plan the fall. The ADON stated on [DATE] she spoke with the charge nurse and told her to put 2 fall mats in place on each side of the bed. She stated she also asked her to leave the head of her bed back because when she was leaning, she would slouch up so that is why she told her to change the position of the bed and she told the charge nurse where the fall mats were. The ADON stated she could have sworn that they did have a fall mat after the first fall on [DATE] and then she went out to [TRUNCATED]

Based on observation, interviews, and record reviews, the facility failed to ensure each resident was free from abuse and neglect for 1 (CR #50) of 7 residents reviewed for abuse and neglect. -The facility failed to ensure CR #50, was free from abuse when she was grabbed and hit by CNA F, causing bruising to the face, torso, and left arm. -RN H and CNA G failed to follow appropriate procedure and notify the facility's abuse coordinator and administrator immediately of knowing an incident of abuse involving CR #50 that occurred on 07/19/2022 and reported on 07/25/2022. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 03/01/2023. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of serious harm from possible abuse and neglect. Findings included: Record review of the face sheet for CR #50 dated 02/08/2023 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE]. Her diagnoses included hypersensitive, heart disease with heart failure, muscle wasting, lack of coordination, dementia, Alzheimer's disease, rheumatoid arthritis, and depression. Record Review of CR #50's Annual MDS assessment dated [DATE] revealed a BIMS score 3 out of 15; indicating residents' cognition had severe impairment. Record review of CR #50's undated care plan revealed the following: -Focus: Difficulty in making decisions due to dx of dementia. -Goal: Make a decision regarding clothing choice through review date 10/30/22. Make a decision regarding activity preference through review date of 10/30/22. -Intervention: assess and document cognitive status frequently. Notify physician of any abnormal findings. Provided consistent direct care givers on all shifts. Limit choices to minimal number. Provided opportunities for resident to make simple choices with ADL care. Interact with resident in non-judgmental manner at all times. -Focus: resident can get resistant and combative at times. -Goal: resident will not show any increased episodes of combative behavior 10/30/22. -Intervention: approach resident warmly and positively. Provided consistency with direct care providers on all shifts. All resident opportunity to make choices and participate in cares. Do not argue with resident. Do not offer assistance for activity before resident attempts activity on own. Activities to evaluate and provide appropriate activities recommendations for resident. Praise resident for demonstration desired behavior. Administer behavior medications as ordered by physician. Record Review completed of the SSA Intake ID 366245 dated 07/25/2022 alleged that CNA F admitted she hit CR #50 in the face after resident acted out on 07/19/2022 at 9:00pm. The incident was witnessed by CNA G who reported the incident to RN H. Record Review completed of the SSA Intake ID 367563 dated 07/30/2022 alleged that unknown staff (CNA F) assaulted CR #50 on 07/25/2022 leaving bruises on the resident's face, chest, and arms. Law enforcement was called, and the incident was assigned to a detective. Record review of PIR associated with Intake ID 366245 dated 07/25/2022 revealed that CNA G witnessed CNA F hit CR #50 on 07/19/2022. CNA G reported the incident to RN H on 07/19/2022. RN H assessed CR #50 on 07/19/2022 to have no injuries or pain. SBAR completed on 07/19/2022 with notifications to physician and responsible party. Neither RN H or CNA G reported the incident to ADMIN B, and ADMIN B was not made aware of the incident until 07/25/2022. CNA F was contracted staff and did not return to the facility after the incident on 07/19/2022. On 07/25/2022 resident safety checks were completed with no concerns for abuse/neglect. On 07/25/2022 resident received skin assessment, met with social worker, and referred for psychological consult. On 07/25/2022 residents on the hall of CR#50 received safety checks with no concerns for abuse/neglect. On 07/25/2023 staffing agency was notified of the incident. On 07/25/2022 facility completed in-service on abuse/neglect, reporting, and dementia care. Record review of CR#50 head to toe assessment dated [DATE] with bruising to right side of the face, torso, upper left arm, and left wrist. Record review of social work progress note dated 07/25/2022 that revealed that social worker met with resident who was not able to communicate what happened. Social Worker referred for psychological consult. Record review of CR# 50 psychological evaluation dated 07/26/2022 with conclusion that resident did not appear to be experience trauma related to the incident. Record review on 02/09/2023 at 10:00am of local police report 22-007400 obtained by SSA dated 07/25/2022 completed by Officer I revealed that local police responded to the facility on [DATE] read in part I could not ask CR #50 any questions due to her mental capabilities. CNA F gave me a verbal and written statement. CNA F stated this incident occurred on Tuesday 07/19/2022 The patient got combative and hit CNA F on the right arm and her right breast. I CNA F had a reflex and pushed her hand back to her face and told her to stop. CNA G stated that CR #50 can be combative and they were starting to change CR #50, and CR#50 hit her partner CNA F and CNA F slapped the resident after. CNA G was shocked and asked why would you do that? After that, CNA G reported the incident to the nurse, which was RN H . Officer I spoke with the County District Attorney office who advised to forward the report to CID for further investigation. Interview on 02/09/2023 at 2:13pm with the DON, she said that she could not remember all the details of the incident involving CR #50. She said that one CNA (CNA G) witnessed a contractor CNA(CNA F) hit the resident. She said that the CNA (CNA G) that witnessed the incident reported it to Nurse(RN H). She said CR # 50 was observed with a bruise on her face by staff whose name she did not remember(CNA J and RN I), and it was believed the contactor CNA (CNA F) caused the bruise. She said that staff involved (CNA G and RN H) did not report the incident timely, so the investigation was delayed. She said that staff who observed the bruising after the incident (CNA J and RN I) reported the information timely, but they did not see the bruising until days later. She said that staff(CNA G and RN H) should have reported the incident immediately to ADMIN B or her. She said that ADMIN B completed the investigation once the incident was made known to her. She said that staff were in-serviced on abuse, neglect, and reporting. She said that the CNA (CNA F) did not return to the facility after the incident. She said that if staff do not report abuse timely it could put residents at risk of the abuse continuing. Interview on 02/09/2023 at 2:26pm with Restorative Aid, he said that he vaguely remembered incident with CR#50. He said a CNA