Every finding on record at Park Manor of Tomball

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 3 of 9 residents (Resident #1, # 86 and #95) reviewed for pharmaceutical services.The facility failed to ensure Resident # 95 received Levothyroxine daily as prescribed by the physician.The facility failed to administer the correct dose of Metoprolol (an antihypertensive medication) as physician ordered to Resident #1 on 03/25/26. The facility failed to administer Clonidine (an antihypertensive medication) as physician ordered when Resident #86's systolic blood pressures were greater than 150 on 03/01/26, 03/02/26, 03/03/26, 03/04/26, 03/07/26, 03/17/26, 03/16/26, 03/17/26 and 03/20/26.These failures could place residents receiving medications at risk of inadequate therapeutic outcomes, reduced quality of life and hospitalization.Findings included:Record review of Resident #95's undated face sheet revealed he was a [AGE] year-old male who admitted on [DATE]. His diagnoses were hypothyroidism (low thyroid hormone levels), hypertension, heart disease, and protein calorie malnutrition.Record review of Resident #95's Initial MDS assessment dated [DATE] revealed a BIMS score 15 of 15 which indicated cognitively intact and he can understand and respond appropriately to questions. Record review of Resident #95's Physician Orders dated 03/22/2026 revealed Levothyroxine Sodium Oral Tablet 75MCG, give 1 tablet by mouth in the morning related to HYPOTHYROIDISM with a start date on 03/23/2026.Record review of Resident #95's eMAR dated 03/24/2026 revealed Resident #95 did not receive a check mark for medication received, but a number 9 which indicated a nurse's note has been attached to the eMAR by LVN L. Record review of Resident #95's Nurses Note dated 03/24/2026 at 5:02am revealed Levothyroxine Sodium Oral Tablet 75MCG- Give 1 tablet by mouth in the morning related to HYPOTHYROIDSIM Awaiting Pharmacy. Author: LVN L [e-SIGNED]During an interview with Resident #95 on 03/24/2026 at 10:17 a.m., he stated he had not received his Levothyroxine for the past two days due to staff reporting that the medication was unavailable and needed to be ordered . During an interview with LVN L on 03/25/2026 at 2:29 p.m., she stated that Levothyroxine for Resident #95 is scheduled to be administered daily between the hours of 4:00 a.m. and 6:00 a.m. On the morning of 03/24/2026, prior to medication administration, she realized the medication was not available. She reported she was unsure whether the medication was available in the e-kit due to the e kit computer rebooting and the screen remaining blank, which prevented her from logging in. LVN L stated she did not notify the physician of the missed dose but did notify the DON. She further stated the medication was reordered to arrive later that evening, resulting in the resident not receiving the medication on 03/24/2026. The failure to administer Levothyroxine as ordered placed the resident at risk for fluctuations in thyroid hormone levels, potentially affecting metabolic function.During an interview with the DON on 03/25/2026 at 4:47 p.m., she stated she asked LVN L why the e-kit was not utilized when the Levothyroxine was unavailable. The DON reported LVN L informed her that the e kit system was not functioning and the screen was completely shut down, preventing access. The DON confirmed the e kit system was down at that time and stated she reset the system. The DON stated she notified the nurse practitioner regarding Resident #95 and that LVN L was re educated on proper medication administration procedures, including the use of the e kit for commonly prescribed medications. The failure to administer the medication as ordered placed the resident at risk for not following physician orders and for impaired thyroid function, which could adversely affect metabolic regulation .During an interview with the Administrator on 03/25/2026 at 4:50 p.m., he stated the expectation for medication administration includes following the physician's orders and verifying the availability of medications in the e-kit prior to reordering. The Administrator stated that failure to follow physician orders and utilize available medications could place residents at risk for adverse outcomes.Record review of New E-kit Inventory List dated 03/25/2026 revealed 8 tablets available for Levothyroxine 75MCG.Record review of Resident #1's face sheet dated 03/25/26 revealed a [AGE] year-old admitted to the facility 03/03/26. Resident #1's diagnoses included Hemiplegia (one sided paralysis or severe loss of strength on one side), Hemiparesis (weakness to one side of body), pneumonitis (swelling and irritation of lung tissue) due to inhalation of other solids and liquids, malnutrition, Dementia (a general term for a group of symptoms that cause a loss of cognitive functioning), hypertension (elevated blood pressure) and atrial fibrillation (irregular heartbeat).Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 3 out of 15 indicating severe impaired cognition. Resident #1 had impairment to the upper extremity on one side of the body. He used a manual wheelchair for mobility. Resident #1 was dependent on staff assistance for oral hygiene, toileting, bathing, dressing, personal hygiene and transfers. He was always incontinent of bowel and bladder. He had a feeding tube to provide nutritional support.Record review of Resident #1's undated care plan revealed: Focus - Resident #1 had hypertension r/t stroke. Goal - Resident #1 will remain free from s/sx of hypertension through the review date, 06/16/26. Interventions included - give antihypertensive medication as ordered; obtain blood pressure readings; take blood pressure readings under the same conditions each time.Record review of Resident #1's active physician orders revealed an order for Metoprolol tartrate 25mg, give 0.5 tablet via G-tube, BID for HTN, hold if SBP < 110 or HR <60. The order date was 03/03/26. Observation on 03/25/26 at 7:30 AM, LVN B checked Resident #1's vital signs: blood pressure was 122/75 and pulse was 68. LVN B prepared medications including the bolus feeding formula for Resident #1. LVN B asked LVN E to retrieve Metoprolol from the medication room d/t Resident #1 did not have a supply in the medication cart. LVN B crushed each tablet separately and added 5ml water to each med cup to dissolve the medications. Resident #1 was easily woken up and when LVN B explained the procedure, Resident #1 said one word (an expletive). LVN B raised the HOB for Resident #1 to at least 30 degrees. LVN B performed hand sanitization, put on clean gown and gloves. LVN B unfastened the abdominal binder which was securing Resident #1's GT. LVN B attached the tip of the 60 ml syringe barrel (hollow cylindrical tube) to Resident #1's GT and poured 30ml of water into the barrel. The water infused via gravity. LVN B poured the first medication: Olanzapine 2.5mg into the barrel and followed with 5ml of water. The following medications were administered with 5ml to 10ml of water between each medication: Aspirin 81mg, Buspirone 10mg, Eliquis 5mg, folic acid 1mg, Multivitamin 1 tablet, Sacubitril-Valsartan 24-26mg, Valproic Acid solution 10ml and Metoprolol 25mg. LVN B poured 30ml of water after the last medication then poured the Isosource 1.5cal/ml, 250ml until all the formula was infused then flushed with 30ml of water. The medication pass was completed at 8:00 AM.Record review on 03/25/26 at 12:30 PM, during medication reconciliation of the medication pass, revealed LVN B administered Metoprolol 25mg to Resident #1 and not the physician ordered Metoprolol 25mg half a tablet.In an interview and observation on 3/25/26 at 12:45 PM, LVN B stated Metoprolol was given to Resident #1 for HTN. LVN B checked the eHR system and stated Resident #1 should have received half of the 25mg tablet of Metoprolol and was not aware the full 25mg of Metoprolol tablet was given. LVN B stated the risk of receiving a higher dose of Metoprolol than what the physician ordered was a drop in blood pressure. Resident #1 was sitting close to the nurse station in a wheelchair. Resident #1 was awake and in no distress. LVN B stated she would check Resident #1's blood pressure immediately then LVN B took Resident #1 down the hallway to his room.In an interview on 03/25/26 at 1:00 PM, the Unit Manager E stated the Metoprolol for Resident #1 was for HTN, to keep blood pressure within normal range and that if too much of the medicine was given the risk would be a drop in blood pressure. Unit Manager E stated when she retrieved the Metoprolol from the medication room for LVN B, she checked the order for Resident #1 and confirmed it was for half a tablet of Metoprolol 25mg. Unit Manager E stated she showed LVN B the medication which was still in the package and expected LVN B to follow the physician orders by splitting the tablet which was already scored. Unit Manager E stated she did not split the tablet herself because it was the responsibility of the administering nurse to do so. Unit Manager E stated going forward she would address the error with LVN B and review the rights of medication administration. Unit Manager E stated the five rights were: right route, right person, right dose, right time, right medication. Unit Manager E stated the expectation was for LVN B to look at what was written on the package and compare it to the MAR before administering.In an interview on 3/25/26 at 1:25 PM, the DON stated she was aware of the medication error by LVN B and that a medication error report and disciplinary action was completed. The DON stated the NP, who was in the building, was notified and Resident #1's RP was notified as well. The DON stated the plan was to check Resident #1's vital signs every hour. The DON stated the Metoprolol was usually in a blister pack from the pharmacy and when it was not in the medication cart LVN B asked for assistance. The DON stated LVN B told her she got distracted and was nervous. The DON stated the expectation was for LVN B to look exactly at the medication, the dose and then split the Metoprolol tablet. The DON stated that Metoprolol peaked 1 to 2 hours after administration. The DON stated the risk to Resident #1 would be low blood pressure and that was the reason why Resident #1 would be monitored for 24 hours. The DON stated that LVN B will never make the same mistake again. Record review of Resident #86's face sheet dated 03/25/26 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Resident #86's diagnoses included ESRD (end stage renal disease), dependence on renal dialysis, diabetes and cirrhosis of the liver (abnormal liver function). Record review of Resident #86's quarterly MDS dated [DATE] revealed a BIMS score of 10 out of 15 indicating moderately impaired cognition. Resident #86 was dependent on assistance for toileting, bathing, lower body dressing and personal hygiene. Resident #86 required supervision for eating, oral hygiene and upper body dressing. Resident #86 used a manual wheelchair for mobility. Record review of Resident #86's undated care plan revealed: Focus - Resident #86 had renal insufficiency r/t renal failure. Goal - Resident #86 will have no s/sx of complications r/t fluid deficit through the review date. Interventions included - Observe/document report to MD PRN the following s/sx: Edema; neck vein distention; difficulty breathing; increased heart rate; elevated blood pressure (hypertension). The responsible staff member listed was the Charge Nurse. Further review revealed there was no focus, goal or interventions addressing hypertension. Record review of Resident #86's active orders revealed an order for Amlodipine 10mg, give one tablet by mouth daily for HTN (hypertension), hold for SBP less than 110 or pulse less than 60. The order date was 02/12/26. Clonidine 0.1 mg by mouth PRN every 8 hours anytime the resident's systolic blood pressure is over 150. The order date was 02/27/26. Hydralazine HCL 25mg, give one tablet by mouth every 8 hours for HTN, hold for SBP <110. The order date was 02/08/26. Record review of resident #86's active MAR/TAR showed clonidine 0.1 mg was administered twice, once on March 6th 2026 and March 25th 2026. Record review of resident #86's recorded vital signs for the month of March 2026 revealed the following blood pressures which were unaddressed with PRN clonidine 0.1mg as per order: 03/01/26 at 3:27 PM = 152/6903/02/26 at 4:50 PM = 174/73 03/02/26 at 6:20 PM =155/8603/03/26 at 4:42 AM = 159/8903/03/26 at 7:31 AM = 159/68 03/03/26 at 11:10 PM = 156/7503/04/26 at 7:06 AM = 177/80 03/04/26 at 11:43 AM = 154/6903/07/26 at 2:12 AM = 168/74 03/13/26 at 8:14 AM = 151/7603/16/26 at 11:46 PM = 151/6503/17/26 at 7:00 AM = 156/5803/20/26 at 2:09 PM = 159/73 In an interview on March 26, 2026 at 9:50 am, MA A, stated that if a medication required a blood pressure reading prior to administration that MA A will take that blood pressure and that if it is out of range then MA A will report it to the nurse. MA A stated that if a PRN medication was needed then the nurse would make that determination and give it. In an interview on March 26, 2026 at 10:05 am, LVN A, stated that the medication aides generally take the residents' blood pressures, but that he will do it himself if they report to him that it is out of range. He said that if it's out of range when he checks it that he will recheck it in an hour. If it is still out of range at that point he will give a PRN medication and if that didn't correct the issue then he would call the physician. Specifically regarding Resident 86, LVN A stated that she is on dialysis and a lot of times her blood pressure is out of parameters so he keeps an eye on it. He said that when Resident 86's blood pressure is high he rechecks it after an hour. LVN A said Resident 86 gets dialysis and scheduled medications for blood pressure so LVN A won't give PRN medication right then, but if it gets really high then LVN A will give it. In a telephone interview on March 26, 2026 at 11:31 am, MD C, stated that the order was not being followed if the PRN clonidine was not given when Resident #86's systolic blood pressure was over 150. He stated that the nurse should follow the order rather than make the decision if Resident #86 gets that medication or not. MD C said that he would review Resident #86's chart and may make Clonidine a scheduled medication in order to prevent a nurse from attempting to make that decision themselves . In an interview on March 26, 2026 at 12:50 pm, the DON, stated that the expectations for staff are to take the resident's blood pressure, follow up in an hour by rechecking the blood pressure, and then give the PRN clonidine 0.1 mg if the blood pressure was still over 150 systolic. She stated that a nurse should not neglect to give the PRN after a 1 hour recheck when the vital sign meets the required parameters for that medication. Record review of the facility's policy for Administering Medications revised December 2012 read.Policy StatementMedications shall be administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation3. Medications must be administered in accordance with the orders, including any required time frame.Record review of the facilities policy for Emergency Medications Revised April 2007 read.Policy StatementThe facility shall maintain a supply of medications typically used in emergencies.Policy Interpretation and ImplementationThe emergency medication kit will include medications and biologicals that are essential in providing emergency treatment.Record review of the facility policy for Administering Medications, revised December 2012, read in part: .Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation.3. Medications must be administered in accordance with the orders, including any required time frame.7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medications.

Based on observations, interviews and record review, the facility failed to ensure all drugs and biologicals were stored securely for one of nine residents (Resident #86) and one of three medication carts (200 Hall nurse medication cart) reviewed for medication storage.The facility failed to keep resident medications stored securely. Two large white oblong tablets were found in Resident #86's possession with no nursing staff present.The facility failed to lock the 200 Hall nurse medication cart and secure an IV medication that was left on top of the cart prior to walking away. These failures could affect residents receiving medications placing them at risk of receiving the wrong medication, adverse side effects and drug diversion.Findings included:Record review of Resident #86's face sheet dated 03/25/26 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Resident #86's diagnoses included ESRD (end stage renal disease), dependence on renal dialysis, diabetes and cirrhosis of the liver (abnormal liver function).Record review of Resident #86's quarterly MDS dated [DATE] revealed a BIMS score of 10 out of 15 indicating moderately impaired cognition. Resident #86 was dependent on assistance for toileting, bathing, lower body dressing and personal hygiene. Resident #86 required supervision for eating, oral hygiene and upper body dressing. Resident #86 used a manual wheelchair for mobility. Active diagnoses included end stage renal disease and dependent on renal dialysis.Record review of Resident #86's undated care plan revealed: Focus - Resident #86 had renal insufficiency r/t renal failure. Goal - Resident #86 will have no s/sx of complications r/t fluid deficit through the review date. Interventions included - Resident/family/caregiver teaching to include the following: The importance of compliance with medications and dialysis treatment; Educate on the medications prescribed. Record review of Resident #86's active orders revealed an order for Sevelamer HCL oral tablet 800mg give 2 tablets by mouth with meals for CKD (chronic kidney disease). The order date was 02/02/26. Further review revealed there were no orders for self-administration of medications. In an interview on 3/25/26 at 6:30 AM, MA A stated Sevelamer was to be given with meals and would wait until Resident #86 received the breakfast tray at approximately 7:30 AM to administer the medication.In an observation and interview on 3/25/26 at 8:25AM, Resident #86 was in her room eating breakfast. On the tray were 2 large white oblong tablets in a clear 30ml medication cup. There were no nursing staff in the room. When asked what the pills were for and who gave them to her, Resident #86 did not reply. Resident #86 took each pill and swallowed them. The two tablets were marked with L025 and identified as Sevelamer 800mg tablets.In an interview on 3/25/26 at 8:55AM LVN A stated the 200 Hall medication aide was responsible for administering scheduled medications to Resident #86. LVN A stated he would watch a resident swallow a medication to ensure the medication was taken properly. LVN A stated it would be against policy and procedure to leave medications with a resident, and he would never do that. LVN A stated if Resident #86 refused the Sevelamer he expected to be notified by the medication aide so he could attempt to administer the medication himself. LVN A stated if nursing staff did not witness Resident #86 to consume the Sevelamer, the resident could throw away the medication, and the risk would be abnormal labs.In an interview on 3/25/26 at 9:45AM, MA A stated she watched Resident #86 swallow the Sevelamer tablets. MA A stated, Did she spit it out? MA A stated the Sevelamer was ordered to be given with meals and did not know why the tablets were on the breakfast tray.In an interview on 3/25/26 at 10:00AM, the DON stated she expected MA A to remain with Resident #86 until the medication was consumed. The DON stated medications should never be left alone with a resident but instead make sure they swallow the medication unless it is refused. The DON stated it was not ok for medications to be left out because another resident may come by and take medication that was not ordered for them.In an interview on 03/25/26 at 10:45AM, using the Spanish interpreter telephone line, Resident #86, stated that she took her morning dose of Sevelamer. She stated that it was given to her before her meal came and that the staff watched her take it. After further questioning, she said that she took it with her meal and that staff were not in the room when she took it. In an observation on 03/26/26 at 10:07 AM, LVN A was preparing medications for administration when called by another staff to assist a resident. LVN A walked away from the 200-hall nurse medication cart, entered a resident's room, and closed the door. The medication cart was left unlocked with an IV medication on top of the cart. LVN A was in the resident's room with the door closed for privacy. There was no direct line of sight to the unsecured cart. Two residents walked past the cart during this time. The medication cart remained untouched during this time. LVN A returned to the med cart at 10:10 am. In an interview on 03/26/26 at 1:12 PM, LVN A stated that the procedure was to ensure medications are secure by locking the medication cart. LVN A stated that he remembered accidentally leaving the medication out but didn't realize that the medication cart was left unsecured as well. LVN A stated locking the cart was forgotten and knew the cart needed to be secure to prevent a resident from walking by and taking medication left there. LVN A stated that the most recent in-service on securing medication was earlier this month (March 2026). Record review of the facility policy for Administering Medications, revised December 2012, read in part: .Medications shall be administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation.3. Medications must be administered in accordance with the orders, including any required time frame.7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medications.16. During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide.No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.Record review of the facility policy for Storage of Medications, revised on April 2007 read in part: .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe and sanitary manner.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 (Resident #9) residents reviewed for comprehensive assessments. The facility failed to ensure Resident #9's care plan addressed the resident's history of UTI (urinary tract infection) and interventions for UTI.These failures could place residents at risk of not having their individually assessed needs determined, monitored and met.Findings included:Record review of Resident #9's face sheet dated 03/25/26 revealed an [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Resident #9's diagnoses included Dementia (a general term for a group of symptoms that cause a loss of cognitive functioning), Hemiplegia (one-sided paralysis or severe loss of strength on one side), Hemiparesis (weakness to one side of body), stroke, urinary tract infection, atrial fibrillation (irregular heart beat), hypertension (elevated blood pressure) and depression.Record review of Resident #9's quarterly MDS dated [DATE] revealed a BIMS score of 9 out of 15 indicating moderately impaired cognition. Resident #9 had both UE and LE impairment to one side of the body. Resident #9 used a manual wheelchair for mobility. Resident #9 was always incontinent of bowel and bladder. Resident #9 was dependent on assistance for lower body dressing, toilet hygiene and bathing. Resident #9 required substantial assistance with bed mobility, transfers and personal hygiene. Resident #9 required moderate assistance with eating and oral hygiene. Section I - Active Diagnoses included urinary tract infection during last 30 days. Resident #9 was taking antibiotics and indication was noted for the medication.Record review of Resident #9's active physician orders revealed an order for Macrodantin oral capsule 50mg, give one capsule by mouth at bedtime for prophylactic (to prevent) UTI. The order was dated 08/18/25.Record review of Resident #9's March 2026 MAR/TAR revealed Macrodantin 50mg for prophylactic UTI was documented as administered daily at bedtime.Record review of Resident #9's undated care plan revealed the potential for UTI and the use of a prophylactic antibiotic to prevent a UTI was not addressed. In an interview on 03/26/26 at 10:11AM, the MDS Nurse stated the purpose of the care plan was to guide the care of the residents to ensure the plan was in the best interest of the residents and their care. MDS Nurse stated it was the responsibility of the unit managers and MDS Nurse to update the care plan. The MDS Nurse stated she did not know why Resident #9's history of UTI and the interventions for Macrodantin as prophylaxis for UTI was not included in the care plan. The MDS Nurse stated she was not an employee of the facility in August 2025, was new to the position and currently catching up, reviewing all resident's care plans. The MDS Nurse stated UTIs should be addressed in Resident #9's care plan as well as monitoring behaviors r/t UTIs and the nursing team should be using the care plan as a guide for the resident's benefit.In an interview on 03/26/26 at 11:30 AM, the DON stated Resident #9's UTI and antibiotic treatment should be part of the plan of care. The DON stated Resident #9 started on the Macrodantin in August 2025 and the person responsible was the MDS Nurse who should have made the additions in the care plan. The DON stated Resident #9's RP was insistent on the antibiotic because of recurrent UTIs. Record review of the facility's policy for Care Plans - Comprehensive, revised on December 2009 read in part: .An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change. 3. Each resident's comprehensive care plan is designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems.e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care.

Based on observation, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety reviewed for 1 of 5 (Dietary Manager) kitchen staff members. The facility failed to ensure food service staff wore appropriate hair nets while in the kitchen and food was being prepared.This failure had the potential to contaminate food and affect residents' health and safety.Findings included:During an observation and interview on 03/24/2026 at 8:11 am the Dietary Manager was cleaning the kitchen floors without wearing a hairnet. The Dietary Manager stated she had just returned from bringing the water hose inside to clean the floors. She stated she knew she should have word a hairnet due to the risk of hair contaminating food.During an interview with the Administrator on 03/25/2026 at 8:30am The Administrator stated that staff are expected to wear hairnets immediately upon entering the kitchen. The Administrator stated that failure to wear hairnets poses a risk for food contamination. Record review of the facilities policy for Staff Hygienic Dress Code Policy Statement undated, read.Policy StatementThis policy mandates that all employees adhere to an approved dress code tailored for their specific job functions to ensure safety, hygiene, and professionalism.Dress Code GuidelinesHair and Facial Hair: Staff must keep hair tied back or off shoulders and secured under a hair net or cap. Facial hair should also be neatly restrained to prevent contamination.

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #1) of 2 residents reviewed for enteral nutrition.LVN B failed to check for Gtube (gastrostomy tube) placement prior to administration of medications as per Physician orders and facility policy.This failure could place residents who receive medications or feedings via Gtube at risk of aspiration, pain and hospitalization.Findings included:Record review of Resident #1's face sheet dated 03/25/26 revealed a [AGE] year-old admitted to the facility 03/03/26. Resident #1's diagnoses included Hemiplegia (one sided paralysis or severe loss of strength on one side), Hemiparesis (weakness to one side of body), pneumonitis (swelling and irritation of lung tissue) due to inhalation of other solids and liquids, malnutrition, Dementia (a general term for a group of symptoms that cause a loss of cognitive functioning), hypertension (elevated blood pressure) and atrial fibrillation (irregular heartbeat).Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 3 out of 15 indicating severe impaired cognition. Resident #1 had impairment to the upper extremity on one side of the body. He used a manual wheelchair for mobility. Resident #1 was dependent on staff assistance for oral hygiene, toileting, bathing, dressing, personal hygiene and transfers. He was always incontinent of bowel and bladder. He had a feeding tube to provide nutritional support.Record review of Resident #1's active physician orders revealed an order for GT (gastrostomy tube -a tube inserted through the abdomen giving direct access to the stomach for nutritional support): GT: bolus give one can of Isosource 1.5cal five times per day, flush with 30ml of water before and after each bolus; check GT placement prior to feeding and/or medication administration by aspiration of gastric contents every shift, order was dated 03/03/26. Resident #1 had the following medications ordered to be given via GT: Acetaminophen 500mg, 1 tablet every 6 hours PRN pain, Aspirin 81mg, daily, Atorvastatin Calcium 40mg at bedtime, buspirone 10mg TID, Eliquis 5mg daily, folic acid 1mg daily, Guaifenesin 5ml every 6 hours PRN, Levothyroxine 100mcg daily, Metoprolol 25mg BID, Multivitamin 1 tablet daily, Olanzapine 2.5mg BID, Sacubitril-Valsartan 24-26mg BID, Trazodone 50mg at bedtime and Valproic Acid solution 250mg/5ml, give 10ml BID.Record review of Resident #1's undated care plan revealed: Focus - Resident #1 required tube feeding d/t dysphagia (swallowing disorder). Goal - will remain free of side effects or complications related to tube feeding. Interventions included - check for tube placement and gastric content/residual volume per facility protocol and record. Hold if greater than 150 ml of aspirate (fluid withdrawn). Keep HOB elevated 30-45 degrees during and thirty minutes after tube feeding. Monitor/document/report to MD PRN: Aspirate - fever, SOB, tube dislodged, infection at tube site, distention, tenderness.Observation and interview on 03/25/26 at 8:00AM, LVN B prepared medications including the bolus feeding formula for Resident #1. LVN B crushed each tablet separately and added 5ml water to each med cup to dissolve the medications. Resident #1 was easily woken up and when LVN B explained the procedure, Resident #1 said one word (an expletive). LVN B raised the HOB for Resident #1 to at least 30 degrees. LVN B performed hand sanitization, put on clean gown and gloves. LVN B unfastened the abdominal binder securing Resident #1's GT. LVN B attached the tip of the 60 ml syringe barrel (hollow cylindrical tube) to Resident #1's GT and poured 30ml of water into the barrel. The water infused via gravity. LVN B poured the first medication: Olanzapine 2.5mg into the barrel and followed with 5ml of water. The following medications were administered with 5ml to 10ml of water between each medication: Aspirin 81mg, Buspirone 10mg, Eliquis 5mg, folic acid 1mg, Multivitamin 1 tablet, Sacubitril-Valsartan 24-26mg, Valproic Acid solution 10ml and Metoprolol 25mg. LVN B poured 30ml of water after the last medication then poured the Isosource 1.5cal/ml, 250ml until all the formula was infused then flushed with 30ml of water. LVN B stated the tip of the Gtube was supposed to be in the stomach. LVN B stated she would check for tube placement by drawing back on the syringe and that more than 100ml of residual would be too much, but said she was unsure of the amount of fluid to be worried about. LVN B stated she understood that the only time to pull back and check for residual would be when a resident received continuous feedings and not for bolus feedings. LVN B stated she was nervous. LVN B stated she would check the facility policy for when to check tube placement and that she would monitor Resident #1 for nausea and vomiting. Resident #1 was observed to cough a few times and LVN B stated the cough was not new for Resident #1 because he had a history of PNA. LVN B stated the risk of not checking for placement of the tube, would be the tube may not be in the stomach and may be in another space in the abdomen which would not be where it should be. LVN B checked the exit site of the Gtube and said there was nothing unusual. LVN B palpated Resident #1's abdomen and stated it was soft. Resident #1 was not in any distress. LVN B replaced the abdominal binder . LVN B stated that when she started working full time on 01/12/2026, she had in-service on medication administration and Gtube at the time.In an interview on 03/25/26 at 10:00 AM, the DON stated it was the facility policy to check proper GT placement by drawing back on the syringe to check for residual fluids. The DON stated she expected all nurses to check for placement before giving any medications or giving formula feedings. The DON stated the nurses received in-services regarding care of the GT during skills checks in December 2025 and that LVN B may not have been part of the training as LVN B returned to work full time starting January 2026 .Record review of the facility policy and procedure of Administering Medications through an Enteral Tube, revised on March 2015 read in part: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. Preparation: 1. Verify that there is a physician's medication order for this procedure.Steps in the Procedure.18. Confirm placement of feeding tube per physician's order. By aspirating stomach contents, if no residual is aspirated check for bowel sounds, bloating, vomiting and pain. If no changes are noted proceed to administer medications/formula. 19. If you suspect improper tube positioning, do not administer feeding or medication and notify the Physician.

Based on observation, interview and record review, the facility failed to ensure bed rails were maintained and checked regularly to make sure they are installed correctly as rails may shift or loosen over time for 1 (Resident #14) of 10 residents reviewed for bed rails.The facility failed to ensure that Resident #14's bedrails were not loose.This failure could place residents at risk of injuries, entrapment or death. Findings included:Record review of Resident #14's face sheet dated 03/25/26 revealed a [AGE] year-old admitted to the facility on [DATE] and initially admitted on [DATE]. Resident #14's diagnoses included fracture of the left femur, sepsis (blood infection), Dementia (a general term for a group of symptoms that cause a loss of cognitive functioning), muscle weakness and depression.Record review of Resident #14's quarterly MDS dated [DATE] revealed a BIMS score of 6 out of 15 indicating severe impaired cognition. Resident #14 used a manual wheelchair for mobility. Resident #14 required supervision for transfers, bed mobility and personal hygiene. Resident #14 required moderate assistance with bathing and dressing. He was frequently incontinent of bowel and bladder. Resident #14 had a fall with a major injury since admission/re-entry. Further review revealed Section P - Restraints and Alarms: Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body was coded as bedrail not used in bed.Record review of Resident #14's March 2026 MAR/TAR revealed: Bed rails - may have 1/4 bilateral bedrails to assist with mobility and self-positioning while in bed r/t weakness and mobility by the patient and family's desire to keep resident as independent as possible, was checked every shift daily at 6:00AM -6:00 PM shift and at 6:00 PM - 6:00 AM shift.Record review of Resident #14's bedrail evaluation effective 04/28/25 included: the resident was currently utilizing the bedrails; the resident was not able to physically release the bed rails; the resident was able to get in/out of bed without assistance and the resident had a history of falls. Record review of Resident #14's Informed Consent for Use of Bed Rails revealed a verbal consent was completed with the RP on 07/10/25 and the recommendations were for 1/4 partial rails for the left and right to be always used when Resident #14 was in bed.In an observation and interview on 03/24/26 at 1:15 PM, Resident #14 was alert, lying in bed. The bed had bedrails attached to the bedframe on both sides of the bed. The bed was in low position and there were fall mats on the floor placed on both sides of the bed. Resident #14 was observed using both rails to self-turn in bed. Both bedrails were loose and the bedrail to Resident #14's right side was wobblier than the rail to the left as noted when the resident grabbed hold of the rail to turn. Resident #14 stated the bedrail was loose. Resident #14 stated he had fallen before but not out of bed. In an interview on 03/24/26 at 1:50PM, CNA F stated the bedrails on Resident #14's bed were loose and that was a safety hazard because the resident could fall or fall under the rail and get hurt. CNA F stated the loose bedrails were reported to Maintenance via the electronic workorder request sometime between 3/16/26 and 3/21/26 but was unsure of the exact date.In an interview on 03/24/26 at 1:55PM, LVN G stated she was assigned to Resident #14 and that it was the nursing department's responsibility to check bedrails. LVN G stated Resident #14 had bedrails d/t the high risk of falls. LVN G stated if the bedrails were not secure the resident could slip and get caught in between the rails.In an interview and observation on 3/24/26 that began at 1:55PM, Maintenance stated there was a workorder to check bedrails for two resident rooms and that he learned about the loose bedrail for Resident #14 on Thursday 3/19/26 but did not get the work order. Maintenance did not explain why the bedrail was not tightened at that time. The cell phone Maintenance had, showed the 2 resident rooms but not Resident #14's room. Then Maintenance stated he just received the work order for Resident #14's bed on 3/24/26 at 2:04 PM. The cell phone Maintenance had confirmed the request for the bedrail workorder for Resident #14 was received on 3/24/26 at 2:04PM. Maintenance stated the bedrails would get loose from being used or handled and would tighten them when a notification was received or if he was verbally notified. Observed Maintenance tighten bedrails for Resident #14.In an interview on 03/24/26 at 4:05 PM, the DON stated it was the responsibility of the nursing staff to always make workorder notifications through the electronic system used to notify Maintenance. The DON stated during Ambassador rounds every day would be another opportunity for staff to check bedrails. The DON stated bedrails can become loose from wear and tear. The DON stated the risk of loose bedrails would be injury to residents and that all bedrails were a potential for injury. The DON stated moving forward, in-services on bedrails had been started.Record review of logs for Ambassador Room Rounds dated 3/19/26 to 3/24/26 revealed there were no issues with Resident #14, or the environment of the resident's room. The log checklist did not include bedrails. Record review of the facility's Owner's Manual for the Long-Term Care Bed, revised 04/01/2018 read in part: .Quarterly inspection.inspect bed and rotating assist bars/rails bolts, if loose tighten and if missing replace.Record review of the facility policy for Proper Use of Side Rails, revised on December 2007 read in part: The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms.10. The resident will be checked periodically for safety relative to side rail use.

Based on observation, interview, and record review, the facility failed to ensure each resident was fully informed in a language that he or she could understand of his or her total health status, including but not limited to, his or her medical condition for 2 (Resident #86 and #75) of 8 residents reviewed for resident rights.The facility failed to communicate effectively with Resident #86 whose primary language was Spanish, and Resident #75 whose primary language was Vietnamese.This failure could place residents who communicate in a foreign language at risk of unmet needs.Findings included:1.Record review of Resident #86's care plan revealed it did not include any plan for addressing her ability to communicate. In an interview on 3/24/26 at 9:40 a.m. via translation line, Resident #86 stated that she had some complaints about care and medications but was unable to communicate those needs to staff due to being Spanish speaking. In an interview on 3/24/26 at 10:45 a.m. via translation line, Resident #86 stated that she have issues getting her needs met due to a language barrier. Resident #86 stated that she understood and could speak a few sentences of English, but that she was Spanish speaking and that Spanish was her preferred language. Resident #86 stated that she quit asking for help with a lot of things (meal preferences, changing medication times, understanding diagnoses, and clothing were among examples given) and would either attempt to try and do it on their own or go without. During an observation on 3/25/26 at 3:45 p.m. of Resident #86 being changed and receiving care, CNA A and CNA B, assisted Resident #86 off the toilet, stood her up, got her cleaned, put on a new brief, and assisted her back into bed. During this time Resident #86 did not speak in English or at all to staff. CNA A and CNA B spoke only in English to Resident #86. Hand gestures were also made by CNA A and CNA B to Resident #86. Resident #86 made no hand gestures in return until getting back in bed at which point resident gestured to her phone. Staff handed the resident her phone, call light, and asked if resident needed anything else. Resident #86 shook her head no. After staff left the room Resident #86 asked surveyor via translation line to plug her phone in. In an interview on 3/25/26 at 3:47 p.m., CNA A stated that they're generally able to communicate with Resident #86 fairly well. CNA A stated that if she did not understand what Resident #86 is saying then they will grab a Spanish speaking staff member to help translate. In the event that Spanish speaking staff are unavailable, CNA A stated that they will use google or apple translate. CNA A stated that they were unaware if the facility has any translation line, but that if so, they have not heard of it. In an interview on 3/25/26 at 3:47 pm. CNA B stated that they're usually able to communicate with Resident #86. CNA B stated that sometimes to make communication with Resident #86 easier they will get Spanish speaking staff to help translate. In the event that a Spanish speaking staff was unavailable, CNA B stated that they use google translate. CNA B stated that they have not heard of the facility having a translation line and did not think that there was one. In an interview on 3/26/26 at 12:50 p.m., the DON stated that the facility does have a translation line and that the expectation was for her staff to use it with residents whose preferred language was not English. She stated that staff should not be using internet translation services or a family member, but the translation line in order to prevent misinterpretation via an internet service or a family member altering a resident's words. 2.Record review of Resident #75's face sheet dated 3/24/26 revealed a [AGE] year-old female who readmitted on [DATE]. Her diagnoses included dementia, diabetes, and chronic respiratory failure.Record review of Resident #75's annual MDS assessment dated [DATE] revealed her race was Vietnamese and her preferred language was English. The assessment indicated she did not need an interpreter to communicate with a doctor or health care staff. She had clear speech, was able to understand others and made herself understood. Her BIMS score was 5 out of 15 which indicated severe cognitive impairment. She required assistance from staff with ADL care.Record review of Resident #75's care plan revealed she had a communication problem related dementia, revised on 4/18/25. The goal was to make basic needs known on a daily basis. Interventions were to use communication techniques which enhance interaction: allow adequate time to respond, repeat as necessary, do not rush, request feedback, clarification from the resident, to ensure understanding, face when speaking and make eye contact, turn off tv/radio as needed to reduce environmental noise, ask yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed, such as communication book/board, writing pad, gestures, signs, and pictures. Date initiated 4/18/25. Resident #75 had impaired cognitive function/impaired thought processes. Interventions were to communicate with the resident/family/caregivers regarding resident's capabilities and needs. Communication: .the resident understands consistent, simple, directive sentences. Provide the resident with necessary cues. date initiated 4/30/24. The care plan did not include that the resident spoke Vietnamese. In an interview on 3/24/26 at 9:48 a.m. this Surveyor greeted Resident #75 and she did not respond. This Surveyor asked if she spoke English or Vietnamese and she said Vietnamese. Interview via the translation line using the Vietnamese language, Resident #75 said she needed medication because her throat had been hurting for over a week. She said she was unable to communicate her concern with the staff because she did not know English. She said whenever her family member visited the facility, she would communicate through her but if the family member was not here, she was unable to. Resident #75 said her throat hurt bad when she swallowed and asked the Surveyor to please let the staff know she needed medication.In an interview on 3/24/26 at 9:59 a.m. LVN J said she was unable to speak with Resident #75 because she did not speak English but spoke Vietnamese. She normally communicated through her family member, and said the resident was able to communicate her needs such as the need for water and ice. She said she checked on the resident this morning and she did not complain of any pain. This Surveyor informed LVN J that the resident communicated a need to the Surveyor and the nurse was asked to verify that need with Resident #75.In an observation and interview on 3/24/26 at 10:25 a.m. LVN J entered Resident #75's room and spoke to her in English. The resident motioned for a shower and said she was ok. LVN J ended the conversation with Resident #75 and exited the room. She said Resident #75 could say key words and could respond no to questions. She was unsure if the resident had a board for communication. This Surveyor told LVN J that the need Resident #75 shared with the Surveyor was still not made known. LVN J said the facility had a translation line and would ask someone for assistance.In an interview on 3/24/26 at 10:30 a.m. the Unit Manager said the translation line phone number used to be on the home page of the electronic chart but was no longer there. She said she did not know what happened to the number and would ask for assistance. She said other ways that staff communicated with Resident #75 was through the family. Resident #75 could point and say things in English. She had not seen a communication board for the resident. In an observation on 3/24/26 at 10:45 a.m. LVN J entered Resident #75's room and spoke with her via the translation line. LVN J said she was informed that the resident was coughing and had a really sore throat. She said the resident also complained of itchy throat and pain in shoulder. LVN J said she was not previously aware of these concerns.Record review of Resident #75's nursing note dated 3/24/26 at 11:10 a.m. and written by LVN J read in part, . Res c/o itching in throat that causes her to cough. Res alleges x 1 week. No redness noted to throat. No enlarged glands noted. No cough or cong noted at this time. Lungs CTA. Res also c/o pain to left shoulder. Res was provided Acetaminophen immediately after complaint. Res tol med well. Call placed to. NP to report res c/o. Pending new orders at this time.In an interview on 3/25/26 at 4:31 p.m. LVN D said Resident #75 could say words in English such as pee pee, number 2, and food. She said the resident also did a lot of pointing. To assess pain the nurse would observe for grimacing to the forehead and facial expressions. She said the resident was able to respond yes if asked if she was in pain. She said she was unaware of a translation line at the facility, had not used one with the resident and was unsure what language she spoke. She had not used communication boards with the resident. She said she could call Resident #75's family member for help with communication. She said she believed Resident #75 was cognitive in her language. It was important to communicate effectively with the resident because that would benefit her and allow staff to take better care of her. In an interview on 3/25/26 at 4:33 p.m. CNA H said he communicated with Resident #75. He said she spoke 25% English and also communicated through her eyes, gestures, pointing, calling her family member or using the translation line. He said Resident #75 said words like number 2. He said she never complained of throat pain but had complained of pain to the side and butt. He said the resident would say hurt, hurt or medicine, medicine to communicate pain.In an interview on 3/25/26 at 4:52 p.m. the DON said the facility had translation service. She said Resident #75 was cognitive for the most part and was able to communicate basic needs such as the need to use the bathroom and pain. She has called the family member to translate. The family member had not reported a sore throat to the staff. The DON said there were also communication boards but did not believe Resident #75 had one. She said it was important to communicate effectively with the residents to ensure they were taken care of and their needs were met. In an interview on 3/25/26 at 4:53 p.m. the Administrator said staff used google translate and families to help translate. In an interview on 3/26/26 at 1:04 p.m. the MDS nurse said she was under the impression that Resident #75 understood English and that was why she coded it as her preferred language on the annual MDS. She said the resident spoke single words in English and her needs were met. She said she could update the MDS assessment.In an interview on 3/26/26 at 10:55 a.m. CNA W said Resident #75 spoke Vietnamese and he used hand signals to communicate with her. He said he was trained on using hand gestures to communicate with the resident and was going to ask about a chart with pictures but did not know where it was. He said she never communicated pain to him.Record review of the facility's Resident rights policy revised October 2009 read in part, .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: 1. Be informed about what rights and responsibilities he or she has;. 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