whose name he did not remember saw a contractor CNA whose name he did not remember hit a resident on date that he did not remember. He said that all staff that provided care to the resident after the incident were interviewed by the Admin B because it was not reported to the DON or Administrator at the time. He said that when he provided care the day after the incident the resident did not have a bruise to her face but later developed bruising to her face. He said that all staff received training for abuse/neglect to include reporting before and after the incident. He said that he has not observed abuse/neglect while working at the facility, but if he did it would be reported to the administrator immediately. In a phone interview with CR #50's Responsible Party on 02/09/2023 at 02:40PM, she said that CR #50 was taken out of the facility after a contractor employee beat the shit out of CR #50. She said that CR #50 got combative with a CNA, and the CNA assaulted CR#50. She said that CR #50 has dementia and that was no excuse for the CNA to assault CR #50. She said that the last time that she spoke with the local police department she was told that they were waiting to see if the district attorney would accept charges against the CNA. She said that she did not feel the facility acted fast enough when investigating the abuse of CR #50. In a phone interview on 02/09/2023 at 2:50pm with ADMIN B, she said that she has not worked at the facility since 12/09/2022. She said that she was not notified of the incident with CR #50 until days after the incident took place because the staff involved did not report it to her timely. She said that as the Administrator and Abuse Coordinator she should have known about the incident immediately, and if she was not present the DON should have been notified. She said that other staff (CNA J and RN I) saw CR #50 with a bruise to the face that was fading days after the incident, she was notified immediately, and she started an investigation. She said that CR #50 had a skin assessment and there were fading bruises to other parts of her body that she did not remember the location. She said that during the investigation she found out that a contractor CNA (CNA F) hit the resident in the face, the incident was witnessed by another CNA (CNA G), and then the incident was reported to a nurse (RN H). She said that when she did get the information she started the investigation, reported to SSA, and contacted the local police department. She said that staff were in-serviced on abuse, neglect, and reporting the same day she found out about the incident. She said that risk of not reporting abuse timely is the abuse could repeat and happen to other residents. She said that the contractor CNA (CNA F) worked at the facility the day of the incident did not return. She said that CNA F's license was not referred as she did not have enough identifying information since the CNA was contracted. Interview on 02/09/2023 at 3:46pm with RN H, she said that the CNA G came to her on the 07/19/2023 at the end of the shift and told her that CNA F hit CR #50. She said that CNA F was a contractor and had already left the facility. She said that she assessed the resident, and she did not have injuries, express pain, and the resident seem fine. She said that ADMIN B was the abuse coordinator at the time, and she did not report the incident to ADMIN or the DON. She said that she did not know what she was thinking that day, and she thought that because the resident was okay, she did not need to report it. She said that CR#50 developed a bruise later. She said that she had previous training on abuse, and the incident should have been reported immediately, and she felt bad afterwards. She said that the risk was that the abuse could continue and could happen to other residents. In a phone interview on 02/09/2023 at 3:55pm with CNA F, she said that in July of 2022 during care CR#50 spit on her, hit her, and grabbed her. She said that she was trying to block the resident from hitting her and she hit CR#50 in the face with the back of her hand. She said that CR#50 had a strong grasp on her arm, and she had to physically remove the resident's hand from her arm. She said that during the incident the resident had backed her up against the wall in the room, hit her multiple time, and she had to block resident from hitting her. She said that she only remembered that she hit the resident the one time, and she had to pull the residents hand from her arm. She said that she did not report the incident to anyone at the facility. She said that there was another CNA in the room that reported the incident. She said that she was trained on abuse and neglect at the start of her shift, she only worked at the facility the day of the incident, and she never returned to the facility. She said that she was contacted by law enforcement as part of their investigation. She said that she was told by law enforcement that CR#50 had multiple bruises and the bruises observed were too old to be caused by her. In an interview on 2/10/2023 at 10:49am with DON, she said that during the time of the incident contracted staff received training to include abuse/neglect on the contractor online portal prior to accepting the shift. She stated that in October of 2022 contracted staff received training on the portal prior to accepting a shift and when they arrived at the facility prior to starting the shift. She said that the staffing coordinator, night/weekend supervisor, or her complete the training with contracted staff. She said that contracted staff can not sign in for a shift at the facility until the training is completed. She stated that the training topics are kept at the nurse's station next to the sign in/out sheets. In an interview on 2/10/2023 at 10:55am with Staffing Coordinator, she said that she has worked at the facility since 2019, and she did not start her current position until October of 2022. She said she was unsure of how contracted staff were trained in July of 2022. She stated that all contracted staff received training to include abuse/neglect on the contractor online portal prior to accepting the shift. She stated that the portal will not allow her to schedule contracted until the training has been completed. She said that the DON, night/weekend supervisor, or her complete the training with contracted staff once they arrive to the facility before starting a shift. She said that contracted staff can not sign in for a shift at the facility until the training is completed. She stated that contracted staff have a K next to their name on the sign in/out sheet for KARE. She stated that the facility had contracts with Shift Key and KARE, but as of December of 2022 the facility only uses KARE for CNA's, and it is rare they contract for RN or LVN staff. She stated that the training topics are kept at the nurse's station next to the sign in/out sheets. In an observation on 02/10/2023 at 11:00am, training topics were observed at the nurse's stations next to the sign/out sheet which included topic on abuse/neglect and reporting. In an observation of the sign in/out sheet it was revealed that CNA L was the only contracted staff scheduled for the day. In an interview on 