Based on observation, interviews and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 facility and 2 of 10 staff (MA A and LVN A ) reviewed for misappropriation. - The facility failed to report to the State Survey Agency allegations of drug theft and misappropriation of resident property by MA A. - The facility failed to report to the State Survey Agency drug theft of 80 controlled substance tablets that occurred when LVN A left the medications unattended at the nursing station on [DATE]. This failure could result in the state agency being unaware of alleged misappropriation of resident property and drug diversion. Findings Include: MA A Record review of the HHSC TULIP (system to which providers report accidents and incidents) on [DATE] revealed, multiple anonymous complaints were submitted that alleged MA A misappropriated multiple resident medications and items. The facility did not submit any Facility Reported Incidents regarding alleged misappropriation by MA A. Record review of an undated chat conversation in a social media app at 09:39 AM revealed, MA As status was active 1 h ago. MA A sent a 14 second video of her injecting Mounjaro (an injectable weight loss medication) into her lower left abdomen. In response the unknown individual responding What are you doing pook to which MA A responded Mounjaro. I wanna get my own script but until I can afford the facility gone supply this shit , to which the unknown induvial responded Oh ok. Record review of the Administrator's Internal Investigation Report signed by the Administrator and ADON on [DATE] revealed, employee name: MA A; Date of Incident Report: [DATE]; Investigator: Administrator; Additional Participants: ADON. Summary of Allegations: On [DATE], the facility received multiple anonymous phone calls alleging that [MA A] was stealing medications. The caller specifically asked if the facility employed her and claimed she had been taking medications from the carts. These calls were very short and the caller refused to leave a name or how she knew of this information. Immediate Actions Taken: Medication Audit- [ADON] immediately conducted a thorough audit of all medication cart; Result: No missing or unaccounted medications were found. Law Enforcement Involvement: On [DATE], officers from the [police department] entered the facility requested to speak with the Administrator regarding similar anonymous reports. The Administrator confirmed to officers that internal audit had been completed with no discrepancies. The police interviewed [MA A] on-site. Following the interview, law enforcement expressed no ongoing concerns and took no further action. Findings: No missing medications were identified. There is no evidence supporting the allegation of theft or diversion. The allegations appear to be malicious in nature, potentially made by an individual known to [MA A] from a previous place of employment. Conclusion: Based on the internal audit, staff interviews, and law enforcement input, there is no substantiated evidence of medication diversion or misconduct by [MA A]. No further investigation is warranted at this time. Corrective/Preventative Measures: continued routine medication carts audits will be performed. Staff reminded to immediately report any concerns of potential diversion. Documentation of this investigation will be retained in the Administrator's reference. Record review of the Police Department Call Record Dated [DATE] revealed, on [DATE] at 03:26 PM the police department received an anonymous call regarding past theft at the facility. The complainant reported that they had observed MA A misappropriate medications at the facility. On [DATE] at 03:57 PM officers spoke to the Administrator at the facility and he notified them that the facility had received multiple calls that accused MA A of drug diversion but the Administrator did not believe the allegation because all the med counts had been accurate since MA A started working at the facility. Observation of an undated video and untimed video revealed, MA A injecting Mounjaro into her lower left abdomen in the facility central supply closet. A cabinet with a sign attached that read PLEASE DO NOT PUT OTC MEDS IN THIS CABINET FROM MED AIDE OR NURSES CARTS. PLACE ON CENTRAL SUPPLY. The rest of the texts could not be interpreted because the sheet was torn and folded. In interview on [DATE] at 09:35 AM, the Administrator said in December of 2024 the facility received multiple anonymous complaints that MA A was misappropriating resident medications. He said the calls came daily for several weeks, the police department was notified, and a state surveyor had investigated the incident in 2024. The Administrator reviewed the video and confirmed that MA A appeared in the video and the video was taken in the facility central supply storage. An observation on [DATE] at 09:43 AM of the central supply closet revealed, a cabinet with a sign that read PLEASE DO NOT PUT OTC MEDS IN THIS CABINET FROM MED AIDE OR NURSES CARTS. PLACE ON CENTRAL SUPPLY. The rest of the texts could not be interpreted because the sheet was torn and folded. In an interview on [DATE] at 10:59 AM, MA A said she took injectable medications for weight loss. She said she administered the medications on either Wednesday or Thursday and sometimes she brought them to work. MA A said when she first starting working in the facility at the end of 2024 the facility received multiple calls that alleged she abused residents and misappropriated narcotic medications. She said she was the individual who appeared in the video administering Mounjaro in the central supply room and she sent the video to the individual because she wanted to keep track of her journey. MA A said she used a virtual prescriber so she had no evidence of a prescription or supporting evidence that she legally had access to injectable medications for weight loss. She said the video was shot sometime at the end of 2024 and she brought and administered her Mounjaro to the facility because she was running late and had a schedule for when she administered the medication. MA A said she did not get a special accommodation or notify any staff prior to administering the medication during work hours and in the central supply room. She said she didn't know it was a problem and denied misappropriating resident medications or telling anyone she misappropriated resident medications. MA A said she had not been reported for any kind of misappropriation, she was not suspended at any time during the complaints pending an investigation and the Administrator called her and notified her that the facility investigation and the surveyor investigation found nothing. In an interview on [DATE] at 11:18 AM, the Administrator said when the facility received a complaint for misappropriation the facility should immediately notify the state and start auditing what was suspected to be missing. He said the alleged perpetrator was typically suspended pending investigation. The Administrator said the facility received multiple anonymous tips that MA A was diverting drugs, the police also received multiple anonymous complaints which resulted in them coming on site to the facility to investigate. He said he received a call from an alleged state surveyor saying they suspected MA A's complaints were due to a disgruntled employee and the state survey agency did not have any concerns about MA A. The Administrator said he sent a message to MA A on [DATE] stating he and the state surveyor thought the complaints were from a disgruntled employee and they found nothing wrong against her. He said the alleged state surveyor, did not come on site, did not provide contact information, did not have an entrance conference or state an intake number they were investigating. The Administrator said he had no evidence that it was a state surveyor that called and in hindsight it probably was not the most legitimate thing. He said MA A had worked on the floor on and off a MA since the facility received the initial tips of alleged drug diversion, she was never suspended, and the facility never restricted her access to medications. LVN A Record review of pharmacy delivery record dated [DATE] revealed, LVN A signed for a delivery of controlled substances that included: 1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).4. 8 tablets of Clonazepam 0.5 mg (anxiety medication).5. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 6. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 7. 8 tablets of Zolpidem 5 mg (sleeping medication).8. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).9. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication). Record review of the HHSC TULIP on [DATE] revealed, facility staff did not submit report of drug diversion that occurred on [DATE] when 80 controlled substance tablets were stolen. Record review of the facility provided undated investigation record revealed, 80 controlled substance tablets were missing which included:10. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).11. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).12. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).13. 8 tablets of Clonazepam 0.5 mg (anxiety medication).14. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 15. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 16. 8 tablets of Zolpidem 5 mg (sleeping medication).17. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).18. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication).On [DATE] LVN A signed for the 80 controlled substance tablets.On [DATE] the facility performed urine drug screens on only nurses and med aide on day shift and night shift. All staff tested negative except for 1 resident who had a valid prescription for stimulant medications. In an interview on [DATE] at 12:20 PM, RN A said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. She said the nurse was terminated after the incident. In an interview on [DATE] at 12:44 PM, LVN D said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. He said in response facility management drug tested all nurses and MAs and the nurse that left the medication on the counter was terminated after the incident. In an interview on [DATE] at 01:17 PM, the Administrator said after the facility received tips regarding MA As alleged drug diversion, the facility did an audit of the med carts and there was nothing found missing. He said since his limited investigation supported that the complaints appeared to be a disgruntled person he did not report the alleged drug diversion to the state survey agency. The Administrator said after the stolen controlled substances were delivered, they were not documented and then they went missing. The medications were never located, and the facility suspected they were stolen so they performed drug tests on staff. He said the alleged misappropriation by MA A and the stolen controlled substances were not reported because the medication that was stolen did not belong to a specific resident and was supposed to stock the automated dispensing system it was not a reportable incident. The Administrator said to his knowledge the medications were left on top of the automated dispensing system in the med room. In an interview on [DATE] at 02:07 PM, the Regional Clinical Director said the diverted controlled substances were delivered to stock the automated dispensing system. He said after the incident, nursing staff checked common areas for the missing medications but they did not search personal belongings of residents or staff. The Regional Clinical Director said drug diversion was reportable only when residents medication was missing. He said when a facility received an allegation of misappropriation the staff should be suspended pending investigation, an investigation should be initiated with a count of narcotics to reconcile all controlled substances, staff in-serviced about controlled substances. The Regional Clinical Director said he was never informed of the allegations and investigation into MA A for alleged drug diversion. He said today, he learned the facility received multiple allegations of misappropriation and drug diversion by MA A so she was immediately pulled off the floor and she no longer had access to residents or medication. In an interview on [DATE] at 09:09 AM, LVN A said on Friday, [DATE], she received medications at the nursing station and when the pharmacy delivered medications they came in a big bag with multiple bags within them. She said when the medications arrived sometime between 7-8:00 PM, she left the medications on the counter because at the time she had a resident who expired on her hall, so she was dealing with the death, the mortuary and the family of the expired resident. She said the medications remained unattended on the counter until approximately 4:00 AM towards the end of her shift when she cleaned up and put the big bag in the med room. LVN A said leaving medication on the counter was not out of the normal, everyone did that, and it just happened to be on her shift that someone decided to steal the medications. She said when she realized the controlled medications were missing on her next shift on [DATE] (Saturday), she immediately notified the Weekend Supervisor and they started looking for the medications in the med room, trash can and common areas. She said on the morning of [DATE] (Sunday) she called the Former DON, they searched the facility again and retraced her steps but the medications were never found. LVN A said on [DATE] (Monday) she was asked for written statements and on [DATE] (Tuesday) she was drug tested, interviewed by the corporate team and wrote a second statement. She said the facility told her that someone stole the medications and she was suspended pending further investigation, and she was notified of her termination on [DATE]. LVN A said prior to the drug theft she had never received any training on medication delivery, stocking the automated dispensing system and she had no idea who stole the medication. She said on the night the medication was stolen there were a lot of different people in the building, there were residents, EMS, family, housekeeping, med aides and nurses. In an interview on [DATE] at 10:22 AM, the Weekend Supervisor said she worked on Saturday and Sundays. She said in the morning of [DATE] (Saturday) she was notified by LVN A that she had misplaced the controlled substance so she notified the Former DON and the pharmacy. The Weekend Supervisor said she and LVN C looked through the facility, the medication carts and trash cans but the medications were never found. She said initially LVN A said she left the medications in the nursing station and then she moved it to the medication room and no staff checked the rooms of residents, or the personal belongings of staff or residents. The Weekend Supervisor said the facility drug tested employees, but herself, nursing administration, non-nurse/med aide staff were not drug tested. She said residents were not assessed for side effects of overdose or administration of medications because they were more focused on locating the medications. She said the medications could have been stolen by anyone, it could have been staff, residents of family members. In an interview on [DATE] at 10:53 AM, the Former DON said she started working at the facility on [DATE] and she was not aware of any allegations of drug diversion or misappropriation made against MA A or any other staff. She said her relationship with MA A was strictly professional, so she didn't know if MA A used weight loss medications but staff were not allowed to administer their own medications in the facility because of potential drug diversion. The Former DON said on [DATE] (Sunday) she was notified that LVN A left controlled substances on the counter on [DATE] and the medication was stolen. She said LVN A assumed someone had put the medication up on [DATE] but she later realized that she left the medication on the counter and never returned to check on it. The Former DON said when she was notified on [DATE] she immediately notified the Administrator and then initiated a search of the building. She said following the advice of the corporate team a drug test was administered to nurses and med aides but nurses in management, CNAs and housekeeping were not tested. The Former DON said she could not say who stole the medications but she didn't see a risk to residents because the residents were asleep. She said unaccounted medications could place residents at risk for potential overdose. The Former DON said when medications were delivered they were to be immediately logged into the automated dispensing system and if staff do not have access the medications should be left with the Unit Manager. In an interview on [DATE] at 11:37 AM, LVN B said on [DATE] she saw LVN A receiving medications at the nursing station. She said when the medications arrived she got what she needed for the 100/400 hall. She said approximately 4 hours later, when she was looking for Tramadol for one of her residents, a coworker notified her that a bag of medication containing the medication was at the nursing station. LVN B said she did not know where LVN A was at that time, but when she returned the next evening LVN A was worried about the missing medication, so they checked the nursing station, med room and the bin containing discontinued medications but the medications were never located. She said staff did not check resident rooms or personal belongings because they didn't think the theft was associated with a resident but on the night of [DATE] LVN A was busy with a new admission, a resident death, waiting for a funeral home and had another resident transitioning. LVN B said unaccounted controlled substances could place residents at risk of drug diversion, and injury or emergency if they ingested the medications. In an interview on [DATE] at 11:59 AM, LVN C said she worked the 6 AM- 6 PM shift on [DATE] (Friday) when the medication was stolen but she stayed late because she had a resident that became unresponsive on her hall. She said LVN A relieved her that night and she observed when LVN A received the medications. LVN C said the next morning (Saturday [DATE]), LVN A had already cleaned up the nursing station, there was no medication left on the counter of the nursing station and she did not know any medications were missing. She said after she returned home on [DATE], LVN A called her to ask her if she saw any medications on the nursing counter and when she returned on Sunday ([DATE]) she along with other staff tried to help LVN A locate the medications. LVN C said during the day of [DATE] she observed medications sitting on the top of the automated dispensing system but she didn't pay any attention to it because at the time she did not know how to restock the medications. She said the medications were never located and the facility never searched resident rooms or personal belongings or assessed residents for potential overdose or ingestion of inappropriate medications. LVN C said unaccounted controlled substances could place residents at risk of overdose and impact the responsible staff professional license. In an interview on [DATE] at 02:49 PM, the Administrator said he was notified of the loss of controlled substances on Monday [DATE]. He said after investigation it was identified that after LVN A signed for the drugs on Friday evening ([DATE]) she left the drugs out on in the nursing station instead of putting it in the automated dispensing system. The Administrator said when LVN A realized she left the medication out, she started calling other nurses to find the medications and then notified the Weekend Supervisor who then notified the Former DON. He said after investigation the facility was unable to identify who stole the medication, but nursing staff were trained on receiving medications, stocking the automated dispensing system and drug security. The Administrator said to his knowledge facility staff checked resident rooms but he was not sure, and any staff who had access to the medication carts or med rooms were drug tested. He said the facility failed to drug test everyone who had access to the nursing station and it was an oversight why they didn't test them. He said he failed to investigate all the way through that the medication was at the nursing station and everyone who had access to the building during the time window the theft occurred had access to the medications. The Administrator said unaccounted controlled substances created a risk of a resident self-administering the medications which could lead to overdose and a lot of bad things could happen. He said as the abuse coordinator he was responsible for ensuring all investigations were thorough, making sure corrective actions were in place and incidents are reported appropriately. The Administrator said reporting requirements for an event like this was made by the regional VP and Regional Clinical Director and in this incident he was notified that the drug theft was not a reportable incident. He said failure to report possible drug diversion to the state survey agency would result in the facility not following the correct protocol and the state survey would not be unaware of the incident and could not follow up on it. In an interview on [DATE] at 09:13 AM, the ADON said she was aware of allegations that were made against MA A regarding drug diversion and misappropriation. She said when MA A started working at the facility, they received call continuously every day for weeks that MA A stole resident's pills so the facility audited the controlled substances and no discrepancies were identified. The ADON said MA A was not suspended during the investigation, and the facility just continued auditing the carts during that time. She said the facility never stopped MA A never from administering medications and her access to medication, nursing carts and medication rooms were never interrupted. She said in September of 2025 medications meant for the automated dispensing system came up missing so she was responsible for managing the drug test of specific employees. The ADON said only nurses and MAs were tested, the facility checked the trashcans and she searched some resident rooms but the facility did not do any assessments to identify if any resident gained access to the controlled substances or experienced any side effects of ingestion of the medications. In an interview on [DATE] at 09:39 AM, the Medical Director said he was never notified of alleged drug diversion allegations made against MA A in 2025 because he was not the medical director at the time. He said in 09/2025 he was notified of an incident in which a team member handling narcotics over the weekend did not store them as per the facility policy. He said drug diversion could place residents at risk of uncontrolled pain or consequences of inappropriately administered medications such as overdose. The Medical Director said he was not aware of any residents with uncontrolled pain or missing pain medications. He said no residents were harmed by this incident because all residents received their medications. Record review of the facility policy titled Investigating Incidents of Theft and/or Misappropriation of Resident Property revised 12/2008 revealed, Policy Statement: All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated. Policy Interpretation and Implementation: 1.When an incident of theft and or misappropriation of resident property is reported, the Administrator will appoint a staff member to investigate the incident. 2. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 3. The investigation shall consist of at least the following: 1. An interview with the person(s) reporting the missing items; 2. An interview with any witnesses that may have knowledge of the missing items; 3. An interview with the resident (as medically appropriate); 4. An interview with the employee (if any) accused of taking the resident's property; 5. A review of the resident's personal inventory record to determine if the missing items were recorded on the report; 6. Interviews with staff members (on all shifts) having contact with the resident during the past 48 hours; 7. Interviews with the resident's roommate, family members, and visitors; 8. A search of the laundry room for missing articles of clothing; and 9. A search of the resident's room for the missing items. 4. Should an alleged or suspected case of misappropriation of resident property be reported, the facility Administrator, or his/her designee, will notify the following persons or agencies within twenty-four (24) hours of such incident, as appropriate: 1. State Licensing and Certification Agency; 2. Ombudsman; 3. Resident Representative; 4. Adult Protective Services;5. Law Enforcement Officials; 5.While the investigation is being conducted, accused individuals not employed by the facility may be denied unsupervised access to the resident. Visits may only be made in designated areas. 6. Employees of this facility who have been accused of misappropriating resident property will be reassigned to non-resident contact duties or suspended without pay until the results of the investigation have been reviewed by the Administrator and a determination of action(s) to be taken has been made. 9.The Administrator will report the results of the investigation to the local police department, the ombudsman, and to the state survey and certification agency within five (5) working days of the incident. Record review of the Administrator's Job Description revised 2003 revealed, The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times. Record review of the facility policy titled Administrator revised in 04/2007 revealed, 1. The governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements. The Administrator is responsible for, but not limited to: Managing the day-to-day functions of the facility; Implementing established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities; Record review of the facility policy titled Conformity with Laws and Professional Standards revised in 04/2007 revealed, Policy Statement: Our facility operates and provides services in compliance with current federal, state, and local laws, regulations, codes and professional standards of practice that apply to our facility and types of services provided. Policy Interpretation and Implementation: 1. Our facility is in conformity with all federal, state, and local laws relating to fire safety and disaster pre-preparedness, sanitation, communicable and reportable diseases, postmortem procedures, resident rights and confidentiality of information as well as other relevant health and safety requirements. Record review of the facility policy titled Unusual Occurrence Reporting revised in 12/2007 revealed, Policy Statement: As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Policy Interpretation and Implementation: 1. Our facility will report the following events to appropriate agencies: g. Allegations of abuse, neglect and misappropriation of resident property; andh. Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations. 4. The administration will keep a copy of written reports on file. Record review of the facility policy tilted Abuse Investigation revised 04/2010 revealed, no instructions on how to investigate or report drug diversion. Record review of the facility policy titled Controlled Substances revised 12/2012 revealed, Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation: 1. Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. 3. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. 5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. 7. The Charge Nurse on duty will maintain the keys to controlled substance containers. The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers. Record review of the facility policy titled Accepting Delivery of Medications revised 04/2007 revealed, Policy Statement: 1. All staff shall follow a consistent procedure in accepting medications. 2. Any errors noted in receiving medications shall be brought to the attention of the Pharmacist and Director of Nursing Services. Policy Interpretation and Implementation: 1. A nurse shall personally accept each medication delivery. 2. Before signing to accept the delivery, the Nurse must reconcile the medications in the package with the delivery ticket/order receipt. 4. A nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket. Both the receiving nurse and the delivery agent must sign any notations about errors. 5. The delivery ticket shall be archived in a designated location. 6. The dispensing pharmacy, consultant pharmacist, and Director of Nursing Services shall be not[TRUNCATED]