02/10/2023 at 11:05am with CNA L, she said that she was contracted staff with KARE, and started accepting shifts at the facility sometime in December of 2022. She stated that she had been trained on abuse/neglect to include reporting. She was knowledge on types of abuse/neglect, and that all abuse/neglect should be reported to the DON or ADMIN immediately. She denied that she has observed abuse/neglect of residents while working at the facility. She stated that there is training that you must complete on the contractor portal before you are scheduled which includes abuse/neglect. She stated that when she arrives to a shift, she receives training with either the DON or staffing coordinator before she can sign in for a shift. She stated that she has the same training every time she accepts a shift at the facility. Interview on 02/10/2023 at 11:53am with the ADMIN, she said that she was the current abuse prevention coordinator. She said that if staff witnessed abuse the incident should be reported immediately to the Administrator and DON. She said that the incident should be reported to the SSA within two hours no later than 24 hours. She said that the risk of not reporting abuse timely was it could expose other residents to potential abuse or harm. She said that she was unsure of how ADMIN B ensured that contracted staff were trained. She said that currently contracted staff receive training prior to accepting the shift on the contractor portal and training when they arrive to the facility with either the DON, staffing coordinator, or night/weekend supervisor. She said that the facility is only using the contractor agency KARE. She said she was not aware of QAPI Meeting to be held or PIP completed after the incident took place. In a phone interview on 02/10/2023 at 2:06pm with Officer J, he said that law enforcement case # 22-007400 was transferred from Officer I to CID an assigned to him. He said that the CNA (CNA F) involved admitted to hitting the resident once, and it was witnessed by other staff. He said that by the time the investigation started the bruises observed were old. He said that he will submit evidence to the grand [NAME] for criminal charges. In an observation on 02/27/2023 at 12:00pm, training topics were observed at the nurse's stations next to the sign/out sheet which included topic on abuse/neglect and reporting. In an observation of the sign in/out sheet it was revealed that contracted staff CNA L, CNA M, CNA N, and CNA O were scheduled for 3:00pm-11:00pm shift. In an interview on 02/27/2023 at 12:05pm with LVN S, she said that she worked at the facility since 2019. She stated that she had been trained on abuse/neglect to include reporting. She was knowledge on types of abuse/neglect, and that all abuse/neglect should be reported to the ADMIN immediately. She denied that she has observed abuse/neglect of residents while working at the facility. She stated that the facility trains on abuse/neglect often, and she received training during the month of February of 2023. In an interview on 02/27/2023 at12:30pm with ADMIN and HR Director, both said that facility stopped using the contractor agency (Shift Key) that CNA F contracted with in December of 2022, but they could provide a copy of the invoices that would show the date and time contracted staff worked. Both indicated that CNA F is not contracted with contractor agency (KARE) the facility is currently using. ADMIN said that the contractor portal for KARE has an option to select contracted staff as do not return, but she was not sure if that was an option for Shift Key. In a phone interview on 02/27/2022 12:35pm with the General Manager, he said that he is employed by the contractor agency KARE. He said that he did not have record that CNA F was contracted with their staffing agency. In an interview on 02/27/2023 at 12:40pm with the Staffing Coordinator she said that both contractor portals for KARE and Shift Key have an option to select contract staff as do not return. In a phone interview on 02/27/2023 at 12:55pm with ADMIN B, she said that incident took place on 07/19/2022 during the 3:00pm-11pm shift toward the end of the shift. She said that CNA F did not finish the shift after the incident. She said that she could not be certain, but she believed that RN H asked CNA F to leave the facility after the incident or CNA F left on her own. She said that during her investigation she contacted that the contractor agency that CNA F worked with to inform them of the incident, and she coded in the staffing agency portal as do not return on 07/25/2022. She said that there was a risk that CNA F could have returned to the facility to work from 07/20/2022-07/25/2022 because she was unaware of the incident. She said that she interviewed all staff that worked the hall of CR#50, and all the staff believed that the incident was reported the night the incident took place. In a phone interview on 02/27/2023 at 3:25pm with CNA G, she said that she witnessed CNA F slap CR# 50 in the face on 07/19/2022 during the 3:00pm -11:00pm shift. She said that she could not remember the exact time the incident took place, but it was between 9:00pm-10:00pm. She said that she did not see CR#50 hit CNA F prior to the slap. She said that she could not remember if CNA F hit CR#50 multiple times and she could only remember the slap. She said that she asked CNA F why she slapped CR #50, CNA F did not reply back to her, and CNA F walked out of the room. She said that she made sure CR #50 was lying in the bed. She said that she followed CNA F down the hall, CNA F clocked out, and CNA F left the building. She said that she could not remember the exact time CNA F left the building but it was shortly after the incident. She said that she found RN H at the nursing station after seeing CNA F leave, and she reported the incident to RN H. She said that she had been trained on abuse/neglect and reporting prior to the incident. She said that the incident should have been reported to ADMIN B immediately. She said that she did not report the incident because it was after hours, and she thought RN H would have called ADMIN B or the DON. She said that after the incident she was trained on abuse/neglect and reporting. She said that the risk of not reporting is that the abuse could continue. In an effort to complete a phone interview on 02/27/2023 at 3:33pm with RN I it was determined that the phone number was no longer in services. In an interview on 02/27/2023 at 3:40pm with the HR Director, he said that RN I had not worked at the facility since December of 2022. In an interview on 02/27/2023 at 3:41pm with RN H, she said that the incident took place on 07/19/2022 during the 3:00pm-11:00pm shift. She said that she could not remember the exact time of the incident, but the shift was almost over. She said that she was sitting at the nursing station charting, when CNA G came to her, and told her that CNA F hit CR #50. She said that she did not have to ask CNA F to leave the facility because she was already gone. She said that she asked CNA G where was CNA F, and she was told that CNA F left the building after the incident. In a phone interview with CNA K on 02/27/2023 at 3:51pm, she said that she worked the night of the incident involving CR #50 on the 11:00pm to 7:00am shift. She said that she arrived at 10:45pm. For her shift. She said that CNA G told her that a contractor CNA hit CR #50 in the face and left the building. She said that when she arrived to her the shift the contractor CNA was not there. She said that CNA G told her that she reported the incident to RN H who contacted ADMIN B. She said that she had been trained to report abuse/neglect to the administrator immediately prior to an after the incident. She said that the risk of not reporting immediately is that the abuse could continue. In an interview with CNA J on 02/27/2023 at 4:12pm, he said that he observed CR #50 with a fading bruise to her face on date he could not remember in July of 2022. He said that he was working with CNA K, and she told him that a contractor CNA had hit CR #50 in the face, but he could not remember the date of the incident. He said that CNA K said that the incident was reported by the staff working the night of the incident. He said that he took the information to RN I who went to ADMIN B. He said that he had been trained to report abuse/neglect to the administrator or DON immediately prior to the incident an after the incident. He said that the risk of not reporting immediately is that the abuse could continue. In an interview on 02/27/2023 at 4:15pm with CNA M, she said that she was contracted staff with KARE. She stated that she had been trained on abuse/neglect to include reporting. She was knowledge on types of abuse/neglect, and that all abuse/neglect should be reported to the ADMIN immediately. She denied that she has observed abuse/neglect of residents while working at the facility. She stated that there is training that you must complete on the contractor portal before you are scheduled which includes abuse/neglect. She stated that when she arrives to a shift, she receives training with the staffing coordinator before she can sign in for a shift. In an interview on 02/27/2023 at 4:20pm with CNA N, she said that she was contracted staff with KARE. She stated that she had been trained on abuse/neglect to include reporting. She was knowledge on types of abuse/neglect, and that all abuse/neglect should be reported to the ADMIN immediately. She denied that she has observed abuse/neglect of residents while working at the facility. She stated that there is training that you must complete on the contractor portal before you are scheduled which includes abuse/neglect. She stated that when she arrives to a shift, she receives training with the staffing coordinator before she can sign in for a shift. In an interview on 02/27/2023 at 4:25pm with CNA O, she said that she was contracted staff with KARE. She stated that she had been trained on abuse/neglect to include reporting. She was knowledge on types of abuse/neglect, and that all abuse/neglect should be reported to the ADMIN immediately. She denied that she has observed abuse/neglect of residents while working at the facility. She stated that there is training that you must complete on the contractor portal before you are scheduled which includes abuse/neglect. She stated that when she arrives to a shift, she receives training with the staffing coordinator before she can sign in for a shift. Record review of contractor invoices to include time reporting from 07/12/2022-12/31/2022 revealed that CNA F worked on 07/19/2022. CNA F clocked in at 3:00pm and clocked out 10:00pm with a 30 minute break. Record review of facility in-services from June 2022 through February of 2023 revealed that the facility trains staff quarterly for abuse and neglect. All staff were in-serviced on abuse neglect to include reporting on 06/07/2022-06/10/2022, 07/25/2022, 10/04/2022 by ADMIN B. All staff were in-serviced on abuse neglect to include reporting on 01/31/2023 and 02/22/2023 by ADMIN. Record review of the facility policy titled, Abuse and Neglect, with effective date October 2022 read in part, .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment, .VII. Reporting/Response (483.13(c)(1)(iii), 483.1 (c)(2) and 483.13 ( c )(4)): Have procedures to: All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. All allegations of abuse will be reported to HHSC immediately after the initial allegation is received This was determined to be a Past Noncompliance IJ that began on 03/01/23 and ended on 03/01/23. The Administrator was notified on 03/01/23 at 4:33 p.m and was provided with IJ template on 03/01/23 at 4:33 p.m. No plan of removal was required.

Based on interview and record review the facility failed to ensure that residents who were fed by enteral means received the appropriate treatment and services to prevent complications of an enteral feeding for 1 of 5 residents (CR#1) reviewed for enteral nutrition in that: -The facility failed to ensure staff accurately and fully reported CR #1's X-ray results to Physician A regarding placement of her [DEVICE]. -The facility failed to ensure that nursing clinical staff were trained to reinsert CR #1's gastrostomy tube. -The facility failed to ensure diagnostic study results confirmed placement of CR #1's gastrostomy tube before restarting medications and feedings. -Nursing staff failed to thoroughly, accurately assess and treat CR #1 for a change in condition. CR#1 was transferred to the hospital where she was found to have peritonitis [MEDICAL CONDITION] due to a misplaced peg tube. CR #1 subsequently developed [MEDICAL CONDITIONS], required intubation and later passed away. An IJ was identified on 12/10/19. While the IJ was lowered on 12/12/19, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy. These failures affected one discharged resident and placed her at risk of injury, harm, delayed medical treatment, hospitalization and death. Finding include: CR #1: Record review of CR #1's admission face sheet revealed she was a [AGE] year-old female, who admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. She was discharged to the hospital on [DATE]. Record review of CR #1's significant change in status/5-day MDS assessment dated [DATE] revealed she had a SAMS score of 3 indicating severely impaired cognitive skills for daily decision making. She was totally dependent on the assistance of 1 staff for eating. She was documented as having received 51% or more of her daily calorie intake from a [MEDICATION NAME]/tube feed for 7 of the past 7 days of the assessment period. She was documented as having received 501 cc/day or more via IV/tube while a resident for 7 of the past 7 days of the assessment period. Record review of CR #1's undated care plan revealed the following: -Resident exhibits non-verbal indicators of pain due to problems with communicating needs to staff, give pain medications daily prior to wound care .Goals and target date 6/11/19 Resident will exhibit no further non-verbal indicators of pain .Interventions .*Monitor for worsening of resident's non-verbal indicators of pain and report to physician .