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect and injury of unknown origin, are thoroughly investigated and results reported of all investigations to the State Survey Agency, within 5 working days of the incident for 1 of 1 facility reviewed for misappropriation. - The facility Administrator failed to thoroughly investigate, put corrective actions in place and to report the results of the investigation to the state agency within 5 working days of the incident following allegations of drug theft and misappropriation of resident property by MA A - The facility Administrator failed to thoroughly investigate, put appropriate corrective actions in place and to report the results of the investigation to the state agency within 5 working days of the incident following drug theft of 80 controlled substance tablets that occurred on [DATE]. These failures could place residents at risk of drug diversion and misappropriation. Findings Include: MA A Record review of the facility's employee records revealed, MA A's date of hire was [DATE] and she was hired as a medication aide. Record review of the Administrator's Internal Investigation Report signed by the Administrator and ADON on [DATE] revealed, employee name: MA A; Date of Incident Report: [DATE]; Investigator: Administrator; Additional Participants: ADON. Summary of Allegations: On [DATE], the facility received multiple anonymous phone calls alleging that [MA A] was stealing medications. The caller specifically asked if the facility employed her and claimed she had been taking medications from the carts. These calls were very short and the caller refused to leave a name or how she knew of this information. Immediate Actions Taken: Medication Audit- [ADON] immediately conducted a thorough audit of all medication cart; Result: No missing or unaccounted medications were found. Law Enforcement Involvement: On [DATE], officers from the [police department] entered the facility requested to speak with the Administrator regarding similar anonymous reports. The Administrator confirmed to officers that internal audit had been completed with no discrepancies. The police interviewed [MA A] on-site. Following the interview, law enforcement expressed no ongoing concerns and took no further action. Findings: No missing medications were identified. There is no evidence supporting the allegation of theft or diversion. The allegations appear to be malicious in nature, potentially made by an individual known to [MA A] from a previous place of employment. Conclusion: Based on the internal audit, staff interviews, and law enforcement input, there is no substantiated evidence of medication diversion or misconduct by [MA A]. No further investigation is warranted at this time. Corrective/Preventative Measures: continued routine medication carts audits will be performed. Staff reminded to immediately report any concerns of potential diversion. Documentation of this investigation will be retained in the Administrator's reference. The file did not include evidence of : interviews of staff, including MA A regarding the alleged drug diversion; documented medication audits; resident interviews, law enforcement notification; reassignment of MA A, state survey agency notification. Record review of the HHSC TULIP (system to which providers report accidents and incidents) on [DATE] revealed, multiple anonymous complaints were submitted that alleged MA A misappropriated multiple resident medications and items. The facility did not submit any Facility Reported Incidents regarding alleged misappropriation by MA A. Record review of Police Department Call Record Dated [DATE] revealed, on [DATE] at 03:26 PM the police department received an anonymous call regarding past theft at the facility. The complainant reported that they had observed MA A misappropriate medications at the facility. On [DATE] at 03:57 PM officers spoke to the Administrator at the facility and he notified them that the facility had received multiple calls that accused MA A of drug diversion but the Administrator did not believe the allegation because all the med counts had been accurate since MA A started working at the facility. Record review of an undated social media app chat conversation at 09:39 AM revealed, MA As status was active 1 h ago. MA A sent a 14 second video of her injecting Mounjaro (an injectable weight loss medication) into her lower left abdomen. In response the unknown individual responding, What are you doing pook MA A responded Mounjaro. I wanna get my own script but until I can afford the facility gone supply this shit , to which the unknown induvial responded Oh ok. Observation of an undated video and untimed video revealed, MA A injecting Mounjaro into her lower left abdomen in the facility central supply closet. A cabinet with a sign attached that read PLEASE DO NOT PUT OTC MEDS IN THIS CABINET FROM MED AIDE OR NURSES CARTS. PLACE ON CENTRAL SUPPLY. The rest of the texts could not be interpreted because the sheet was torn and folded. In interview on [DATE] at 09:35 AM, the Administrator said in December of 2024 the facility received multiple anonymous complaints that MA A was misappropriating resident medications. He said the calls came daily for several weeks, the police department was notified and a state surveyor had investigated the incident in 2024. The Administrator reviewed the video and confirmed that MA A appeared in the video and the video was taken in the facility central supply storage. An observation on [DATE] at 09:43 AM of the central supply closet revealed, a cabinet with a sign that read PLEASE DO NOT PUT OTC MEDS IN THIS CABINET FROM MED AIDE OR NURSES CARTS. PLACE ON CENTRAL SUPPLY. The rest of the texts could not be interpreted because the sheet was torn and folded. In an interview on [DATE] at 10:59 AM, MA A said she took injectable medications for weight loss. She said she administered the medications on either Wednesday or Thursday and sometimes she brought them to work. MA A said when she first starting working in the facility at the end of 2024 the facility received multiple calls that alleged she abused residents and misappropriated narcotic medications. She said she was the individual who appeared in the video administering Mounjaro in the central supply room and she sent the video to the individual because she wanted to keep track of her journey. MA A said she used a virtual prescriber so she had no evidence of a prescription or supporting evidence that she legally had access to injectable medications for weight loss. She said she said the video was shot sometime at the end of 2024 and she brought and administered her Mounjaro to the facility because she was running late and had a schedule for when she administered the medication. MA A said she did not get a special accommodation or notify any staff prior to administering the medication during work hours and in the central supply room. She said she didn't know it was a problem and denied misappropriating resident medications or telling anyone she misappropriated resident medications. MA A said she had not been reported for any kind of misappropriation, she was not suspended at any time during the complaints pending investigation and the Administrator called her and notified her that the facility investigation and the alleged state surveyor investigation found nothing. In an interview on [DATE] at 11:18 AM, the Administrator said when the facility received a complaint for misappropriation the facility should immediately notify the state and start auditing what is suspected to be missing. He said the alleged perpetrator was typically suspended pending investigation. The Administrator said the facility received multiple anonymous tips that MA A was diverting drugs, the police also received multiple anonymous complaints which resulted in them coming on site to the facility to investigate and he received a call from an alleged state surveyor saying they suspected MA As complaints were due to a disgruntled employee and the state survey agency did not have any concerns about MA A. The Administrator said he sent a message to MA A on [DATE] stating he and the state surveyor thought the complaints were from a disgruntled employee and they found nothing wrong against her. He said the alleged state surveyor, did not come on site, did not provide contact information, did not have an entrance conference or state an intake number they were investigation. The Administrator said he had no evidence that it was a state surveyor that called and in hindsight it probably was not the most legitimate thing. He said MA A had worked on the floor on and off a MA since the facility received the initial tips of alleged drug diversion, she was never suspended and the facility never restricted her access to medications. LVN A Record review of pharmacy delivery record dated [DATE] revealed, LVN A signed for a delivery of controlled substances that included: 1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).4. 8 tablets of Clonazepam 0.5 mg (anxiety medication).5. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 6. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 7. 8 tablets of Zolpidem 5 mg (sleeping medication).8. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).9. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication). Record review of the HHSC TULIP (system to which providers report accidents and incidents) on [DATE] revealed, facility staff did not submit report of drug diversion that occurred on [DATE] when 80 controlled substance tablets were stolen. Record review of the facility provided undated investigation record revealed, 80 controlled substance tablets were missing which included:1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).4. 8 tablets of Clonazepam 0.5 mg (anxiety medication).5. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 6. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 7. 8 tablets of Zolpidem 5 mg (sleeping medication).8. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).9. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication).On [DATE] LVN A signed for the 80 controlled substance tablets.On [DATE] the facility performed urine drug screens on only nurses and med aide on day shift and night shift. All staff tested negative except for 1 resident who had a valid prescription for stimulant medications. In an interview on [DATE] at 12:20 PM, RN A said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. She said the nurse was terminated after the incident. In an interview on [DATE] at 12:44 PM, LVN D said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. He said in response facility management drug tested all nurses and CMAs and the nurse that left the medication on the counter was terminated after the incident. In an interview on [DATE] at 01:17 PM, the Administrator said after the facility received tips regarding MA As alleged drug diversion, the facility did an audit of the med carts and there was nothing found missing. He said since his limited investigation supported that the complaints appeared to be a disgruntled person he did not report the alleged drug diversion to the state survey agency. The Administrator said after the stolen controlled substances were delivered, they were not documented and then they went missing. The medications were never located, and the facility suspected they were stolen so they performed drug tests on staff. He said the alleged misappropriation by MA A and the stolen controlled substances were not reported because the medication that was stolen did not belong to a specific resident and was supposed to stock the automated dispensing system it was not a reportable incident. The Administrator said to his knowledge the medications were left on top of the automated dispensing system in the med room. In an interview on [DATE] at 02:07 PM, the Regional Clinical Director said the diverted controlled substances were delivered to stock the automated dispensing system. He said after the incident, nursing staff checked common areas for the missing medications but they did not search personal belongings of residents or staff. The Regional Clinical Director said drug diversion was reportable only when a residents medication was missing. He said when a facility received an allegation of misappropriation the staff should be suspended pending investigation, an investigation should be initiated with a count of narcotics to reconcile all controlled substances, staff in-serviced about controlled substances. The Regional Clinical Director said he was never informed of the allegations and investigation into MA A for alleged drug diversion. He said today, he learned the facility received multiple allegations of misappropriation and drug diversion by MA A so she was immediately pulled off the floor and she no longer had access to residents or medication. In an interview on [DATE] at 09:09 AM, LVN A said on Friday, [DATE], she received medications at the nursing station and when the pharmacy delivered medications they came in a big bag with multiple bags within them. She said when the medications arrived sometime between 7-8:00 PM she left the medications on the counter because at the time she had a resident who expired on her hall, so she was dealing with the death, the mortuary and the family of the expired resident. She said the medications remained unattended on the counter until approximately 4:00 AM towards the end of her shift when she cleaned up and put the big bag in the med room. LVN A said leaving medication on the counter was not out of the normal, everyone did that, and it just happened to be on her shift that someone decided to steal the medications. She said when she realized the controlled medications were missing on her next shift on [DATE] (Saturday), she immediately notified the Weekend Supervisor and they started looking for the medications in the med room, trash can and common areas. She said on the morning of [DATE] (Sunday) she called the Former DON, they searched the facility again and retraced her steps but the medications were never found. LVN A said on [DATE] (Monday) she was asked for written statements and on [DATE] (Tuesday) she was drug tested, interviewed by the corporate team and wrote a second statement. She said the facility told her that someone stole the medications and she was suspended pending further investigation, and she was notified of her termination on [DATE]. LVN A said prior to the drug theft she had never received any training on medication delivery, stocking the automated dispensing system and she had no idea who stole the medication. She said on the night the medication was stolen there were a lot of different people in the building, there were residents, EMS, family, housekeeping, med aides and nurses. In an interview on [DATE] at 10:22 AM, the Weekend Supervisor said she worked on Saturday and Sundays. She said in the morning of [DATE] (Saturday) she was notified by LVN A that she had misplaced the controlled substance so she notified the Former DON and the pharmacy. The Weekend Supervisor said she and LVN C looked through the facility, the medication carts and trash cans but the medications were never found. She said initially LVN A said she left the medications in the nursing station and then she moved it to the medication room and no staff checked the rooms of residents, or the personal belongings of staff or residents. The Weekend Supervisor said the facility drug tested employees, but herself, nursing administration, non-nurse/med aide staff were not drug tested. She said residents were not assessed for side effects of overdose or administration of medications because they were more focused on locating the medications. She said the medications could have been stolen by anyone, it could have been staff, residents of family members. In an interview on [DATE] at 10:53 AM, the Former DON said she started working at the facility on [DATE] and she was not aware of any allegations of drug diversion or misappropriation made against MA A or any other staff. She said her relationship with MA A was strictly professional, so she didn't know if MA A used weight loss medications but staff were not allowed to administer their own medications in the facility because of potential drug diversion. The Former DON said on [DATE] (Sunday) she was notified that LVN A left controlled substances on the counter on [DATE] and the medication was stollen. She said LVN A assumed someone had put the medication up on [DATE] but she later realized that she left the medication on the counter and never returned to check on it. The Former DON said when she was notified on [DATE] she immediately notified the Administrator and then initiated a search of the building. She said following the advice of the corporate team a drug test was administered to nurses and med aides but nurses in management, CNAs and housekeeping were not tested. The Former DON said she could not say who stole the medications but she didn't see a risk to residents because the residents were asleep. She said unaccounted medications could place residents at risk for potential overdose. The Former DON said when medications were delivered they were to be immediately logged into the automated dispensing system and if staff do not have access the medications should been left with the Unit Manager. In an interview on [DATE] at 11:37 AM, LVN B said on [DATE] she saw LVN A receiving medications at the nursing station. She said when the medications arrived she got what she needed for the 100/400 hall. She aid approximately 4 hours later, when she was looking for Tramadol for one of her residents, a coworker notified her that a bag of medication containing the medication was at the nursing station. LVN B said she did not know where LVN A was at that time, but when she returned the next evening LVN A was worried about the missing medication, so they checked the nursing station, med room and the bin containing discontinued medications but the medications were never located. She said staff did not check resident rooms or personal belongings because they didn't think the theft was associated with a resident but on the night of [DATE] LVN A was busy with a new admission, a resident death, waited for a funeral home and had another resident transitioning. LVN B said unaccounted controlled substances could place residents at risk of drug diversion, and injury or emergency if they ingested the medications. In an interview on [DATE] at 11:59 AM, LVN C said she worked the 6 AM- 6 PM shift on [DATE] (Friday) when the medication was stolen but she stayed late because she had a resident that became unresponsive on her hall. She said LVN A relieved her that night and she observed when LVN A received the medications. LVN C said the next morning (Saturday [DATE]), LVN A had already cleaned up the nursing station, there was no medication left on the counter of the nursing station and she did not know any medications were missing. She said after she returned home on [DATE], LVN A called her to ask her if she saw any medications on the nursing counter and when she returned on Sunday ([DATE]) she along with other staff tried to help LVN A locate the medications. LVN C said during the day of [DATE] she observed medications sitting on the top of the automated dispensing system but she didn't pay any attention to it because at the time she did not know how to restock the medications. She said the medications were never located and the facility never searched resident rooms or personal belongings or assessed residents for potential overdose or ingestion of inappropriate medications. LVN C said unaccounted controlled substances could place residents at risk of overdose and impact the responsible staff professional license. In an interview on [DATE] at 02:49 PM, the Administrator said he was notified of the loss of controlled substances on Monday [DATE]. He said after investigation it was identified that after LVN A signed for the drugs on Friday evening ([DATE]) she left the drugs out on in the nursing station instead of putting it in the automated dispensing system. The Administrator said when LVN A realized she left the medication out, she started calling other nurses to find the medications and then notified the Weekend Supervisor who then notified the Former DON. He said after investigation the facility was unable to identify who stole the medication, but nursing staff were trained on receiving medications, stocking the automated dispensing system and drug security. The Administrator said to his knowledge facility staff checked resident rooms but he was not sure, and any staff who had access to the medication carts or med rooms were drug tested. He said the facility failed to drug test everyone who had access to the nursing station and it was an oversight why they didn't test them. He said he failed to investigate all the way through that the medication was at the nursing station and everyone who had access to the building during the time window the theft occurred had access to the medications. The Administrator said unaccounted controlled substances created a risk of a resident self-administering the medications which could lead to overdose and a lot of bad things could happen. He said as the abuse coordinator he was responsible for ensuring all investigations were thorough, making sure corrective actions were in place and incidents are reported appropriately. The Administrator said reporting requirements for an event like this was made by the regional VP and Regional Clinical Director and in this incident he was notified that the drug theft was not a reportable incident. He said failure to report possible drug diversion to the state survey agency would result in the facility not following the correct protocol and the state survey would not be unaware of the incident and could not follow up on it. The Administrator said following the incident the facility in-serviced only MAs, LVNs and RNs on medication storage, restocking the automated dispensing system, controlled substances and the delivery/receipt of medication. He said he did not complete a thorough investigation about MA A's alleged drug diversion. He said while the facility completed medication audits to confirm nothing was checked, there was no documentation of the audits, there were no staff or resident interviews about potential misappropriation. The Administrator going forward, if an allegation of drug diversion or misappropriation was made the police would be notified immediately, interviews would start immediately, and the facility would be placed almost in a lockdown mode to ensure resident safety and to ensure no one is walking away with medication. He would investigate who was in the building, talk to every single person in the building, residents would be monitored per the recommendation of the clinical team and everything would be documented in his records or PCC. The administrator said failure to complete a thorough investigation could result in the facility not having answers or knowing what fell short and what to address in the future like corrective actions, training or education. He said failure to investigate incidents like drug theft and misappropriation could place residents tat risk of adverse reactions if the resident took the medication and drug diversion. The administrator said he fell short in documentation of the facility incidents regarding drug diversion In an interview on [DATE] at 09:13 AM, the ADON said she was aware of allegations that were made against MA A regarding drug diversion and misappropriation. She said when MA A started working at the facility they received call continuously every day for weeks that MA A stole resident's pills so the facility audited the controlled substances and no discrepancies were identified. The ADON said MA A was not suspended during the investigation, and the facility just continued auditing the carts during that time. the facility never stopped MA A never from administering medications and her access to medication, nursing carts and medication rooms were never interrupted. She said in September of 2025 medications meant for the automated dispensing system came up missing so she was responsible for managing the drug test of specific employees. The ADON said only nurses and MAs were tested, the facility check the trashcans and she searched some resident rooms but the facility did not do any assessments to identify if any resident gained access to the controlled substances or experienced any side effects of ingestion of the medications. In an interview on [DATE] at 09:39 AM, the Medical Director said he was never notified of alleged drug diversion allegations made against MA A in 2025 because he was not the medical director at the time. He said in 09/2025 he was notified of an incident in which a team member handling narcotics over the weekend did not store them as per the facility policy. He said drug diversion could place residents at risk of uncontrolled pain or consequences of inappropriately administered medications such as overdose. The Medical Director said he was not aware of any residents with uncontrolled pain or missing pain medications. He said no residents were harmed by this incident because all residents received their medications. Record review of the facility policy titled Administrator revised in 04/2007 revealed, 1. The governing board of this facility has appointed an Administrator who is duly licensed in accordance with current federal and state requirements. The Administrator is responsible for, but not limited to: Managing the day-to-day functions of the facility; Implementing established resident care policies, personnel policies, safety and security policies, and other operational policies and procedures necessary to remain in compliance with current laws, regulations, and guidelines governing long-term care facilities; Record review of the facility policy titled Unusual Occurrence Reporting revised in 12/2007 revealed, Policy Statement: As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors. Policy Interpretation and Implementation: 1. Our facility will report the following events to appropriate agencies: g. Allegations of abuse, neglect and misappropriation of resident property; andh. Other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees or visitors. 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within twenty-four (24) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within forty-eight (48) hours of reporting the event or as required by federal and state regulations. 4. The administration will keep a copy of written reports on file. Record review of the facility policy titled Investigating Incidents of Theft and/or Misappropriation of Resident Property revised 12/2008 revealed, Policy Statement: All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated. Policy Interpretation and Implementation: 1.When an incident of theft and or misappropriation of resident property is reported, the Administrator will appoint a staff member to investigate the incident. 2. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 3. The investigation shall consist of at least the following: 1. An interview with the person(s) reporting the missing items; 2. An interview with any witnesses that may have knowledge of the missing items; 3. An interview with the resident (as medically appropriate); 4. An interview with the employee (if any) accused of taking the resident's property; 5. A review of the resident's personal inventory record to determine if the missing items were recorded on the report; 6. Interviews with staff members (on all shifts) having contact with the resident during the past 48 hours; 7. Interviews with the resident's roommate, family members, and visitors; 8. A search of the laundry room for missing articles of clothing; and 9. A search of the resident's room for the missing items. 4. Should an alleged or suspected case of misappropriation of resident property be reported, the facility Administrator, or his/her designee, will notify the following persons or agencies within twenty-four (24) hours of such incident, as appropriate: 1. State Licensing and Certification Agency; 2. Ombudsman; 3. Resident Representative; 4. Adult Protective Services;5. Law Enforcement Officials; 5.While the investigation is being conducted, accused individuals not employed by the facility may be denied unsupervised access to the resident. Visits may only be made in designated areas. 6. Employees of this facility who have been accused of misappropriating resident property will be reassigned to non-resident contact duties or suspended without pay until the results of the investigation have been reviewed by the Administrator and a determination of action(s) to be taken has been made. 9.The Administrator will report the results of the investigation to the local police department, the ombudsman, and to the state survey and certification agency within five (5) working days of the incident. Record review of the facility policy tilted Abuse Investigation revised 04/2010 revealed, no instructions on how to investigate or report drug diversion. Record review of the facility policy titled Controlled Substances revised 12/2012 revealed, Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation: 1. Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. 3. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. 5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. 7. The Charge Nurse on duty will maintain the keys to controlled substance containers. The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers. Record review of the facility policy titled Accepting Delivery of Medications revised 04/2007 revealed, Policy Statement: 1. All staff shall follow a consistent procedure in accepting medications. 2. Any errors noted in receiving medications shall be brought to the attention of the Pharmacist and Director of Nursing Services. Policy Interpretation and Implementation: 1. A nurse shall personally accept each[TRUNCATED]