*Monitor resident behavior to determine pain level. Record review of CR #1's Physician Orders for the month of (MONTH) 2019, revealed the following physician orders: Flush gtu-be with 200cc water every 8 hours. -bowel rest 2 hours daily from 6am to 8 am (off @ 6am, on @ 8am) -clean [DEVICE] site with wound cleanser and (sic) pad dry then put split 4X4 (sic) gauze every shift. -Assessment of pain q shift Scale used 1=Verbal descriptor 2= facial grimace scale 3= Activity tolerance scale -NPO. -Change spike set with each new feeding hung. -Check G Tube for proper placement with 10-30cc of air before infusion of meds or formula Q shift. -Flush [DEVICE] with 60cc (sic) H2o before and after administration of meds. -Give 5 cc of H20 between crushed meds and liquid medication per [DEVICE] . - Check residual before feeding Qshift if >150cc. Hold feeding and notify MD. -[MEDICATION NAME] cal 1.5 per g tube at 50 cc continuously. -[MEDICATION NAME] 75 mg tablet- give one tablet via [DEVICE] daily. -[MEDICATION NAME] hcl 50 mg tablet-----give 1 tab per feeding tube every 4 hours as needed for pain. -[MEDICATION NAME] 10 mg tablet - give 1 tab per [DEVICE] twice daily. -[MEDICATION NAME] 5 mg tablet-give one tablet via [DEVICE] twice daily. -[MEDICATION NAME] 150 mg tablet give 1 tablet per tube twice daily. -[MEDICATION NAME] hcl 0.1 mg tablet -give 1 tab via peg tube bid. -Vitamin c 500 mg tablet - give 1 tab via peg tube daily. -Zinc sulfate 220 mg tablet - give 1 tab via peg tube daily. -Ningxia wolfberry supplement--- give 10cc via peg tube daily. Record review of CR #1's Departmental Notes revealed the following documentation by RN A on 5/25/2019 at 5:56 AM, bowel rest given between 3:55 am to 5:55 am due to functional issue with tubing, oncoming nurse informed that CR #1 will not need bowel rest between 6am and 8am. RN A then documented on 5/25/19 at 6:02 AM, [MEDICATION NAME] HCL 50 mg tablet-give 1 tab .prn administered .pt noted moaning most of shift, CNA staff advised that patient moans every night, med given for possible pain. RN A went on to document on 5/26/19 at 5:37 AM, (sic) approx 5am CNA A had found that resident pulled out her [DEVICE] 20fr with 10cc bulb intact, 18fr 20cc bulb [DEVICE] was reinserted back into patient, placement verified via auscultation with air bolus, patient denies pain at this time, resp e/u, no s/sx of distress at this time, vitals stable, pending MD orders for KUB (xray) verification of placement, (family member name) notified of occurrence. There was additional late entry documentation by RN A on 5/26/19 at 5:51 AM that [MEDICATION NAME] HCL 50 mg tablet-----give 1 tab .late entry 1:25 am, pt moaning. Followed by 5/26/19 7:12 AM Medication Follow-up- [MEDICATION NAME] HCL 50 mg tablet-----give 1 tab) Medication was effective. Record review of CR #1's facility provided copies of Physician's telephone orders dated 5/26/19 at 0515 and signed by RN A, read as follows; Replace [DEVICE] due to [DEVICE] dislodgement V.O.R.B/Physician [NAME] A second order by RN A, dated 5/26/19 at 0525, which read, (MONTH) replace [DEVICE] c` 18 fr due to 20 fr unavailable. Order stat KUB to verify g tube placement. Hold [DEVICE] feeding until further notice from MD V.O.R.B/Physician [NAME] Record review of facility Departmental Notes on 12/10/19 at 12:42 pm revealed there was no nursing documentation of physician notification of KUB results or documentation regarding resumption of CR #1's enteral tube for feeding or medication administration. Record review of CR #1's facility provided, Radiology Report dated 5/26/19 at 09:27 am read in part: .Examination: XRAY ABDOMEN 1 VIEW . Results: .There is a tube overlying the upper abdomen. Tip appears to be in the region of the gastric body. On the 2 -dimensional plain x-ray image, it is not possible to accurately locate the exact position of the [DEVICE] . Interview on 12/05/19 at 4:00 pm with the DON about CR #1, she said that CR #1 was discharged the last time because her PGT had become dislodged and RN A had called Physician A and got an order to reinsert it. The DON said that placement of the reinserted PGT was confirmed by auscultation and x-ray and after that, an order was received from Physician A to restart CR#1's feedings. She said later on in the day CR #1 ran a fever and was sent to the hospital and never returned to the facility. She said she found out later through another staff member who had kept in touch with CR #1's family after discharge, that CR #1 had passed away in (MONTH) or July. The DON said that after CR #1's last discharge from the facility, CR #1's family came back about 1 week later and accused the staff of putting the PGT in incorrectly. She said the family told them that the nurse did it wrong and told the DON that was the reason why CR #1 was hospitalized . Interview with DON on 12/5/19 at 7:00 pm with the Administrator present, when asked why there were no physician progress notes [REDACTED].#1 on 5/26/19, the DON said there were nursing progress notes. When asked why there were no nursing progress notes regarding CR #1's condition and physician notification of resumption of [DEVICE] for enteral feeding and medication administration, throughout the 8-12 hour shift on 5/26/19 the DON said she did not know but felt that perhaps LVN A's progress note proved physician notification and did contain vital signs. The DON said that RN A's progress note had confirmed reinsertion but also said the documentation could have been better. Telephone interview with Physician A on 12/10/19 at 10:53 am who said he that from what he remembered of CR #1, she had an obstructed [DEVICE]. He said he received a call from the nurses that reported CR #1 was having abdominal pain and that the tube was out, so he gave an order to replace the tube and confirm placement with a stat KUB. He said that 6-8 hours after the reinsertion, CR #1 was having recurring pain and the nurse tried to trouble shoot issues but could not get the [DEVICE] patent so he gave an order to send the resident to the ER for evaluation of possible [DEVICE] dislodgement. When asked if the nurse read the entire KUB radiology report to him over the telephone, he said no, he was just told that the KUB looked good. Physician A was then read the entire radiology report dated 5/26/19 at 09:27 am, that included the following passage: Examination: XRAY ABDOMEN 1 VIEW .Results: .There is a tube overlying the upper abdomen. Tip appears to be in the region of the gastric body. On the 2 -dimensional plain x-ray image, it is not possible to accurately locate the exact position of the [DEVICE]. Physician A said the results were a normal template that radiologists used in reporting. He said that if the [DEVICE] was not in the right area, the radiologists report would have to say so. He said the report would have to specifically say that it was not visualized in place. Telephone interview with LVN A on 12/10/19 at 1:21 pm who said she remembered working with CR #1 on the day she went to the hospital. She said CR #1's [DEVICE] had come out the night before on the night shift and per the night nurse, it had been replaced the night before with no pain other than her normal leg pain. She said that CR #1's behavior and vital signs were all within normal limits for CR #1's baseline. LVN A said that CR #1 was medicated for pain during her shift, but the pain was related to ulcers/wounds CR #1 had. She said that during her shift the [DEVICE] flushed fine and there was no residual or little to none. LVN A said after the KUB was done, she waited for the results and read them to Physician [NAME] LVN A said she did not remember anything standing out to her in the report or she would have asked Physician A to send CR #1 out to the hospital. LVN A was read the following passage from the Radiology Report dated 5/26/19 at 09:27 am: Examination: XRAY ABDOMEN 1 VIEW .Results: .There is a tube overlying the upper abdomen. Tip appears to be in the region of the gastric body. On the 2 -dimensional plain x-ray image, it is not possible to accurately locate the exact position of the [DEVICE]. LVN A then stated, well, that it would've been his call. LVN A said she did not necessarily remember that part of the report standing out to her specifically and said it was ultimately the decision of Physician A, to restart CR #1's feedings and she followed the orders. LVN A repeated, it would've been his call. LVN A said she assessed CR #1 and her stomach was no harder than usual and felt like it was within normal for CR #1. LVN A said she got an order later on in her shift to send CR #1 to the hospital per the family request. LVN A said she reassessed CR #1 when the family complained, she said she auscultated and palpated CR #1's abdomen and it was fine. She said she also checked CR #1's vital signs and they were also normal. LVN A said she was trained when she started working at the facility on [DEVICE]s and that she received a refresher course at least once during the year. LVN A said she could not remember who conducted the course which was an in-service and check off competency, mostly on medication pass. LVN A said she would not be comfortable reinserting any [DEVICE]s and would call the MD for orders to have a resident sent out if ever a [DEVICE] came out on her shift. Interview with RN A on 12/11/19 at 1:54 pm she said that she had been trained by the facility on [DEVICE]s. She said that every facility she had worked at, did go over [DEVICE] medication pass and that this facility did their training via in-servicing and checklists. She said that during the last training for state readiness, they just went through the facility's policy and procedure and the steps on what to do for [DEVICE] medication pass and [DEVICE] reinsertion, but not necessarily a return demonstration. Record review of CR #1's MAR for the month of (MONTH) 2019 revealed staff documented they had administered medications on 5/26/19 after RN A had reinserted CR #1's dislodged gastrostomy tube. They documented with their initials and a checkmark indicating Administered per the legend on the document. The following medications were documented by LVN A as being given: [MEDICATION NAME] 5 mg tablet, [MEDICATION NAME] 75 mg tablet, [MEDICATION NAME] 10 mg tablet, [MEDICATION NAME] HCL 50 mg tablet, [MEDICATION NAME] 150 mg tablet, [MEDICATION NAME] HCL 0.1 mg tablet, vitamin c 500 mg tablet zinc sulfate 220 mg tablet, Ningxia wolfberry supplement. Also, the tube was documented as being flushed with 200CC WATER. Blood pressure readings were documented as being exactly the same at both 9 am and 5 pm at 138/83. Record review of facility Departmental Notes on 12/10/19 at 12:42 pm revealed there was no nursing documentation of physician notification of KUB results or documentation regarding resumption of CR #1's enteral tube for feeding or medication administration. There were no written physician's orders found, for CR #1 to resume the use of her gastrostomy tube for feeding or medication administration. Record review of CR #1's MAR for the month of (MONTH) revealed LVN A documented CR #1's pain level on 05/26/19 at 10:04 AM and again at 4:34 PM as being a 3, indicating activity intolerance per the legend. At 2:30 PM LVN A documented CR #1's pain level as being a 2 indicating facial grimace per the legend. At 2:30 PM LVN A also documented that she had checked CR #1's G Tube for proper placement with 10-30cc of air. There was no further documentation on CR #1's pain response or tolerance to the [DEVICE] check at that time. Record review of CR #1's MAR for the month of (MONTH) 2019 revealed RN A documented with her initials and a checkmark indicating Administered per the legend on the document, that she completed the following on CR #1 on 5/26/19: .Assessment of pain q shift . Scale used 1=Verbal descriptor 2=facial grimace scale 3=Activity tolerance scale. 06:30 AM Pain Scale 0/1, indicating CR #1 gave a verbal descriptor of having 0 out of 10 rating for pain. -Check G Tube for proper placement with 10-30cc of air before infusion of meds or formula Q shift. at 6:30 AM. -Flush [DEVICE] with 60cc (sic) H2o before and after administration of meds at 6:30 AM. -[MEDICATION NAME] HCL 50 mg tablet-----give 1 tab per feeding tube every 4 hours as needed for pain. at 1:25 am. - Check residual before feeding Qshift if >150cc. Hold feeding and notify MD at 6:30 AM. -Intake Q Shift. Documented at 6:30 AM as 206. -Bowel rest 2 hours daily from 6am to 8 am (off @ 6am, on @ 8am) Documented at 06:00 AM. Followed by, -bowel rest 2 hours daily from 6am to 8 am (off @ 6am, on @ 8am) Documented as N for not administered per the legend on the document at 8:00 AM. -[MEDICATION NAME] cal 1.5 per g tube at 50 cc continuously. Documented at 06:30 AM as administered per the legend on the document. There was no physician order to restart enteral feeding at this time. There was no SBAR, change in condition or head to toe nursing assessment completed or documented and no mention of [DEVICE] site assessment. Record review of CR #1's Departmental Notes revealed LVN A documented the following on 5/26/2019 at 6:00 PM, Pt family stated pt was in pain when they arrived, family wanted b/p checked, b/p 126/85, p 112, resp, 18, family stated that pt was in distress and needed to be taken to the hospital, contacted on call md for pt, md stated possible [DEVICE] dislodgement and to send her out, called 911 and paramedics arrived and transported pt to hospital. pt had previously pulled out [DEVICE] and a new tube placed this am, KUB was ordered and placement verified, pt had tolerated meds this shift, only 10 cc of residual noted when (sic) asperated, pt did receive pain med for pain to the right foot, pt was transported via ambulance to local hospital . Record review revealed another order dated 5/26/19 and signed by LVN A at 6pm, read, Resident sent to .local Hospital per RP request [DEVICE] replacement. Record review of CR #1's hospital records dated 5/26/19 at 5:43 pm read in part: .Triage Chief complaint : Pt presents with [MEDICAL CONDITION] tremors, and [MEDICAL CONDITION]. EMS called for PEG tube being pulled out. NH (name) replaced. Pt (sic) grimicing when lower abdominal area touched. A&O x 0 baseline. Hx of CABG, [MEDICAL CONDITION]. Bilateral deficits Reason for Visit_ED : [MEDICAL CONDITION] or Shock . Record review of CR #1's hospital radiology results dated on 5/26/19 at approximately 9:18 pm, of ED abdomen/Pelvis IV contrast only CT, read in part, as follows: 05/26/19 .Impression: Moderate amount of pneumoperitoneum. Moderate ascites. The PEG tube is located outside the stomach at the inferior aspect of antrum . Record review of CR #1's hospital records Discharge Summary, signed 6/11/19 at 