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident and ensure it had a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that drug records were in order and an account of all controlled drugs was maintained and periodically reconciled for 1 of 10 staff (LVN A) for pharmacy services. - LVN A failed to maintain an accurate inventory of controlled substances when she failed to log into 80 controlled substances into the automated dispensing system on [DATE] which resulted in drug diversion. This failure could result in accurate controlled substance counts and drug diversion. Findings include: Record review of pharmacy delivery record dated [DATE] revealed, LVN A signed for a delivery of controlled substances that included: 1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).4. 8 tablets of Clonazepam 0.5 mg (anxiety medication).5. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 6. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 7. 8 tablets of Zolpidem 5 mg (sleeping medication).8. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).9. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication). An observation on [DATE] at 09:45 AM revealed, the facility medication room had a keypad controlled access door. There was an automated dispensing system that required credentials to sign in. Record review of the facility provided undated investigation record revealed, 80 controlled substance tablets were missing which included:1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).4. 8 tablets of Clonazepam 0.5 mg (anxiety medication).5. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 6. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 7. 8 tablets of Zolpidem 5 mg (sleeping medication).8. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).9. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication).On [DATE] LVN A signed for the 80 controlled substance tablets.On [DATE] the facility performed urine drug screens on only nurses and med aide on day shift and night shift. All staff tested negative except for 1 resident who had a valid prescription for stimulant medications. In an interview on [DATE] at 12:20 PM, RN A said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. She said the nurse was terminated after the incident. In an interview on [DATE] at 12:44 PM, LVN D said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. He said in response facility management drug tested all nurses and CMAs and the nurse that left the medication on the counter was terminated after the incident. In an interview on [DATE] at 01:17 PM, the Administrator said after the stolen controlled substances were delivered, they were not documented and then they went missing. The medications were never located, and the facility suspected they were stolen so they performed drug tests on staff. The Administrator said to his knowledge the medications were left on top of the automated dispensing system in the med room In an interview on [DATE] at 02:07 PM, the Regional Clinical Director said the diverted controlled substances were delivered to stock the automated dispensing system. He said after the incident, nursing staff checked common areas for the missing medications but they were never found. In an interview on [DATE] at 09:09 AM, LVN A said on Friday, [DATE], she received medications at the nursing station and when the pharmacy delivered medications they came in a big bag with multiple bags within them. She said when the medications arrived sometime between 7-8:00 PM she left the medications on the counter because at the time she had a resident who expired on her hall, so she was dealing with the death, the mortuary and the family of the expired resident. She said the medications remained unattended on the counter until approximately 4:00 AM towards the end of her shift when she cleaned up and put the big bag in the med room. LVN A said leaving medication on the counter was not out of the normal, everyone did that, and it just happened to be on her shift that someone decided to steal the medications. She said when she realized the controlled medications were missing on her next shift on [DATE] (Saturday), she immediately notified the Weekend Supervisor and they started looking for the medications in the med room, trash can and common areas. She said on the morning of [DATE] (Sunday) she called the Former DON, they searched the facility again and retraced her steps but the medications were never found. LVN A said on [DATE] (Monday) she was asked for written statements and on [DATE] (Tuesday) she was drug tested, interviewed by the corporate team and wrote a second statement. She said the facility told her that someone stole the medications and she was suspended pending further investigation, and she was notified of her termination on [DATE]. LVN A said prior to the drug theft she had never received any training on medication delivery, stocking the automated dispensing system and she had no idea who stole the medication. She said on the night the medication was stolen there were a lot of different people in the building, there were residents, EMS, family, housekeeping, med aides and nurses. In an interview on [DATE] at 10:22 AM, the Weekend Supervisor said she worked on Saturday and Sundays. She said in the morning of [DATE] (Saturday) she was notified by LVN A that she had misplaced the controlled substance so she notified the Former DON and the pharmacy. The Weekend Supervisor said she and LVN C looked through the facility, the medication carts and trash cans but the medications were never found. She said initially LVN A said she left the medications in the nursing station and then she moved it to the medication room. LVN A said the medications could have been stolen by anyone, it could have been staff, residents of family members. In an interview on [DATE] at 10:53 AM, the Former DON said on [DATE] (Sunday) she was notified that LVN A left controlled substances on the counter on [DATE] and the medication was stollen. She said LVN A assumed someone had put the medication up on [DATE] but she later realized that she left the medication on the counter and never returned to check on it. The Former DON said when she was notified on [DATE] she immediately notified the Administrator and then initiated a search of the building. She said following the advice of the corporate team a drug test was administered to nurses and med aides but nurses in management, CNAs and housekeeping were not tested. The Former DON said she could not say who stole the medications but she didn't see a risk to residents because the residents were asleep. She said unaccounted medications could place residents at risk for potential overdose. The Former DON said when medications were delivered they were to be immediately logged into the automated dispensing system and if staff do not have access the medications should be left with the Unit Manager. In an interview on [DATE] at 11:37 AM, LVN B said on [DATE] she saw LVN A receiving medications at the nursing station. She said when the medications arrived she got what she needed for the 100/400 hall. She aid approximately 4 hours later, when she was looking for Tramadol for one of her residents, a coworker notified her that a bag of medication containing the medication was at the nursing station. LVN B said she did not know where LVN A was at that time, but when she returned the next evening LVN A was worried about the missing medication, so they checked the nursing station, med room and the bin containing discontinued medications but the medications were never located. She said staff did not check resident rooms or personal belongings because they didn't think the theft was associated with a resident but on the night of [DATE] LVN A was busy with a new admission, a resident death, waited for a funeral home and had another resident transitioning. LVN B said unaccounted controlled substances could place residents at risk of drug diversion, and injury or emergency if they ingested the medications. In an interview on [DATE] at 11:59 AM, LVN C said she worked the 6 AM- 6 PM shift on [DATE] (Friday) when the medication was stolen but she stayed late because she had a resident that became unresponsive on her hall. She said LVN A relieved her that night and she observed when LVN A received the medications. LVN C said the next morning (Saturday [DATE]), LVN A had already cleaned up the nursing station, there was no medication left on the counter of the nursing station and she did not know any medications were missing. She said after she returned home on [DATE], LVN A called her to ask her if she saw any medications on the nursing counter and when she returned on Sunday ([DATE]) she along with other staff tried to help LVN A locate the medications. LVN C said during the day of [DATE] she observed medications sitting on the top of the automated dispensing system but she didn't pay any attention to it because at the time she did not know how to restock the medications. She said the medications were never located and the facility never searched resident rooms or personal belongings or assessed residents for potential overdose or ingestion of inappropriate medications. LVN C said unaccounted controlled substances could place residents at risk of overdose and impact the responsible staff professional license. In an interview on [DATE] at 02:49 PM, the Administrator said he was notified of the loss of controlled substances on Monday [DATE]. He said after investigation it was identified that after LVN A signed for the drugs on Friday evening ([DATE]) she left the drugs out on in the nursing station instead of putting it in the automated dispensing system. The Administrator said when LVN A realized she left the medication out, she started calling other nurses to find the medications and then notified the Weekend Supervisor who then notified the Former DON. He said after investigation the facility was unable to identify who stole the medication, but nursing staff were trained on receiving medications, stocking the automated dispensing system and drug security. The Administrator said unaccounted controlled substances created a risk of a resident self-administering the medications which could lead to overdose and a lot of bad things could happen. In an interview on [DATE] at 09:39 AM, the Medical Director said in 09/2025 he was notified of an incident in which a team member handling narcotics over the weekend did not store them as per the facility policy. He said drug diversion could place residents at risk of uncontrolled pain or consequences of inappropriately administered medications such as overdose. The Medical Director said he was not aware of any residents with uncontrolled pain or missing pain medications. He said no residents were harmed by this incident because all residents received their medications. In an interview on [DATE] at 01:34 PM, the DON said when controlled substances were delivered they should be counted against the pharmacy record. Resident specific medications should be documented as received with the accompanying control sheet and back up medications scanned and entered into the inventory of the automatic dispensing system. She said accurate documentation of the receipt of controlled substances is necessary to keep a perpetual (never ending) count of medications to ensure there is an accurate account of all controlled substances. The DON said on [DATE] the nurse failed to log medication in the automated dispensing system and failure to keep a proper inventory of controlled substances would result in inaccurate records which could result in the facility being unable to accurately and timely identify drug diversion. Record review of the facility policy titled Accepting Delivery of Medications revised 04/2007 revealed, Policy Statement: 1. All staff shall follow a consistent procedure in accepting medications. 2. Any errors noted in receiving medications shall be brought to the attention of the Pharmacist and Director of Nursing Services. Policy Interpretation and Implementation: 1. A nurse shall personally accept each medication delivery. 2. Before signing to accept the delivery, the Nurse must reconcile the medications in the package with the delivery ticket/order receipt. 4. A nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket. Both the receiving nurse and the delivery agent must sign any notations about errors. 5. The delivery ticket shall be archived in a designated location. 10. The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings. Record review of the facility policy titled Controlled Substances revised 12/2012 revealed, Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation: 1. Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. 3. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. 5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. 7. The Charge Nurse on duty will maintain the keys to controlled substance containers. The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers.

Based on observation, interview and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 10 staff (LVN A) reviewed for medication storage . - LVN A failed to ensure that controlled substances were stored behind a double lock when she left them unattended at the nursing station on [DATE] which resulted in 80 tabs of controlled medication stolen from the facility. This failure could place residents at risk of misappropriation of medications, adverse reactions to medications, overdose and hospitalization. Findings include: Record review of pharmacy delivery record dated [DATE] revealed, LVN A signed for a delivery of controlled substances that included: 1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).4. 8 tablets of Clonazepam 0.5 mg (anxiety medication).5. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 6. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 7. 8 tablets of Zolpidem 5 mg (sleeping medication).8. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).9. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication). An observation on [DATE] at 09:45 AM revealed, the facility medication room to have a keypad controlled access door. There was an automated dispensing system that required credentials to sign in. Record review of the facility provided undated investigation record revealed, 80 controlled substance tablets were missing which included:1. 8 tablets of Acetaminophen/Codeine 300-30 mg (narcotic opioid pain medication).2. 8 tablets of Lacosamide 50 mg ( anti-seizure medication).3. 16 tablets of Hydrocodone/Acetaminophen 5 mg-325 mg (narcotic opioid pain medication).4. 8 tablets of Clonazepam 0.5 mg (anxiety medication).5. 8 tablets of Hydrocodone/Acetaminophen 10 mg-325 mg (narcotic opioid pain medication) 6. 8 tablets of Lorazepam 0.5 mg (anxiety medication) 7. 8 tablets of Zolpidem 5 mg (sleeping medication).8. 8 tablets of Pregabalin 50 mg (anti-seizure and pain medication).9. 8 tablets Tramadol 50 mg (synthetic narcotic opioid pain medication).On [DATE] LVN A signed for the 80 controlled substance tablets.On [DATE] the facility performed urine drug screens on only nurses and med aide on day shift and night shift. All staff tested negative except for 1 resident who had a valid prescription for stimulant medications. In an interview on [DATE] at 12:20 PM, RN A said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. She said the nurse was terminated after the incident. In an interview on [DATE] at 12:44 PM, LVN D said on an unknown date in September an unknown nurse left medications unattended at the nursing station desk and someone stole it. He said in response facility management drug tested all nurses and CMAs and the nurse that left the medication on the counter was terminated after the incident. In an interview on [DATE] at 01:17 PM, the Administrator said after the stolen controlled substances were delivered, they were not documented and then they went missing. The medications were never located, and the facility suspected they were stolen so they performed drug tests on staff. The Administrator said to his knowledge the medications were left on top of the automated dispensing system in the med room. In an interview on [DATE] at 02:07 PM, the Regional Clinical Director said the diverted controlled substances were delivered to stock the automated dispensing system. He said after the incident, nursing staff checked common areas for the missing medications but they were never found. In an interview on [DATE] at 09:09 AM, LVN A said on Friday, [DATE], she received medications at the nursing station and when the pharmacy delivered medications they came in a big bag with multiple bags within them. She said when the medications arrived sometime between 7-8:00 PM she left the medications on the counter because at the time she had a resident who expired on her hall, so she was dealing with the death, the mortuary and the family of the expired resident. She said the medications remained unattended on the counter until approximately 4:00 AM towards the end of her shift when she cleaned up and put the big bag in the med room. LVN A said leaving medication on the counter was not out of the normal, everyone did that, and it just happened to be on her shift that someone decided to steal the medications. She said when she realized the controlled medications were missing on her next shift on [DATE] (Saturday), she immediately notified the Weekend Supervisor and they started looking for the medications in the med room, trash can and common areas. She said on the morning of [DATE] (Sunday) she called the Former DON, they searched the facility again and retraced her steps but the medications were never found. LVN A said on [DATE] (Monday) she was asked for written statements and on [DATE] (Tuesday) she was drug tested, interviewed by the corporate team and wrote a second statement. She said the facility told her that someone stole the medications and she was suspended pending further investigation, and she was notified of her termination on [DATE]. LVN A said prior to the drug theft she had never received any training on medication delivery, stocking the automated dispensing system and she had no idea who stole the medication. She said on the night the medication was stolen there were a lot of different people in the building, there were residents, EMS, family, housekeeping, med aides and nurses. In an interview on [DATE] at 10:22 AM, the Weekend Supervisor said she worked on Saturday and Sundays. She said in the morning of [DATE] (Saturday) she was notified by LVN A that she had misplaced the controlled substance so she notified the Former DON and the pharmacy. The Weekend Supervisor said she and LVN C looked through the facility, the medication carts and trash cans but the medications were never found. She said initially LVN A said she left the medications in the nursing station and then she moved it to the medication. LVN A said the medications could have been stolen by anyone, it could have been staff, residents of family members. In an interview on [DATE] at 10:53 AM, the Former DON said on [DATE] (Sunday) she was notified that LVN A left controlled substances on the counter on [DATE] and the medication was stollen. She said LVN A assumed someone had put the medication up on [DATE] but she later realized that she left the medication on the counter and never returned to check on it. The Former DON said when she was notified on [DATE] she immediately notified the Administrator and then initiated a search of the building. She said following the advice of the corporate team a drug test was administered to nurses and med aides but nurses in management, CNAs and housekeeping were not tested. The Former DON said she could not say who stole the medications but she didn't see a risk to residents because the residents were asleep. She said unaccounted medications could place residents at risk for potential overdose. The Former DON said when medications were delivered they were to be immediately logged into the automated dispensing system and if staff do not have access the medications should be left with the Unit Manager. In an interview on [DATE] at 11:37 AM, LVN B said on [DATE] she saw LVN A receiving medications at the nursing station. She said when the medications arrived she got what she needed for the 100/400 hall. She aid approximately 4 hours, when she was looking for Tramadol for one of her residents, a coworker notified her that a bag of medication containing the medication was at the nursing station. LVN B said she did not know where LVN A was at that time, but when she returned the next evening LVN A was worried about the missing medication, so they checked the nursing station, med room and the bin containing discontinued medications but the medications were never located. She said staff did not check resident rooms or personal belongings because they didn't think the theft was associated with a resident but on the night of [DATE] LVN A was busy with a new admission, a resident death, waited for a funeral home and had another resident transitioning. LVN B said unaccounted controlled substances could place residents at risk of drug diversion, and injury or emergency if they ingested the medications. In an interview on [DATE] at 11:59 AM, LVN C said she worked the 6 AM- 6 PM shift on [DATE] (Friday) when the medication was stolen but she stayed late because she had a resident that became unresponsive on her hall. She said LVN A relieved her that night and she observed when LVN A received the medications. LVN C said the next morning (Saturday [DATE]), LVN A had already cleaned up the nursing station, there was no medication left on the counter of the nursing station and she did not know any medications were missing. She said after she returned home on [DATE], LVN A called her to ask her if she saw any medications on the nursing counter and when she returned on Sunday ([DATE]) she along with other staff tried to help LVN A locate the medications. LVN C said during the day of [DATE] she observed medications sitting on the top of the automated dispensing system but she didn't pay any attention to it because at the time she did not know how to restock the medications. She said the medications were never located and the facility never searched resident rooms or personal belongings or assessed residents for potential overdose or ingestion of inappropriate medications. LVN C said unaccounted controlled substances could place residents at risk of overdose and impact the responsible staff professional license. In an interview on [DATE] at 02:49 PM, the Administrator said he was notified of the loss of controlled substances on Monday [DATE]. He said after investigation it was identified that after LVN A signed for the drugs on Friday evening ([DATE]) she left the drugs out on in the nursing station instead of putting it in the automated dispensing system. The Administrator said when LVN A realized she left the medication out, she started calling other nurses to find the medications and then notified the Weekend Supervisor who then notified the Former DON. He said after investigation the facility was unable to identify who stole the medication, but nursing staff were trained on receiving medications, stocking the automated dispensing system and drug security. The Administrator said unaccounted controlled substances created a risk of a resident self-administering the medications which could lead to overdose and a lot of bad things could happen. In an interview on [DATE] at 09:39 AM, the Medical Director said in 09/2025 he was notified of an incident in which a team member handling narcotics over the weekend did not store them as per the facility policy. He said drug diversion could place residents at risk of uncontrolled pain or consequences of inappropriately administered medications such as overdose. The Medical Director said he was not aware of any residents with uncontrolled pain or missing pain medications. He said no residents were harmed by this incident because all residents received their medications. In an interview on [DATE] at 01:34 PM, the DON said controlled medications should be stored behind a double lock regardless of it being stored in a medication cart or an automated dispensing system to prevent unauthorized entry and to keep residents safe. She controlled substances should be counted against the pharmacy record. Resident specific medications should be documented as received with the accompanying control sheet and back up medications scanned and entered into the inventory of the automatic dispensing system. The DON said on [DATE] the nurse failed to timely store medication in the automated dispensing system and the medications should not have been left on the counter. failure to store medications per facility policy could place residents at risk for a change of condition, illness, tiredness and CNS depression (when the brain is slowed down resulting in decreased heart and breathing rates that can cause unconsciousness, coma or death). Record review of the facility policy titled Accepting Delivery of Medications revised 04/2007 revealed, Policy Statement: 1. All staff shall follow a consistent procedure in accepting medications. 2. Any errors noted in receiving medications shall be brought to the attention of the Pharmacist and Director of Nursing Services. Policy Interpretation and Implementation: 1. A nurse shall personally accept each medication delivery. 2. Before signing to accept the delivery, the Nurse must reconcile the medications in the package with the delivery ticket/order receipt. 4. A nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket. Both the receiving nurse and the delivery agent must sign any notations about errors. 5. The delivery ticket shall be archived in a designated location. 6. The dispensing pharmacy, consultant pharmacist, and Director of Nursing Services shall be notified of medication order errors. 10. The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings. 11. The Director of Nursing Services shall consult with the provider pharmacy and the Administrator to determine whether any further legal action is indicated. 12. In the event there is concern about controlled substances being discharged with the resident and/or resident's representative, the Attending Physician may choose not to discharge the resident with those medications. 13. The Director of Nursing Services shall maintain and disseminate to appropriate individuals a list of personnel who have access to medication storage areas and controlled substance containers. Record review of the facility policy titled Storage of Medication revised 04/2007 revealed, Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. 2. The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Record review of the facility policy titled Controlled Substances revised 12/2012 revealed, Policy Statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation: 1. Only authorized licensed nursing and/or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. 3. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record. 5. Controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. This container must remain locked at all times, except when it is accessed to obtain medications for residents. 7. The Charge Nurse on duty will maintain the keys to controlled substance containers. The Director of Nursing Services will maintain a set of back-up keys for all medication storage areas including keys to controlled substance containers.

Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - The facility failed to update the facility nursing postings on 10/14/25 and 10/21/25. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: Observations on Tuesday, 10/14/25, at 08:21 AM and 10:14 AM revealed, the facility Direct Care Report posting on the top of the nursing station facing the front door that read Monday [DATE]. The posting indicated that that the facility had a Day shift (6 AM and 6 PM) and Night Shift (6 PM- 6 AM) for LVNs, 3 Shifts ( 6AM- 2 PM, 2 PM - 10 PM, 10 PM- 6 AM) for CNAs, 2 shifts for CMAs (6 AM- 2 PM), 2 shifts for Restorative Aides (7:30 AM- 3:30 PM and 8 AM- 4 PM), 1 shift for RN Unit Mangers (8 AM - 4 PM) and 1 shift for RNs (6 PM- 6 AM). The posting indicated the facility census, number of staff types (RN, LVN, CNA, CMA and Restorative Aide) and total hours worked for all shifts. An observation on Tuesday. 10/21/25, at 09:57 AM revealed, the facility Direct Care Report posting on the top of the nursing station facing the front door that read Monday [DATE]. The posting indicated that that the facility had a Day shift (6 AM and 6 PM) and Night Shift (6 PM- 6 AM) for LVNs, 3 Shifts (6AM- 2 PM, 2 PM - 10 PM, 10 PM- 6 AM) for CNAs, 2 shifts for CMAs (6 AM- 2 PM), 2 shifts for Restorative Aides (7:30 AM- 3:30 PM and 8 AM- 4 PM), 1 shift for RN Unit Mangers (8 AM - 4 PM) and 1 shift for RNs (6 PM- 6 AM). The posting indicated the facility census, number of staff types (RN, LVN, CNA, CMA and Restorative Aide) and total hours worked for all shifts. In an interview on 10/22/25 at 10:17 AM, the Staffing Coordinator said her daily responsibilities included the daily schedule, managing the on call phone and the direct care report. She said she worked Monday through Friday from 08:00 AM to 05:00 PM and she put out the Direct Care Report daily in the morning when she came into work. The Staffing Coordinator said when she did not work on the weekend the Weekend Supervisor was responsible for it on the weekend. She said the Direct Care Report included the name of the facility, date, census type of staff, shifts and the total number of hours scheduled for the day. The Staffing Coordinator said she was not sure what time of the day the nursing posting had to be updated by but if the posting was not updated daily people would not know the staffing or coverage for the building for the day. She said she did not work on Monday 10/14/25 and Monday 10/21/25. She said when she returned from her day off she observed that the nursing posting was the same one she posted on Monday so it was not changed during her absence. The Staffing Coordinator said the DON and the Administrator were responsible for updating the posting when she did not work. In an interview on 10/22/25 at 01:34 PM, the Administrator said the staffing coordinator was responsible for updating the Direct Care Report, when she was absent, Talent or Learning staff made updates, but the DON and Administrator were ultimately responsible to update the staff posting. He said on 10/14/25 and 10/21/25 he was responsible for updating the Direct Care Report because both the Staffing Coordinator and Talent and Learning Staff were absent on those day and he failed to update the posting on those days because it was overlooked. The administrator said failure to update the posting daily could result in people not knowing the facility had adequate coverage and that residents were being taken care of to the best of their ability with appropriate staffing types. Record review of the facility policy Posting Direct Care Daily Staffing Numbers revised 07/2016 revealed, Policy Statement:Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation: 1.The number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 3. Shift staffing information shall be recorded on the Daily Nursing Hours Posting form for each shift. The information recorded on the form shall include: a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facility. e. The shift for which the information is posted. f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted shift. 5. Within two (2) hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the Administrator.

Based on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); for 1 of 4 residents (CR #1) when reviewed for quality of care. 1. The facility failed to notify CR#1's physician at 7 am when he had blurry vision, increased heart rate, shortness of breath, and his O2 levels dropped below baseline. 2. The first attempt at contact was made by text at 8:17 am but the NP did not respond until 9:30 am. CR#1 was transported to the hospital at 10am on 06/02/25, 3 hours after chief complaints of shortness of breath and unsuccessful interventions. An IJ was identified on 06/05/25. The IJ template was provided to the facility on [DATE] at 12:45pm. While the IJ was removed on 06/07/25, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective action. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or additional injury, paralysis or death. The findings included: Record review of CR#1's face sheet revealed a [AGE] year old man who was admitted to the skilled nursing facility on [DATE]. His admitting diagnoses were osteomyelitis (infection that has spread to the bone) of left foot and ankle, peripheral vascular disease, and atherosclerotic heart disease. Record review of CR#1's care plan disclosed that he was on antibiotic therapy related to a bacterial infection. No information was documented regarding the resident's anxiety or shortness of breath. Record review of CR#1's O2 stats documented that on 05/28/25, his O2 was 99%. On 05/29 his O2 stats read 98%. On 05/30/35, CR#1 O2 levels read 97%. On 05/31/25, his O2 levels read 96% and on 06/01/25, his O2 levels were at 95%. Record review of CR#1's progress note dated 06/02/25 created by Nurse A documented that CNA A notified Nurse A that CR#1 complained of blurry vision and difficulty breathing. Nurse A elevated the head of bed and vitals read: BP 119/108, Heart rate 199, and O2 saturation 76%. O2 supplement maxed at 4 L were given and saturation increased to 86-87%. Norvsac 5mg, ASA (aspirin) 81 mg were administered, and resident was placed on the non-rebreather mask on 10 L. O2 saturation was increased to 90-92% and vitals read: BP 113/71, heart rate 98. CR#1 began to desaturate on the non-rebreather mask and was ordered to be sent out by NP at 9:20am. At 9:33am, 911 was called and EMS transferred CR#1 to the hospital at 10am. In an interview on 06/04/25 at 11:17 am, the NP recalled that she received a text message from Nurse A at 8:20 am on 06/02/25. She stated that if CR#1 was on a non-rebreather mask and he was still desaturating, there would be no reason for the Nurse to wait for a response from anyone (NP or PCP) because by that time CR#1 was in need of assistance. The NP checked her phone and saw that she responded to Nurse A at 9:20 am and ordered CR#1 to be sent out. The NP stated that when she arrived to the facility, CR#1 was already gone. In an interview on 06/04/25 at 12:10 pm, Nurse A stated she had worked at the facility for 1 year and worked the 6am-6pm shift. On Monday, 06/02/25, CNA A told her during breakfast that CR#1 had complaints of blurry vision and SOB (shortness of breath). When she went to check on him, CR#1 told her that he thought it could be his anxiety, and she explained that he had been experiencing increased anxiety over the last few days she worked. When she performed her assessment at 7am, CR#1 had rapid breathing and his pulse 199 bpm. When she noticed this, the first thing she did was elevate the bed for proper posture. Once she checked the vitals, she noticed his O2 was low, so she grabbed the portable O2 and gave him 2 L to help increase his O2. After CR#1 failed to return to baseline, Nurse A increased the O2 in the portable O2 machine to 4 L, which she stated was still not working. At 8 am, Nurse A placed a non-rebreather mask on CR#1 at 10 L, which helped increase his O2 to 90-91%. Although CR#1's O2 levels increased, he began to desaturate on the no-rebreather mask. Nurse A attempted to contact the NP at 8:17 am, 8:26 am, and sent a text at 8:20 am but she did not get a response. The DON was contacted, and she told Nurse A that she would have the NP assess CR#1 once she arrived at the facility sometime that day. At 9:20 am, the NP responded to Nurse A's text message and told her to send CR#1 out to the hospital because utilizing the non-rebreather mask would not be sustainable. Nurse A stated she contact 911 at 9:33 am and the resident was escorted to the hospital via EMS at 10 am. In an interview with the FM on 06/04/25 at 12:34 pm, she stated that CR#1 had complained more than once of having trouble breathing, but she felt the facility pushed it under the rug and said it was his anxiety. She stated that when she met CR#1 at the hospital, he could barely speak, and the ER doctor informed her that CR#1 might not pull through. The FM informed the investigator that CR#1 passed away at 3:30 am on 06/04/25. In an interview with CNA A on 06/04/25 at 2:14 pm, he stated that he went into CR#1's room to change him at 6:30 am and CR#1 informed him that he had blurry vision and was having trouble breathing. CNA A raised the head of the bed to assist with his breathing and went to inform Nurse A. He stated that during this time, CR#1 had his hands paced on his temples and he was crying, but he did not depict any pain or a headache. In an interview with the DON on 06/04/25 at 2:45 pm, she stated that she could not say what time Nurse A informed her of CR#1's condition, but she was aware that he was having SOB. She explained that Nurse did place CR#1 on 2 L of O2, but CR#1 began to desaturate, and he was then placed on the non-rebreather mask so that he could obtain optimal levels of O2. The DON stated that when a resident had decreased O2 with SOB, the interventions would be to sit them up and let them lean over their bedside table to help open their lungs. While doing that, the nurse should check the pulse to see if the resident's O2 was increasing. The resident should be placed on O2 immediately if it was not working. Nurses were trained to call the NP or the PCP to know what the interventions were at the moment. If the NP or PCP don't answer, the DON stated she would try to call them and explained that she could not send a resident out to the hospital without a doctor's order because it was not in her scope of practice. If the DON could not reach the attending doctor, then she would contact the medical doctor , but she would only send them out if there was a doctor's order (unless they were code). In an interview on 06/04/25 at 3:51 pm with the HRN, she stated that CR#1 was admitted on [DATE] with SOB and his O2 was in the 70's. EMS tried to give CR#1 a BiPAP (machine that helped you breathe) but it was not tolerated well. She revealed that CR#1 had a fever of 101.4 Fahrenheit and review of his bloodwork showed that he had elevated Trinomen enzymes, which was an enzyme the heart releases when it is in distress. The HRN explained that when that enzyme was elevated, it signified that CR#1was under a ton of emotional and physical stress. Review of his radiology report showed that CR#1 had pneumonia and edema in both lungs. When informed that the nursing facility paced CR#1 on a non-rebreather mask, she explained that the mask gave a significant amount of oxygen and a person should not use the mask for a long amount of time. A non-rebreather mask should be used as a band-aid and 911 one should be called so that the resident could receive a higher level of care. The HRN stated that although a long time was subjective, if someone received a large amount of O2 for too long, it could reverse the body's oxygen regulating system. Record review of the facility's policy titled Change in a Resident's Condition or Status, revised 2016 stated that: 3. Our facility shall prom promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 4. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; f. refusal of treatment or medications; g. need to transfer the resident to a hospital/treatment center; h. discharge without proper medical authority; and/or i. specific instruction to notify the Physician of changes in the resident's condition. The ADM and DON were notified on 06/05/25 at 12:45 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 06/06/25 at 10:38 am: Date: June 6, 2025 What corrective actions have been implemented for the identified residents? A. Resident CR#1 involved in alleged deficient practice was discharged to the hospital on 6/2/25. B. On 6/05/2025 at 01:35 pm the Administrator notified the Medical Director of alleged deficient practice. C. Nurse Managers completed a 100% respiratory assessment of all residents residing in the facility for respiratory concerns on 6/05/2025, and none were identified. D. The DON and Nurse Managers audited the changes in conditions for the last 3 days for respiratory concerns and notification to the physician, no concerns were identified. Completion date 6/5/2025. E. On 6/05/2025 the DON was in-serviced on Notification of Changes in Residents Conditions by the Clinical Services Director. F. On 6/05/2025 LVN A was in-serviced on Notification of Changes in Residents Conditions by the DON. G. The Clinical Services Director reviewed facility policy on 6/05/2025 regarding notification of changes and no revisions were deemed necessary. How were other residents at risk to be affected by this deficient practice identified? A. All residents have the potential to be affected by the alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. An in-service was initiated on 6/05/2025 by the Corporate Clinical Service Director and Director of Nursing with the licensed nursing staff on notifying the attending physician immediately when a change occurs. Staff were instructed that if there is no response, they must call the Medical Director using the contact number posted at the nurse's station or initiate 911, based on the resident's clinical condition. Licensed nurses will not be allowed to return to work until they receive this in-service. Completion date 6/5/2025. a. Call 911 for life-threatening emergencies or rapidly deteriorating conditions, such as chest pain, severe respiratory distress, unresponsiveness, or suspected trauma. Always assess vital signs, consult facility protocols or providers as needed, and document the decision-making process thoroughly to ensure appropriate and timely care. B. An in-service was initiated on 6/05/2025 by DON and the Administrator with the facility frontline on reporting any changes in resident conditions to the charge nurse. Completion date 6/5/2025. C. Newly hired nurses will be in-serviced by the Director of Nursing or designee on notifying the attending physician immediately when a change occurs and if there's no response instructed that if there is no response, they must call the Medical Director using the contact number posted at the nurse's station or initiate 911, based on the resident's clinical condition. Licensed nurses will not be allowed to return to work until they receive this in-service. Completion date 6/5/2025. Completion date 6/5/2025. How will the system be monitored to ensure compliance? A. The 24-hour report will be reviewed daily on the day shift capturing all shifts from the prior day by the DON/designee to audit nurse documentation in progress notes notifying the attending physician of patient change of conditions. On weekends, the Weekend Supervisor will conduct the review during the day shift for the previous 24-hour period. Discrepancies noted during reviews will be immediately corrected by contacting the attending physician of the change of condition and completing documentation in the patient's progress note. Further training will be provided as identified by the nurse manager who identified the discrepancy when and if necessary. Review will be documented on an audit report form. B. The DON/designee will review 24-hour report to ensure nurses document timely notification to the attending physician of resident changes of condition 2x week X 6 weeks. Review will be documented on an audit report form. C. Administrator will review the audit reports on a weekly basis to ensure nurse managers are following the plan of correction for six weeks. Review will be documented on an audit report form. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6/05/2025 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Surveyor monitored the POR from 06/06/25 - 06/07/25 as followed: Review of an in-service titled Notification in change in condition dated 06/05/25, 06/06/25, 06/07/25 documented that all nursing staff had been in-serviced. Review of the in-service date 06/05/25 revealed that the DON and the nurse managers on notifying the attending physician immediately when there is a change in condition in a resident's condition. During interviews on 06/05/25 from 1:38 pm - 4:00 pm and on 06/07/25 from 8:47 pm - 9:10 pm, nurses from the 6am-6pm and 6pm-6am shift were asked to review what was covered during their in-services. This included 8 LVN's and 2 RN's. All staff stated that in the event that a resident was experiencing a change in condition, the protocol would be to first assess the resident and If there was a deviation from their baseline, their NP or MD should be notified immediately. If the resident has interventions in place, nurses are to follow them or follow the orders given by the NP/MD. If the interventions were not sustainable, 911 should be called so that the resident can receive a higher level of care. It was verbalized that the chain in notification would be that the NP would be notified first and if there was no answer, an attempt would be made to the MD, and the immediate scalation would be to call 911. If contact is made with the NP and an Intervention had been started, all nurses should contact the family and facility administration. During interviews on 06/05/25 from 1:38 pm - 4:00 pm and on 06/07/25 from 8:47 pm - 9:10 pm, nurses from the 6am-6pm and 6pm-6am shift were asked to review what was covered during their in-service. This was reviewed by 11 CNA's who worked the 6am-2pm, 2pm- 10pm, and 10pm- 6am shifts. All aids had knowledge on what a change in condition looked like which could range from a skin tear or vomiting, to dizziness or shortness in breath. Aids were aware that if there was a change in condition in a resident, a nurse should be notified immediately. They stated that if the floor nurse was not available, they would inform another nurse and if that nurse was not available, they would immediately notify the ADON or DON. Review of the resident assessments to identify changes in respiratory systems and vision conditions revealed no residents were affected. Review of the resident 24-hour charts from dates 06/05/25-06/09/25 revealed that all staff were following the protocol in regards to physician notification in changed in condition and appropriate documentation in PCC. This reported has been monitored daily and was reviewed up into the exit date. Review of the Facility's QAPI Agenda, dated 06/05/25, reflected that the MD had reviewed and agreed with the plan. An amendment was made to the IJ template on 06/09/25 to include CR#2. The ADM and DON were notified on 06/07/25 9:40 pm that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure based on the comprehensive assessment of a resident, that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 of 4 residents (CR #1, CR#2) reviewed for quality of care. 1. The facility failed to notify CR#1's physician at 7 am when he had blurry vision, increased heart rate, shortness of breath, and his O2 levels dropped below baseline. 2. The first attempt at contact was made by text at 8:17 am but the NP did not respond until 9:30 am. CR#1 was transported to the hospital at 10am on 06/02/25, 3 hours after chief complaints of shortness of breath and unsuccessful interventions. 3. The facility failed to notify the Doctor when CR#2 began to have open wounds to her lower legs, identified on 09/24/24. As wounds progressed, no treatments, new orders, or interventions were initiated. Resident was admitted to the hospital on [DATE] with a diagnosis of cellulitis to the left and right lower limbs. An IJ was identified on 06/05/25 at 12:45 pm. The IJ template was provided to the facility on [DATE] at 12:45pm. While the IJ was removed on 06/07/25 , the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective action. These failures could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition and/or additional injury, paralysis or death. The findings included: CR#1 Record review of CR#1's face sheet revealed a [AGE] year old man who was admitted to the skilled nursing facility on [DATE]. His admitting diagnoses were osteomyelitis (infection that has spread to the bone) of left foot and ankle, peripheral vascular disease, and atherosclerotic heart disease. Record review of CR#'s care plan disclosed that he was on antibiotic therapy related to a bacterial infection. No information was documented regarding the resident's anxiety or shortness of breath. Record review of CR#1's O2 stats documented that on 05/28/25, his O2 was 99%. On 05/29 his O2 stats read 98%. On 05/30/35, CR#1 O2 levels read 97%. On 05/31/25, his O2 levels read 96% and on 06/01/25, his O2 levels were at 95%. Record review of CR#1's progress note dated 06/02/25 created by Nurse A documented that CNA A notified Nurse A that CR#1 complained of blurry vision and difficulty breathing. Nurse A elevated the head of bed and vitals read: BP 119/108, Heart rate 199, and O2 saturation 76%. O2 supplement maxed at 4 L were given and saturation increased to 86-87%. Norvsac 5mg, ASA (asprin) 81 mg were administered, and resident was placed on the non-rebreather mask on 10 L. O2 saturation was increased to 90-92% and vitals read: BP 113/71, heart rate 98. CR#1 began to desaturate on the non-rebreather mask and was ordered to be sent out by NP at 9:20am. At 9:33am, 911 was called and EMS transferred CR#1 to the hospital at 10am. In an interview on 06/04/25 at 11:17 am, the NP recalled that she received a text message from Nurse A at 8:20 am on 06/02/25. She stated that if CR#1 was on a non-rebreather mask and he was still desaturating, there would be no reason for the Nurse to wait for a response from anyone (NP or PCP) because by that time CR#1 was in need of assistance. The NP checked her phone and saw that she responded to Nurse A at 9:20 am and ordered CR#1 to be sent out. The NP stated that when she arrived to the facility, CR#1 was already gone. In an interview on 06/04/25 at 12:10 pm, Nurse A stated she had worked at the facility for 1 year and worked the 6am-6pm shift. On Monday, 06/02/25, CNA A told her during breakfast that CR#1 had complaints of blurry vision and SOB (shortness of breath). When she went to check on him, CR#1 told her that he thought it could be his anxiety, and she explained that he had been experiencing increased anxiety over the last few days she worked. When she performed her assessment at 7am, CR#1 had rapid breathing and his pulse 199 bpm. When she noticed this, the first thing she did was elevate the bed for proper posture. Once she checked the vitals, she noticed his O2 was low, so she grabbed the portable O2 and gave him 2 L to help increase his O2. After CR#1 failed to return to baseline, Nurse A increased the O2 in the portable O2 machine to 4 L, which she stated was still not working. At 8 am, Nurse A placed a non-rebreather mask on CR#1 at 10 L, which helped increase his O2 to 90-91%. Although CR#1's O2 levels increased, he began to desaturate on the no-rebreather mask. Nurse A attempted to contact the NP at 8:17 am, 8:26 am, and sent a text at 8:20 am but she did not get a response. The DON was contacted, and she told Nurse A that she would have the NP assess CR#1 once she arrived at the facility sometime that day. At 9:20 am, the NP responded to Nurse A's text message and told her to send CR#1 out to the hospital because utilizing the non-rebreather mask would not be sustainable. Nurse A stated she contact 911 at 9:33 am and the resident was escorted to the hospital via EMS at 10 am. In an interview with the FM on 06/04/25 at 12:34 pm, she stated that CR#1 had complained more than once of having trouble breathing, but she felt the facility pushed it under the rug and said it was his anxiety. She stated that when she met CR#1 at the hospital, he could barely speak, and the ER doctor informed her that CR#1 might not pull through. The FM informed the investigator that CR#1 passed away at 3:30 am on 06/04/25. In an interview with CNA A on 06/04/25 at 2:14 pm, he stated that he went into CR#1's room to change him at 6:30 am and CR#1 informed him that he had blurry vision and was having trouble breathing. CNA A raised the head of the bed to assist with his breathing and went to inform Nurse A. He stated that during this time, CR#1 had his hands paced on his temples and he was crying, but he did not depict any pain or a headache. In an interview with the DON on 06/04/25 at 2:45 pm, she stated that she could not say what time Nurse A informed her of CR#1's condition, but she was aware that he was having SOB. She explained that Nurse did place CR#1 on 2 L of O2, but CR#1 began to desaturate, and he was then placed on the non-rebreather mask so that he could obtain optimal levels of O2. The DON stated that when a resident had decreased O2 with SOB, the interventions would be to sit them up and let them lean over their bedside table to help open their lungs. While doing that, the nurse should check the pulse to see if the resident's O2 was increasing. The resident should be placed on O2 immediately if it was not working. Nurses were trained to call the NP or the PCP to know what the interventions were at the moment. If the NP or PCP don't answer, the DON stated she would try to call them and explained that she could not send a resident out to the hospital without a doctor's order because it was not in her scope of practice. If the DON could not reach the attending doctor, then she would contact the medical doctor , but she would only send them out if there was a doctor's order (unless they were code). In an interview on 06/04/25 at 3:51 pm with the HRN, she stated that CR#1 was admitted on [DATE] with SOB and his O2 was in the 70's. EMS tried to give CR#1 a BiPAP (machine that helped you breathe) but it was not tolerated well. She revealed that CR#1 had a fever of 101.4 Fahrenheit and review of his bloodwork showed that he had elevated Trinomen enzymes, which was an enzyme the heart releases when it is in distress. The HRN explained that when that enzyme was elevated, it signified that CR#1was under a ton of emotional and physical stress. Review of his radiology report showed that CR#1 had pneumonia and edema in both lungs. When informed that the nursing facility paced CR#1 on a non-rebreather mask, she explained that the mask gave a significant amount of oxygen and a person should not use the mask for a long amount of time. A non-rebreather mask should be used as a band-aid and 911 one should be called so that the resident could receive a higher level of care. The HRN stated that although a long time was subjective, if someone received a large amount of O2 for too long, it could reverse the body's oxygen regulating system. CR#2 Record review of CR#2's face sheet revealed a ninety-one-year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were end stage heart failure, atherosclerotic heart disease, Stage 3 chronic kidney disease, dementia (memory impairment), and hypertension (high blood pressure). Record review of CR#2's care plan revealed that she had a communication problem related to dementia and had a pacemaker related to atrial fibrillation. In an interview on 06/09/25 at 1:17 pm, the FM2 stated that she had went on vacation from 09/16/24- 09/23/24. When she returned to visit the facility on 09/24/24, she noticed swelling on CR#2's hand and she noticed there were small open red wounds on her right and left leg. The nursing staff were informed (who was not specified) of the swelling and wounds and she assumed treatment would begin. On 09/25/25, the FM2 returned to the facility and noticed the red wounds on her legs were getting worst and the swelling to the hand had remained the same. This was documented by camera phone at on 09/25/24 at 4:06 pm The FM2 immediately flagged down the nurse and told them that she wanted the doctor to come and check on CR#2. The FM2 also requested to give CR#2 a cold compress for her hands. She took another picture on 09/27/24 at 11:53 am that showed the wounds had begun to move up her legs. The FM2 stated that when the doctor finally arrived, she stated he took one look at CR#2 and sent her to the hospital on [DATE]. The FM2 disclosed that CR#2 passed away on 10/04/24. Record review of the photographs submitted by FM2 regarding the wounds on her legs showed that on 09/25/24, there were two wounds that consisted of a deep cranberry color. Seven smaller markings could also be seen that were very faint in color and did not appear to go below the surface of the skin. On 09/27/24, the picture showed that the wounds had spread up her lower extremities. There were over 10 small deep red wounds that ranged from a deep cranberry color to bright red. Record review of CR#2's Weekly Skin review dated 09/24/24 at 7:57 pm revealed open, red, scabbed over areas were identified on her (BLE) bilateral lower extremities. Note stated that CR#2 was unable to identify how scabbed areas to BLE occurred. Notification of physician and the date the physician was notified was left blank on the assessment. Record review of CR#2's orders revealed no orders initiated for treating the open areas on her legs. Record review of CR#2's TAR (treatment administration record) for September 2024 reflected that new treatments had been started to tend to BLE. Record review of CR#2's progress note documented by Nurse B on 09/24/24 at 1:39 pm wrote that This nurse placed a call to neighborhood x-ray to find out when a Tech will be here for her left arm doppler and she said a Tech will come soon. Record review of CR#2's progress note documented by Nurse A on 09/24/24 at 10:15 pm revealed that a CIC (change in condition) note was added. This note identified CR#2 had an episode of confusion where she wondered into hallway screaming and became more upset when she was redirected. A Urinalysis culture was ordered by the doctor. Record review of CR#2's progress note documented by Nurse A on 09/25/24 at 5:43 pm wrote Neighborhood x-ray notify checking on the Left ARM Venous Doppler ETA, spoke to x-ray tech she states she will have tech notify facility on the ETA as soon as possible. Record review of CR#2's progress note documented by Nurse C on 09/25/24 at 4:34 pm wrote Urine sample collected this morning and put in collection refrigerator located in soiled utility room. Lab informed of specimen and is scheduled to pick up in am 9/26. Record review of CR#2's progress note documented by Nurse B on 09/27/24 at 7:55 am wrote Resident pickup by EMS and is being transported to , she denies discomfort or aches this morning after taking her morning meds and had her breakfast, copies of her face sheet, med list and doppler result is sent with her, she is taking her phone, charger and kindle with her, report called in and I spoke with nurse, daughter notified. Record review of CR#2's hospital admission record from the facility, dated 09/27/24, the documented the problem of right leg cellulitis (bacterial skin infection that causes redness, swelling, pain, and warmth in the affected are), right leg superficial wounds, congestive heart failure, and acute chronic respiratory failure with hypoxia (failure of oxygen to reach the body's tissue). In an interview on 06/05/25 at 1:44 pm, Nurse B stated that when CR#2 was last at the facility, she remembered that CR#2 had experienced swelling in her hand and Nurse B reached out to the doctor to receive an order for a doppler to check for circulation. She could not remember much regarding this resident and she could not recall if there open areas on her legs. An attempt for an interview was made on 06/09/25 at 3:48 pm with the previous WCN. A voicemail was left and a text message was sent requesting a call back. In an interview on 06/09/25 at 4:41 pm with Dr. D, he stated that he remembered CR#2 to have advanced dementia and congestive heart failure. He could recall leg swelling but no recollection of an infection. He stated that because she was one of his long-term care patients, he would visit the resident once every 3 months but if the staff called him when something bad happened, he would come out and visit the resident. He stated he did no t receive a call from the nurses regarding anything bad that would prompt him to come out aside from the call he got from the FM2. Record review of the facility's policy titled Change in a Resident's Condition or Status, revised 2016 stated that: 1. Our facility shall prom promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). 2. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source; c. adverse reaction to medication; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; f. refusal of treatment or medications; g. need to transfer the resident to a hospital/treatment center; h. discharge without proper medical authority; and/or i. specific instruction to notify the Physician of changes in the resident's condition. The ADM and DON were notified on 06/05/25 at 12:45 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 06/06/25 at 12:45 pm: Date: June 6, 2025 NF XXX submits the following Plan of Removal for the alleged failure to ensure treatment and care was provided to CR #1 consistent with professional standards of practice on 06/05/25. The Texas Department of Health and Human Services entered the facility on June 4, 2025, for a Complaint Survey. During the survey process an IJ (Immediate Jeopardy) was cited regarding F684 - Quality of Care, consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. The facility failed to ensure CR # 1 receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices in that: the facility failed to contact 911 after CR #1's O2 dropped and did not return to baseline after the use of supplemental oxygen interventions. The resident was transported to hospital at 10am on 6/2/25, 3 hours after chief complaints of shortness of breath and unsuccessful interventions. Immediate action: What corrective actions have been implemented for the identified residents? CR #1 discharged from the facility on 6-2-25 to the hospital and did not return to the facility. o On 6/05/2025 at 01:35 pm the Administrator notified the Medical Director of alleged deficient practice. o On 6-5-25, the Clinical Service Director in-serviced the nurse managers to include the DON to notify the attending physician immediately when there is a change in the resident's condition. If there is no sustained improvement during interventions at the facility, then 911 is to be contacted to transport resident to the hospital to receive a higher level of care. The DON/designees will be notified by licensed nurses when there is a change in residents' condition and interventions attempted to include residents' response to the interventions. The DON/designees will determine if improvement is sustained or if 911 needs to be called and resident transported to the hospital to receive a higher level of care. Completion date 6/5/2025. o On 6-5-25, DON/designees in-serviced all licensed nurses (full-time, part-time, and PRN) to notify the attending physician immediately when there is a change in the resident's condition. If there is no sustained improvement during interventions at the facility, then 911 is to be contacted to transport resident to the hospital to receive a higher level of care. The DON/designees will be notified by licensed nurses when there is a change in residents' condition and interventions attempted to include residents' response to the interventions. The DON/designees will determine if improvement is sustained or if 911 needs to be called and resident transported to the hospital to receive a higher level of care. Completion date 6/5/2025. o On 6-5-25, DON/Nurse Managers assessed all residents for changes in respiratory system and vision condition. No residents were found to be affected. o On 6-5-25, DON/designees audited residents' charts for changes in respiratory system and vision condition in the past 72 hours. No residents were found to be affected. o The training is immediately notifying the attending physician when there is a change in the residents' condition. If there is no sustained improvement during interventions at the facility, then 911 is to be contacted to transport resident to the hospital to receive a higher level of care will be ongoing. Training to be conducted during the orientation of newly hired licensed nursing staff (full-time, part-time, and PRN). The DON/designees to provide oversight and ensure compliance. Completion date 6/5/2025. o No licensed nursing staff will be allowed to work without receiving the in-service on the regarding timely notifying the attending physician timely when there is a change in the residents' condition. If there is no sustained improvement during interventions at the facility, then 911 is to be contacted to transport resident to the hospital to receive a higher level of care. On 6-5-25, the facility Administrator notified the Medical Director via phone. Items discussed were: IJ (Immediate Jeopardy) was cited on 6-5-25 as evidenced by facility's failure to: F684 - Quality of Care o On 6-5-25, the Clinical Service Director in-serviced the nurse managers to include the DON to notify the attending physician immediately when there is a change in the resident's condition. If there is no sustained improvement during interventions at the facility, then 911 is to be contacted to transport resident to the hospital to receive a higher level of care. Completion date 6/5/2025. o On 6-5-25, DON/designees in-serviced all licensed nurses (full-time, part-time, and PRN) to notify the attending physician timely when there is a change in the resident's condition. If there is no sustained improvement during interventions at the facility, then 911 is to be contacted to transport resident to the hospital to receive a higher level of care. o On 6-5-25, DON/Nurse Managers assessed all residents for changes in respiratory system and vision condition. No residents were found to be affected. o On 6-5-25, DON/designees audited residents' charts for changes in respiratory system and vision condition in the past 72 hours. No residents were found to be affected. o The training regarding timely notifying the attending physician timely when there is a change in the residents' condition. If there is no sustained improvement during interventions at the facility, then 911 is to be contacted to transport resident to the hospital to receive a higher level of care will be ongoing. Training to be conducted during the orientation of newly hired licensed nursing staff (full-time, part-time, and PRN). The DON/designees to provide oversight and ensure compliance. o No licensed nursing staff will be allowed to work without receiving the in-service on the regarding timely notifying the attending physician timely when there is a change in the residents' condition. If there is no sustained improvement during interventions at the facility, then 911 is to be contacted to transport resident to the hospital to receive a higher level of care. How were other residents at risk to be affected by this deficient practice identified? A. All residents have the potential to be affected by the alleged deficient practice. What does the facility need to change immediately to keep residents safe and ensure it does not happen again? A. An in-service was initiated on 6-5-25 by the Corporate Clinical Service Director and Director of Nursing with the licensed nursing staff on notifying the attending physician timely when a change of condition occurs. If there is no sustained improvement during interventions at the facility, then 911 is to be contacted to transport resident to the hospital to receive a higher level of care. Licensed nurses will not be allowed to return to work until they receive this in-service. Completion date: 6-5-25. B. An in-service was initiated on 6-5-25 by DON and designees with the facility licensed nursing staff on reporting any changes in resident conditions notifying the attending physician timely when a change of condition occurs. If there is no sustained improvement during interventions at the facility, then 911 is to be contacted to transport resident to the hospital to receive a higher level of care. Completion date: 6-5-25. C. Newly hired nurses will be in-serviced by the Director of Nursing or designee on timely notifying the attending physician of patient change of conditions timely when a change of condition occurs. If there is no sustained improvement during interventions at the facility, then 911 is to be contacted to transport resident to the hospital to receive a higher level of care. How will the system be monitored to ensure compliance? A. The 24-hour report will be reviewed daily during the day shift by the Director of Nursing (DON) or designee to audit nurse documentation in progress notes, specifically ensuring timely notification to the attending physician regarding any resident change in condition. On weekends and holidays, the Weekend Supervisor will conduct this review during the day shift for the prior 24-hour period. If there is no sustained improvement during in-house interventions, 911 will be contacted to transport the resident to the hospital for a higher level of care. Any discrepancies identified during these reviews will be immediately corrected by notifying the attending physician and completing appropriate documentation in the resident's progress notes. Additional staff training will be provided as needed, based on findings by the Nurse Manager. All reviews will be documented on an audit report form twice weekly for six weeks. B. The administrator will review the audit reports on a weekly basis to ensure nurse managers are following the plan of correction for six weeks. The review will be documented on an audit report form. C. This will be reviewed monthly in QAPI until sustained compliance is achieved. Quality Assurance An impromptu Quality Assurance and Performance Improvement review of the plan of removal was completed on 6-5-25 with the Medical Director. The Medical Director has reviewed and agrees with this plan. The Surveyor monitored the POR from 06/06/25 - 06/07/25 as followed: Review of an in-service titled Notification in change in condition dated 06/05/25, 06/06/25, 06/07/25 documented that all nursing staff had been in-serviced. Review of the in-service date 06/05/25 revealed that the DON and the nurse managers were trained on notifying the attending physician immediately when there is a change in condition in a resident's condition. During interviews on 06/05/25 from 1:38 pm - 4:00 pm and on 06/07/25 from 8:47 pm - 9:10 pm, nurses from the 6am-6pm and 6pm-6am shift were asked to review what was covered during their in-services. This included 8 LVN's and 2 RN's. All staff stated that in the event that a resident was experiencing a change in condition, the protocol would be to first assess the resident and if there was a deviation from their baseline, their NP or MD should be notified immediately. If the resident has interventions in place, nurses were to follow them or follow the orders given by the NP/MD. If the interventions were not sustainable, 911 should be called so that the resident can receive a higher level of care. It was verbalized that the chain in notification would be that the NP would be notified first and if there was no answer, an attempt would be made to the MD, and the immediate scalation would be to call 911. If contact is made with the NP and an Intervention had been started, all nurses should contact the family and facility administration. During interviews on 06/05/25 from 1:38 pm - 4:00 pm and on 06/07/25 from 8:47 pm - 9:10 pm, nurses from the 6am-6pm and 6pm-6am shift were asked to review what was covered during their in-service. This was reviewed by 11 CNA's who worked the 6am-2pm, 2pm- 10pm, and 10pm- 6am shifts. All aides had knowledge on what a change in condition looked like which could range from a skin tear or vomiting to dizziness or shortness in breath. Aides were aware that if there was a change in condition in a resident, a nurse should be notified immediately. They stated that if the floor nurse was not available, they would inform another nurse and if that nurse was not available, they would immediately notify the ADON or DON. Review of the resident assessments to identify changes in respiratory systems and vision conditions revealed no residents were affected. Review of the resident 24-hour charts from dates 06/05/25-06/09/25 revealed that all staff were following the protocol in regard to physician notification in changed in condition and appropriate documentation in PCC. This reported has been monitored daily and was reviewed up into the exit date. Review of the Facility's QAPI Agenda, dated 06/05/25, reflected that the MD had reviewed and agreed with the plan. An amendment was made to the IJ template on 06/09/25 to include CR#2. The ADM and DON were notified on 06/07/25 9:40 pm that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 40 of 106 residents reviewed for kitchen safety. 1. Dietary staff failed to ensure all perishable items were fresh before serving to residents. 2. During the lunch service on 06/09/25, Resident #1 took a sip of chocolate milk that had an expiration date of 05/19/25. This failure could place residents at risk of contracting a food borne illness. Findings include: Record review of Resident #1's face-sheet revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were type 2 diabetes, major depressive disorder, and morbid obesity. Record review of Resident #1's MDS (Minimum Data Set) assessment, Section C Cognitive Patterns dated 06/03/25 revealed a score of 11, signifying moderately impaired cognition. Record review of Resident #1's care plan revealed that she was dependent on staff for activities, cognitive stimulation, and social interaction. Resident #1 had the potential for fluid deficit related to poor intake and she was encouraged to drink the fluids of her choice. It was also documented that she experienced symptoms of GERD (gastro-intestinal reflux disorder). In an observation and interview on 06/09/25 at 11:43 am, Resident #1 was laying in bed and was in a pleasant disposition. She explained that she was doing amazing and that she had been at the facility for several years. As she began to describe her experience with the investigator, an aide (name not taken) brought the resident's lunch. On the tray with Resident#1's lunch was an 8 fl oz carton of chocolate milk. The aide set up the tray for Resident #1 and she continued her conversation with the investigator. When Resident #1 opened the carton of chocolate milk and took a sip, she yelled Oh God!! What is the date on this?. The expiration date on the milk was 05/19/25. Resident #1 stated that is terrible! They don't even check the date. The investigator immediately flagged down the ADON in the hallway and let her know that they needed to check and remove all the milk that had been passed during lunch. Alongside the ADON and aides, they removed the milk from each resident's lunch tray. On the halls, most of the milk was poured into plastic cups and was covered with plastic wrap. The cups that were not wrapped with plastic denied being consumed by the residents. On one of the halls, the investigator grabbed a cup and smelled the milk. The smell was sour and pungent. In the kitchen, were 4 empty cartons of chocolate milk set on the counter. The Dietary Aide walked the investigator to the walk-in kitchen and the date was checked on all the food. In an interview on 06/09/25 at 12:08 pm with DA A, she stated that DA B and herself were responsible for passing out the milk during the lunch service. DA A said they opened 6 cartons of chocolate milk and poured them into plastic cups. Resident #1 was the only person who got a full carton during her meal. DA A disclosed that she did not check the date on the milk nor did she smell the milk for freshness. She stated that it was the responsibility of the dietary aides to ensure that all food and beverages were fresh for the residents. In an interview on 06/09/25 at 12:10 pm with the DM , she stated that DA A didn't check the date on the milk. She explained that she saw the cartons of expired chocolate milk mixed in a crate with other cartons of milk and she separated them out. She stated that she would check the date on perishable items daily, but she guessed that the night shift forgot to pour out the expired cartons. The expiration date of 05/19/25 was reiterated to the DM. She said that she understood, and the date was the reason why she had them separated. The DM stated the process for prepackaged items was to check them before food service. The DM explained that the harm in a resident consuming expired milk was that they could get sick. In an interview on 06/09/25 at 3:01 pm with the ADM, he stated that he was made aware of the expired milk during the lunch service and he in-serviced the dietary staff and the nursing staff. The in-service covered communication, checking the dates on all items, and nursing staff checking the dates on tray items. The ADM affirmed that the expectation of fresh food fell on everybody. Record review of the facility's policy titled Facility Nutrition Program, revised April 2007 documented that A Food Services Manager (who may be a Working Supervisor) will oversee the activities and functions of the kitchen staff (i.e., those responsible for storing, preparing, and delivering meals), including food storage and preparation, sanitation issues, personnel matters, and menu planning and preparation.