6:06 pm read as follows: .Hospital course 75 y.o with a h/[MEDICAL CONDITION] dysphagia presented to ER with peritonitis [MEDICAL CONDITION] due to a dislodged peg tube. Went to the OR for ex lap with wash out and closure of gastrostomy. Developed [MEDICAL CONDITION] and required intubation. Later had a [MEDICAL CONDITION] placement since was unable to be liberated from the vent. GI placed another peg later in the hospital course . Interview on 12/05/19 at 4:00 pm with the DON about CR #1, the DON said that CR #1 had admitted from another facility and had resided at the facility for about a year. The DON said CR #1 had bad, infected wounds upon admission and other injuries she had suffered as a result of a bad fall at another facility. The DON said CR #1's family was very involved and there had been some conflict during her stay because the family constantly disagreed with physician orders and recommendations. The DON said that CR #1 had frequent infections and was constantly in and out to the hospital due to over-all poor condition and wounds. The DON said that CR #1 was discharged the last time because her PGT had become dislodged and RN A had called Physician A and got an order to reinsert it. She said later on in the day CR #1 ran a fever and was sent to the hospital and never returned to the facility. The DON said they could not get CR #1's medical records from the hospital after her discharge, but informed the family at that time, that according to the facility policy and procedure an RN could reinsert a PGT and that the staff working had followed physician orders and placement was confirmed through nursing auscultation and KUB. The DON said RN A did not really work at the facility anymore, because she had been prn and was so prn that she rarely if ever picked up any shifts and had not worked in months. She said that LVN A still worked at the facility but only on the weekends. The DON said that CR #1's family did not like LVN A but that she did not know why. During an interview on 12/5/19 at 4:15 pm with the Administrator regarding CR #1, she said the facility IDT met with the family repeatedly and there were grievances that were always addressed. The Administrator said she was not sure if any of the grievances related to CR #1's [DEVICE] and would have to check. The Administrator said that she and the DON essentially had a care plan meeting with CR #1's family about 1-2 weeks after CR #1's last discharge. She said they mostly discussed whether or not the facility could meet CR #1's needs. She said CR #1's family mentioned something about nurses not being able to reinsert the feeding tubes but that she mostly discussed with them, whether or not CR #1 was returning to the facility because the family was asking if she could return. Interview on 12/5/19 at 4:45 pm the DON said that CR #1 had some of her medical records and physician orders missing. She said that all of CR #1's orders were missing from (MONTH) through (MONTH) 2019 and she would have to follow up with the medical records department. She said medical records department would be the only place the orders would be and she did not know why those orders were not with the rest of CR #1's chart. The DON said she was sure the orders had been there because she remembered looking at them and checking them at the time of CR #1's family complaint about the [DEVICE]. She said she believed the orders must have been somehow misfiled. Interview with LVN B on 12/10/19 at 9:22 am she said that she was trained on [DEVICE]s during her orientation. She said she remembered things like, hand washing, separating each medication individually for med admin, flushing between meds, assessing the site for signs/symptoms of infection or abnormalities and how to check for residual and placement. She said that basically she just follows the PGT orders. She said that if a [DEVICE] comes out, she is supposed to call the doctor and get orders. She said that most of the doctors say to send the resident out to the hospital, but some will say to place a Foley to keep the site patent and then send the resident to the hospital. When asked if she had been trained on putting a Foley in, to keep the site patent, she said no. She said she had no specific training on how to reinsert a [DEVICE]. Telephone interview with Physician A on 12/10/19 at 10:53 am who said he was one of the attending physicians for CR #1. He said he wrote a note about this on a handwritten statement not an MD progress note. He said he was told by the nurse, that CR #1's family was present at the facility and they were requesting to send CR #1 out to the ED. Physician A said he had no problem with that and gave the nurse the order to send CR #1 to the ED for further evaluation for possible dislodged [DEVICE]. Physician A said CR #1 had previous history of GI and [DEVICE] obstruction. He said after that he spoke with a colleague at the hospital that told him CR #1's [DEVICE] had been significantly obstructed related to the residents' chronic GI issues. He said they told him, CR #1 transferred to an LTAC and then back to LTC. He said from what he remembered, CR #1's family had some issues with a nurse or nursing and that one of CR #1's family members was an NP or something. He said he communicated with her constantly, basically every other day on MWF. He said she initially had issues with the doctors because she wanted to know why a Dr. did not see the resident daily, but he said after the SNF/LTC setting was explained to her she got better, but then had some issues with nursing. He said her expectations did not seem to match the LTC nursing home and it seemed like she wanted more LTAC. He said in this instance he did not believe the nurses could have done anything differently. He said that CR #1 had a previous obstruction related to all her complexities before and they discussed this with the family when CR #1 admitted to the facility and the family kept saying everything was okay with the tube at that time. He said that he was not familiar with the specifics for the facilities policy and procedure on [DEVICE] reinsertion but he knew the nurse that reinserted the [DEVICE] was an RN. He said he was aware of and gave verbal orders to reinsert a different sized [DEVICE] based on what was available at the time and he also recalled giving a verbal order to restart CR #1's [DEVICE] feeding after receiving the KUB results from the day shift nurse. Record review of the written statement containing the same information as above, and signed by Physician A and dated 12/6/19, was observed in additional information provided by facility which read in part: I was attending physician for CR#1. On 5/26/19 I was notified by the night shift RN, that her [DEVICE] was dislodged, I gave a verbal order to replace it in the facility. I also ordered a STAT KUB X-Ray to check for placement. I was aware that the 20 French [DEVICE] was not available and that an 18 French would be inserted. I gave the order to hold the feeding until the KUB results came back. The day shift Charge Nurse called me mid-morning and read me the results of the KUB, at that time I gave the order to restart the feeding, the results were also faxed to my office. Later on the same day, the