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 6.9 % based on 2 errors out of 29 opportunities, which involved 2 of 8 residents (Resident #15 and Resident #96) reviewed for medication errors in that:. - LVN L failed to administered medication as ordered to Resident #96 by administering Multivitamins w/ Minerals instead of plain Multivitamins as ordered. - LVN M failed to administer medications as ordered to Resident #15 by administering eye drops with Tetrahydrozoline Hydrochloride 0.05% instead of eye drops with Carboxymethylcellulose Sodium as ordered. These failures could place residents receiving medication at risk of inadequate therapeutic outcomes. Resident #96 Record review of Resident #96's Face Sheet dated 12/11/2024 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: end stage kidney disease (kidney reaches advanced state of loss of function), muscle weakness, high potassium and high sodium. Record review of Resident #96's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, needs extensive assistance with bed mobility, transfers, and requires tube feeding. Record review of Resident #96's Care Plan revealed, focus- requires tube feeding related to dysphagia (difficulty swallowing); interventions- give medications per order. Record review of Resident #96's Physicians Order dated 11/14/2024 revealed, multivitamin oral tablet, give 1 tablet via G-tube one time a day. Observation on 12/11/24 at 7:00 am, revealed LVN L provided Resident #96 morning medications to include Multivitamin with minerals one tab. The physician ordered multivitamin one tab. Resident #15 Record review of Resident #15's Face Sheet dated 12/11/24 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of: diabetes type 2 with mild non-proliferative diabetic retinopathy (tiny blood vessels in the retina leak, causing swelling). Record review of Resident #15's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, is dependent with eating, hygiene, dressing and is always incontinent of bowel and bladder. Record review of Resident #15's Care Plan revealed, focus- resident has impaired cognitive function/impaired thought processed related to dementia, resident forgetful at time. Intervention: no changes to medication. Record review of Resident #15's Physician Order dated 10/14/2024 revealed, Artificial Tears Ophthalmic solution 1% (Carboxymethylcellulose Sodium) ordered. Observation on 12/11/24 at 7:20 am revealed LVN M provided Resident # 15 morning eye drops which contained Tetrahydrazoline Hydrochloride a decongestant used to relieve redness in the eyes. The physician ordered Carboxymethylcellulose Sodium a lubricant to treat dry eyes. In an interview with LVN L on 12/11/24 at 11:32 am, he stated he didn't think giving a Multivitamin with minerals when a multivitamin was ordered was a medication error. He stated he should only give medications ordered by the doctor. He stated if resident is given the wrong medicine, resident may have unwanted consequences. In an interview with LVN M on 12/11/24 at 11:37 am, she stated she should only give medications ordered by the doctor. She stated she thought she had given moisturizing eye drops and stated she gave the wrong eye drops. She stated if resident received the wrong medicine, resident may not be treated correctly. In an interview with the DON on 12/11/24 at 1:45 pm. The DON stated nurses and med aides should only give medications ordered by doctor. Medications should be verified prior to administration to residents. She stated giving the wrong medication to a resident could cause an allergic reaction and possible hospitalization due to the reaction. Record review of the facility policy titled Administering Medications revised 12/2012 revealed, Policy Statement: Medications shall be administered in a safe and timely manner, and as prescribed. Policy interpretation and implementation: 3. Medications must be administered in accordance with the orders, including any required time frame. 7. The individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on interview and record review, the facility failed to ensure all Pre Admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Level II assessment for 1 of 2 residents reviewed for a mental illness, intellectual disability or developmental disability. (Resident #64) Resident #64 was admitted to the facility with a pre-admission screening reflecting no indicators of a mental illness when the resident had a diagnosis of Bipolar Disorder. This failure could place residents with mental illness, intellectual disability or developmental disability at risk for not receiving needed care and services to meet their needs or decreased quality of life. Findings included: Record review of Resident #64's face sheet revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with disorder of the autonomic nervous system, history of transient ischemic attack, hemiplegia, and hemiparesis (partial paralysis of extremities), following cerebral infarction affecting left dominant side, bipolar disorder and mood disorder. Record Review of Resident #64's MDS, dated [DATE], reflected resident had a score of 14 indicating resident's cognition was intact. It also reflected resident was documented to have bipolar disorder. Record review of Resident #64's care plan, dated 12/11/24, revealed resident had a potential psychological well-being problem related to bipolar disorder. Record review of Resident #64 PASRR level 1 screening, dated 07/14/2023, reflected resident was marked no for having, . evidence or an indicator this is an individual with a mental illness . Record review of Resident #64's electronic health chart, on 12/11/24, revealed resident had no other PASRR evaluations performed. In an interview with the MDS coordinator on 12/12/24 at 12:33PM, she stated she started her job in July 2024. She said she only worked with all new admissions since that time to revise any PASRR level one screens that needed to be corrected. She stated she did not go back to audit any possibly incorrect PASRR assessments. She stated she is the only one responsible for submitting positive screenings and setting up meetings with a local authority. She also said her corporate staff was the only person who could audit her work but had not received an audit related to PASRR screenings since she started working with this facility. She stated the risk to a resident like Resident #64, who was found to have a mental illness diagnosis, is the risk of losing out on extra services that she could be eligible for. In an interview with the DON, on 12/12/2024 at 12:39PM, she stated she was not responsible for performing audits and the MDS Nurse was responsible for auditing her own work. She stated the risk Resident #64 faced was possibly missing services that she could be eligible for and that shows the importance of ensuring accurate PASRR level one screenings are performed and revised when needed. Record review of the facility's policy titled, PASRR Clinical Policy, dated May 2014, reflected, . The PASRR level 1 (PL1) Screening Form is designed to identify persons who are suspected of having Mental Illness (MI), Intellectual Disability (ID) of a Developmental Disability (DD) also referred to as Related Conditions. The PASRR Evaluation (PE) is designed to confirm the suspicion of MI, ID or DD/RC and ensure the individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain the individual's level of functioning. If documentation entered on the PL1 Indicates MI/ID/DD, a PE must be completed Section C; PASRR Screen (Screener) INTENT: This section to be completed for resident's suspected of having Mental Illness. 2. Identify diagnoses: Review the medical record, if available, for diagnoses. Medical record sources can include but are not limited to: verbal interview with the resident or LAR, observation, progress notes, Annual Physical Exam, the most recent History and Physical, hospital discharge summaries or diagnosis list. 3. If the answers to C0100=No, Co200=No, one nursing facility choice must be entered in section D. If the PL1 is being submitted on to the LTC Online Portal by an LA, the evaluation is complete. 4. These are required fields. 5. C0100. Mental Illness - Select whether or not this resident demonstrates evidence of a Mental Illness. 0 = No, 1 = Yes 6. A mental disorder is defined as the following: a schizophrenic, mood, paranoid, panic or other severe anxiety disorder, somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability. Dementia including Alzheimer's disease or a related disorder, is a neurologically driven disease that through evaluation is not indicative of a mental illness, it is a medical condition. 7. If Alzheimer/Dementia is the primary diagnosis and there is MI diagnosis no PE is needed. 8. If Alzheimer/Dementia is the primary diagnosis and there is ID/DD diagnosis PE is needed. 9. If Alzheimer/Dementia is not the primary diagnosis and there is MI diagnosis PE is needed .