nurse notified me that the family was in the facility and was concerned about her pain and wanted to (sic) sent to the ER, I gave the order to send her to the ER. Interview on 12/10/19 at 12:08 pm with DON, with Administrator present, when asked what she did when CR #1's family returned to the facility and reported their concerns with the [DEVICE], the DON said that it was 2-3 weeks after CR #1 was sent to the hospital before the family came back. She said the family said that CR #1 had been trached and did not blame anyone specifically but also told them that they did not believe that a nurse could reinsert a [DEVICE]. The DON said this seemed to be their main issue. The DON said CR #1's family kept arguing about what was in the nursing scope of practice and she kept reassuring them that an RN could reinsert/change a [DEVICE]. When asked if she had read the Texas BON recommendations regarding [DEVICE]s, she said yes, she had read it. When asked if any type of QAPI, PIP or IDT meeting had been done after the family raised concerns, she said no. The DON said CR #1's family did not like or care for LVN A for some reason, and they had expressed that they felt like LVN A had not reacted or responded quickly enough. She said the family member/s said they felt like LVN A did not take their concerns seriously enough because LVN A waited for a physician order to send CR #1 out to the hospital instead of just calling 911. The DON said that she informed the family that LVN A had followed the procedure, because CR #1 was stable and her vital signs and everything were stable at the time, so LVN A did not call 911 at that time and notified the MD of the concerns. The DON said LVN A reported that it took all of 5 minutes to notify the MD and get the order. The DON said that she had not really reviewed the nursing documentation at the time of CR #1's hospitalization and said that the documentation should have been better. She said she did not counsel or reeducate LVN A or RN A on documentation at that time. Interview with the Administrator on 12/10/19 at approximately 12:12 pm, who said they (the facility), did everything they knew to do at the time. The Administrator said that CR #1's family was asking if the facility could/would take her back and they were told that CR #1 would be accepted back if they wanted. The Administrator said the meeting was like and actual mini care plan meeting, but when asked if she documented anything they discussed, she said no. The Administrator said the meeting mostly focused on whether or not the facility could meet CR #1's needs and the family members expectations, if she returned, due to the family members previous concerns throughout CR #1's previous stay. When asked if any type of QAPI, PIP or IDT meeting had been done after the family raised concerns, she said no. Interview with DON on 12/10/19 at approximately 12:18 pm she said that they did not have a specific curriculum of [DEVICE] insertion or reinsertion. The DON said there was a general training on [DEVICE]s during nursing orientation at the facility upon hire and again annually. She said the facility training was more of a generalized checklist on [DEVICE]s related to [DEVICE] medication administration. When asked about any specific documented training any of the staff RN's had been given at the facility, the DON said no, she did not have anything except the orientation checklists which mainly referred to [DEVICE] medication administration. When the DON was asked about any return demonstrations as part of the [DEVICE] insertion/reinsertion training, she said that she and the Administrator had been discussing the facility policy and procedure on [DEVICE] reinsertions and that the facility will most likely no longer allow nurses to do them. The DON was asked who did the [DEVICE] training and she said that the Medical Director trained her and delegated her to complete the staff training on [DEVICE]s. She said she did not have a curriculum or competency delegating her to train on [DEVICE]s or [DEVICE] reinsertion, documented anywhere. The DON said that [DEVICE] reinsertion was not something that could really be demonstrated back, in the SNF setting because they would not discontinue a [DEVICE] on an actual resident and then reinsert it. The DON said that was why she and the Administrator had just been discussing revising the facility policy and procedure. The DON said there had been no other specific training on [DEVICE]s or [DEVICE] reinsertion before (MONTH) 2019, that she could find copies of. Interview with LVN C on 12/10/19 at 1:00 pm she said she had been working at the facility for the last 3 years. LVN C said she was trained by the facility on [DEVICE] site care and how to give medications. She said she was trained when a [DEVICE] comes out or gets dislodged, she was supposed to call the doctor and get orders. She said if needed, she could put a Foley catheter in the site to maintain patency. LVN C said she had never had a [DEVICE] come out or get dislodged and had never inserted a Foley catheter to keep a site patent. She said that if a doctor gave her an order to reinsert a [DEVICE], she would get someone else to carry out the order, because she had not been trained to do that. LVN C said the [DEVICE] training on medication administration was at least twice a year and that the pharmacist usually did the training. She said that her training had been in-service only, with no return demonstration, just a check-off and initial. Interview with RN A on 12/11/19 at 1:54 pm she said that on the night of the incident with CR #1, CNA A notified her that that the residents [DEVICE] was out and she went to the bedside to assess how long it had been out. RN A said she determined it had not been dislodged long because the tubing was still in CR #1's hand with the balloon inflated and there was very little feeding spilled onto the bed or bedding. She said she palpated CR #1's stomach/abdomen, auscultated her lung sounds, and assessed her vital signs and all were within normal limits or range for CR #1. She said that CR #1 was non-verbal and spoke Spanish but could still communicate to let anyone know whether or not she was in pain. She said that CR #1 would wince, facial grimace or nod her head and she said when she palpated CR #1's stomach that night of the incident and the pain response was not there, she said she checked CR #1's vital signs B/P and pulse with auto cuff, temperature and O2 saturation levels are all okay. She said she called Physician A and reported her findings and got orders which she carried out. She said CR #1 was stable after the reinsertion and she called her family to let them know as well. She said she gave LVN A report when she arrived to take over and they were pending a KUB for confirm placement. RN A said she placed CR #1's enteral feeding and medications on hold and did not administer anything after the reinsertion on her shift. She said when she rechecked CR #1 before the end of the shift, CR #1 was asleep and appeared to be in no distress. She said she did not reassess her abdomen. RN A said that she did give CR #1 prn pain medication during her shift because CR #1 was moaning, but that was before the [DEVICE] became dislodged.