Based on observation, interview, and record review, the facility failed to ensure 1 of 2 residents (Resident #96) reviewed for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, in that: Resident #96 was observed to not be repositioned off of sacral wound for a span of 4 hours. This failure could place residents at risk for skin breakdown or failure for ulcers to heal. Findings included: Record review of Resident #96's face sheet, dated 12/12/2024, reflected a [AGE] year-old male resident who was admitted to the facility on [DATE] with diagnoses including diagnosed with end stage renal disease and stage 4 pressure ulcer on the sacrum. Record review of Resident #96's MDS, dated [DATE], reflected the resident was at risk for pressure ulcers, he had a BIMS score of 10 indicating resident's cognition was moderately impaired and he needed substantial/maximal assistance for bed mobility. Record review of Resident #96's care plan, dated 08/09/2024, reflected, . [Resident #96] has potential for further skin breakdown r/t: a cognitive impairment, hx of pressure injuries, impaired mobility, incontinence, nutritional deficit STAGE 4 SACRUM . The goal was for the pressure to show signs of healing and remain free from infection. Interventions listed included assisting resident with turning/repositioning during rounds and wound vac therapy. Record review of Resident #96's wound evaluation, dated 12/05/2024, revealed the resident had a stage IV sacral pressure ulcer measuring 8 x 6 x 1.5 cm with a surface area of 48 cm2. The pressure ulcer wound progress at this time was noted to have improved . Record review of Resident #96's wound evaluation, dated 12/09/2024, revealed the resident's sacral pressure ulcer was still measuring 8 x 6 x 1.5 cm with a surface area of 48 cm2. The pressure ulcer wound progress at this time was noted to be not at goal. Record review of Resident #96's active physician's orders, dated 12/12/2024, included: - Starting 12/07/2024: . every day shift every Tue, Thu, Sat Clean with normal saline pat dry, apply Collagen Powder then apply Negative Pressure Wound Therapy @ 125 MM/HG AND every 24 hours as needed Treatment order: CLEANSE WITH NORMAL SALINE, PAT DRY, APPLY NEGATIVE PRESSURE WOUND THERAPY @ 125 MM/HG . Observation of Resident #96 on 12/11/2024 at 10:20AM, revealed Resident #96 was observed sleeping in bed while lying flat on his back with wound vac to sacrum in place. Observation and interview with Resident #96 on 12/11/2024 at 11:57AM, revealed Resident #96 sitting with back against the bed eating a grilled cheese sandwich. When asked if the nursing staff offer to reposition him, he stated, they never tried that with me. He stated he had never been offered to be repositioned or turned from side to side. Observation of Resident #96 on 12/11/2024 at 12:40PM, revealed the Resident #96 was sleeping again still flat on his back. Observation of Resident #96 on 12/11/2024 at 1:55PM, revealed the resident was observed sleeping still on his back. In an interview with Family Member #1 on 12/11/2024 at 1:56PM, she stated she visited Resident #96 every other day and finds the resident lying flat on his back every time. She stated she has never seen any nursing staff come in to offer to reposition the resident or prop him off of his sacral wound. In an interview with CNA B on 12/11/2024 at 2:00PM, she stated she was in charge of caring for Resident #96 during her shift from 6AM - 2PM. When asked if the resident was repositioned during her shift today, she said in the past, she generally has offered to reposition him before but the resident would refuse. She stated residents are supposed to be repositioned every two hours and not repositioning a resident could cause the resident to have increased risk of skin breakdown. In an interview with LVN B on 12/11/2024 at 2:36 PM, he stated aides should be repositioning residents with wounds and reporting any issues related to the wound vac to him. He stated he had never rounded on and checked patients to ensure CNA B was repositioning them and she has never reported any issues to him about Resident #96. He stated he should not have to check if the aide was repositioning Resident #96 because she should have known what to do. He stated not offloading wounds could cause aggravation of the wound and an increase of pain. In an interview with Wound Care Nurse A on 12/11/2024 at 3:28PM, she stated there were multiple factors contributing to wound aggravation including weight loss and infrequent repositioning. She said she did not audit or monitor and nursing staff and was unaware of who was rounding to ensure repositioning was being done. She stated she believed she was told Resident #96 had refused repositioning, but all refusals needed to be reported and documented and repositioning should have still been offered. In an interview with the DON on 12/11/2024 3:32PM, she stated the aides were expected to reposition their bed bound residents every two hours. She stated in the case where the resident often refused, repositioning should have still continually be offered and all refusals for repositioning should be reported to the nurse and documented as well. She stated not repositioning residents with sacral wounds could prevent wounds from healing. In a phone interview with the Wound Physician on 12/12/2024 at 1:04PM, she stated there was no decline or improvement seen in the wound from her assessments on 12/05/2024 to 12/09/2024. She stated repositioning is important for wound healing. Record review of the facility's policy and procedure, Turning a Resident on His/Her Side Away from You, dated March 2004, reflected, . The purposes of this procedure are to provide comfort to the resident, to prevent skin irritation and breakdown, and to promote good body alignment The following information should be recorded in the resident's medical record:1. The date and time that care was given. 2. The name and title of the individual(s) who assisted with the care. 3. The position in which the resident was placed. 4. The reason for changing the resident's position. 5. If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure. 6. Any problems or complaints made by the resident related to the procedure. 7. If the resident refused the treatment, the reason(s) why and the intervention taken. 8. The signature and title of the person recording the data .

Based on observation, interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day 7 days a week from 10/2/2023 to 10/7/2023, 10/9/2023 to 10/13/2023, 10/15/2023 to 10/31/2023 and 11/1/2023 to 11/16/2023. The facility had no DON from 9/29/2023 to 10/10/2023. These failures placed the residents at risk for not having decisions made that would have required an RN to make in the management of the resident's healthcare needs and in managing and monitoring of the direct care staff. Findings: Record review of employee file revealed the previous DON termination date of 9/29/2023. Record review of employee file revealed current DON hire date of 10/10/2023. Record review of employee time stamps revealed no significant RN coverage for 10/2023 . Record review of employee files revealed no RN coverage from 11/1/2023 to 11/16/2023. In an interview on 11/15/2023 at 4:00pm with the DON, she said there were no health needs in the facility for RNs. She said they had no acuity for RNs. She said she had come into the facility on some weekends and worked to learn and update her position as a DON at the facility since starting her position. When asked what days she came in on weekends she did not give an answer. She said when she came in, she was not doing any patient care or acting as a charge nurse. She said she was not at the facility on 11/11/2023 or 11/12/2023. She said there was a difference in the educational levels of an RN and an LVN. She said LVNs were not able to assess and stage a wound and having an RN in the building could have helped with that. She said as a DON the importance of having a registered nurse at the facility was being able to assess a change in condition and having a resource for the LVNs. In an interview on 11/16/2023 at 7:45am with the DON, she said they did not use contracted staff for RN coverage. In an interview on 11/16/2023 at 7:45am with the Clinical Services Director, he said they had problems getting an RN for the past year. He said they are located next to a hospital, so it made hiring RNs more difficult. He said they did not use temporary agencies for filling the gaps in coverage for registered nurses. Record review of facilities policy titled, Staffing dated 2001 reflected in part . Our facility maintains adequate staffing on each shift to ensure that our residents needs and services are met. Licensed registered nursing and licensed nursing are available to provide and monitor the delivery of resident care services.

Based on observation, interview and record review the facility failed to accurately assess each resident's status for 2 of 4 residents (Resident #52 and Resident #78) reviewed for assessment accuracy in that: - The facility failed to accurately assess and document Resident #78's use of hearing aids. - The facility failed to ensure Resident #52's MDS reflected the correct pain medication regimen. These failures could place residents at risk of not having accurate assessments, which could compromise their plan of care. Findings included: Resident #52 Review of Resident #52's Face Sheet dared 11/14/23 revealed, a [AGE] year-old female who was admitted to the facility on [DATE] with Diabetes type 2 as the primary diagnosis and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) as the secondary diagnosis. Review of Resident #52 physician's medication order dated 6/14/2023 revealed, Tramadol to be given every 6 hours for pain. Review of the MAR for Resident #52's Tramadol administration dated from 9/10/2023 through 11/7/2023 revealed the resident was receiving Tramadol medication on a regular schedule of every 6 hours. Review of Resident #52's MDS dated [DATE], revealed Section J0100, regarding scheduled pain medication regimen required an answer to the question: Received scheduled pain medication regimen?. The answer was marked no. Interview with MDS Nurse A on 11/16/23 at 11:30am regarding section J0100 of the MDS for Resident #52. When asked why the MDS was not updated to reflect the medication regimen change to regularly scheduled medication every 6 hours, she stated that it was missed. The MDS nurse thought the order change came after MDS completion date and did not update the MDS record. Resident #78 Record review of Resident #78's Face Sheet dated 11/16/23 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: epilepsy, hypotension (low blood pressure), anxiety, muscle wasting, and depression. Record review of Resident #78's Admission Report dated 05/09/23 revealed, Resident #78 admitted with a left ear hearing aid. Record review of Resident #78's MDS dated [DATE] revealed, ability to hear: adequate with no difficulty in normal conversation, social interaction, or listening to the tv. The MDS reflected Resident #78 had no hearing aid or other hearing appliance used and she understood verbal content. An observation an interview on 11/14/23 at 10:20 AM revealed, Resident #78 lying in bed well dressed, well-groomed in no immediate distress with a pair of hearing aids on her bedside table. When asked questions, Resident #78 said she did not have her hearing aids in so she could not understand the surveyor. The surveyor asked the resident questions in writing and Resident #78 responded verbally. Resident #78 said she had hearing aids since she entered the facility but she didn't know how to put them in so her nursing staff helped her put them in daily. She said she did not have any issues with staff helping her with inserting her hearing aids and she would like someone to help her put them in. The surveyor notified MA A that Resident #78 would like help with her hearing aids. An observation and interview on 11/16/23 at 10:06 AM with the ADON revealed, the surveyor and ADON observing Resident #78 to confirm the presence of hearing aids. After exiting the resident's room CNA A confirmed Resident #78 used hearing aids and she helped her place them in and removed them daily. The ADON said she was unaware Resident #78 used hearing aids. In an interview on 11/16/23 at 10:10 AM, the DON said she was unaware that Resident #78 used hearing aids and she was unaware the resident admitted with hearing aids. She said upon assessment on admission nursing staff should identify the need for hearing aids and the resident's family could also notify the facility of the resident's use of hearing aids. She said Resident #78's use of hearing aids should have been documented in the MDS and failure to identify for a resident's use of hearing aids could result in issues with communication and the resident not having their needs met. In an interview on 11/16/23 at 02:20 PM, the DON said the facility did not have a policy for completing the MDS. She said the MDS nurses used the CMS provided RAI to complete the residents MDS. In an interview on 11/16/23 at 02:45 PM, MDS Nurse A said she Resident MDSs are completed by physically observing/interviewing the resident, reading the admissions records, talking to nursing/rehab staff and family. She said the areas documented in the MDS also trigger into the care plan. She said a resident's MDS should address the needs to take care of the resident, diagnoses and if a resident had hearing aids. She said she had seen Resident #78 but she never noticed the resident had hearing aids and was never informed by staff that the resident used hearing aids. She said failure to identify, document in the MDS a resident's use of hearing aids could place residents at risk for the inability to communicate adequately. In an interview on 11/16/23 at 03:10 PM, MDS Nurse B said she completed Resident #78's Admission MDS. She said a residents MDS is completed by reviewing the resident's clinicals, and when the resident arrives the resident is interviewed and the pertinent information is collected. MDS Nurse B said the MDS is an interdisciplinary process and if a resident used hearing aids, hearing impairment should be documented in the MDS. She said she did not know how Resident #78's hearing aids were missed, but based on the admission report documenting the use of and the observed hearing aids on Resident #78 it should have been documented in the MDS. MDS Nurse B said failure to identify the use of hearing aids could result in a breakdown in communication between the resident and staff; she said staff could think the resident had behaviors and that the resident was ignoring them when she was just unable to hear. Record review of CMS's RAI Version 3.0 Manual revised 10/2023 revealed, B0200 (Hearing) Item Rationale Health-related Quality of Life- Problems with hearing can contribute to sensory deprivation, social isolation, and mood and behavior disorders; Unaddressed communication problems related to hearing impairment can be mistaken for confusion or cognitive impairment. Planning for Care- Address reversible causes of hearing difficulty (such as cerumen impaction) ;Evaluate potential benefit from hearing assistance devices; Offer assistance to residents with hearing difficulties to avoid social isolation. Consider other communication strategies for persons with hearing loss that is not reversible or is not completely corrected with hearing devices; Adjust environment by reducing background noise by lowering the sound volume on televisions or radios. Steps for Assessment 1. Ensure that the resident is using their normal hearing appliance if they have one. Hearing devices may not be as conventional as a hearing aid. Some residents by choice may use hearing amplifiers or a microphone and headphones as an alternative to hearing aids. Ensure the hearing appliance is operational. 2. Interview the resident and ask about hearing function in different situations (e.g. hearing staff members, talking to visitors, using the telephone, watching TV, attending activities). 3. Observe the resident during your verbal interactions and when they interact with others throughout the day. 4. Think through how you can best communicate with the resident. For example, you may need to speak more clearly, use a louder tone, speak more slowly or use gestures. The resident may need to see your face to understand what you are saying, or you may need to take the resident to a quieter area for them to hear you. All of these are cues that there is a hearing problem. 5. Review the medical record. 6. Consult the resident's family, caregivers, direct care staff, activities personnel, and speech or hearing specialists. B0300 Hearing Aid Item Rationale Health-related Quality of Life : Many residents who own hearing aids do not have the hearing aids with them or have nonfunctioning hearing aids upon arrival. Planning for Care: Knowing if a hearing aid was used when determining hearing ability allows better identification of evaluation and management needs; For residents with hearing aids, use and maintenance should be included in care planning. Steps for Assessment 1. Prior to beginning the hearing assessment, ask the resident if they own a hearing aid or other hearing appliance and, if so, whether it is at the nursing home. 2. If the resident cannot respond, write the question down and allow the resident to read it. 3. If the resident is still unable, check with family and care staff about hearing aid or other hearing appliances. 4. Check the medical record for evidence that the resident had a hearing appliance in place when hearing ability was recorded. 5. Ask staff and significant others whether the resident was using a hearing appliance when they observed hearing ability (above). Coding Instructions: Code 1, yes: if the resident did use a hearing aid (or other hearing appliance) for the hearing assessment coded in B0200, Hearing.

Based on observation, interview and record review, the facility failed to ensure services provided or arranged by the facility, as outlined by the comprehensive care plan, must be provided in accordance with each resident's written plan of care for 2 of 6 residents (Resident #2 and CR#1) reviewed for physician's orders. - The facility failed to follow CR #1's Physician's Orders to have his Foley Catheter to bedside drainage and provide catheter care every shift. - In addition, the facility failed to ensure CR #1's catheter bag and tubing were positioned below his bladder per the resident's care plan. CR #1 was sent to the hospital and was found with the Foley catheter in the prostatic urethra and urinary tract infection. - The facility failed to ensure Resident #2's [MEDICATION NAME] (opioid pain medication), Trazadone (antidepressant) and [MEDICATION NAME] (anxiolytic and sedative) were discontinued as ordered by the physician. - In addition, the facility failed to obtain STAT laboratory work for Resident #2 as ordered by the physician. These failures affected 1 current resident and one former resident and could place the remaining 103 residents in the facility at risk of a decline in health status. Findings include: Intake TX 278 / # 5 and TX 778 / # 4 CR #1 Record review of CR #1's medical record revealed he was admitted to the facility on [DATE] and re-admitted on [DATE] with the following [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of CR #1's admission MDS assessment dated [DATE] revealed he had a BIMS score of 1 out of the possible 15, indicating severe cognitive impairment. He required supervision with set up for bed mobility, transfer, walking, dressing, toilet use and required limited assistance of one person for personal hygiene. CR #1 had an indwelling catheter and was frequently incontinent of bowel. Record review of CR #1's Care Plan initiated on 10/01/2017 revealed in part; - Focus: CR #1 has Indwelling Catheter related to [MEDICAL CONDITION] (Foley catheter is a flexible tube which a clinician passes through the urethra and into the bladder to drain urine. It is the most common type of indwelling urinary catheter). -Interventions: Position catheter bag and tubing below the level of the bladder. Check for patency and urinary output every shift. Record review of CR #1's consolidated Physician's Orders revealed in part; -10/02/2017 Foley Catheter 16FR 10cc bulb to bedside drainage, for [DIAGNOSES REDACTED]. -10/02/2017 Record Foley catheter output every shift. -10/02/2017 Foley Catheter care every shift and as needed. Record review of CR #1's Medication Administration Record/Treatment Administration Record dated October 2017 revealed that on 9/22/2017 during 10 p.m. and 6:00 a.m. shift no output was recorded. Record review of CR #1's Nurses/progress notes revealed in part; - 10/23/2017 at 4:40 p.m. .Observed CR #1 in bed shivering, refused for leg bag to be changed to regular Foley bag and pericare. Vital signs: Temperature: 100.1 degrees (Fahrenheit), Pulse 110 beat per minute and 66% (oxygen) room air. Administered 3 liters of oxygen as needed. Called MD and RP immediately. Received verbal orders for laboratory work and as needed pain medication. While on the phone talking to RP, the aide by CR #1's bed side yelled out that CR #1 was not responding but upon arrival to the room, CR #1 was noticed breathing but shallow. Immediately called for crash cart, 911 and notified MD. Vital signs Temperature 100.1 degrees (Fahrenheit), Pulse 74 beat per minute, blood sugar 115, respirations 22, blood pressure 64/40 and 77 % (oxygen) room air. Noticed blood in leg bag, immediately changed to regular bag and 911 crew arrived . Signed by LVN C. -10/23/2017 at 6:41 p.m. CR #1 refused for leg bag to be changed to regular Foley bag (drainage bag) and pericare about 4:31 p.m Signed by LVN C. -10/23/2017 at 6:43 p.m. CR #1 was sent to ER for evaluation and treatment for [REDACTED]. CR #1 was picked up by 911 . Signed by LVN C. Record review of CR #1's hospital History and Physical dated 10/23/2017 revealed in part; CR #1 sent to emergency room because of his altered mental status. His heart rate was in 130s, blood pressure was 80 systolic. CR #1 was confused on arrival. He was found to be hypotensive, blood pressure was 85/50. Temperature was 99.9. CR #1 was admitted to the hospital. CT (computed tomography ) scan of the abdomen and pelvis done, which shows Foley catheter in the prostatic urethra (The portion of the urethra that is within the prostate is called the prostatic urethra). CR #1 had blood in the urine. CR #1 was taken to the Operation Room. He had a cystoscopy done (is a test that allows your doctor to look at the inside of your bladder and urethra). The 3-way Foley catheter was placed (A 3-way catheter is a style of catheter that ends in three separate prongs instead of a single or double tube. It is used to treat bladder infections and other conditions that require a medical professional to introduce something into the bladder as well as drain it). Impression and Plan: CR #1 had a urinary tract infection. He was treated with intravenous fluids and antibiotics. In an interview on 11/7/2017 at 3:35 p.m. with LVN C, she stated that on 10/23/2017 at around 4:30 p.m. CR #1 was on his bed and was noted to be shivering. LVN C then said I then asked him if he was OK, and he did not respond. Then he said he was not doing well, that he did not feel good. I then checked his vital signs. A day before, on 10/22/2017, a Sunday, during change of shift at 2:00 p.m. I got report that CR #1's Foley catheter drainage bag had come off from the drainage tube. RN D did not really say how the drainage bag had come off from the drainage tube. The nurse (RN D), told me that as a result, she placed a leg bag (Urinary Leg bags are used to collect urine during the day and are secured to the leg) to CR #1. LVN C then said that in the evening around 11:00 p.m. she saw CR #1 coming out of the bathroom and that he told LVN C that he had already emptied his urine leg bag. LVN C further said CR #1 would always walk with his urinary drainage bag hanging on the walker. He would go to the bathroom by himself and would empty his urinary drainage bag by himself. Continued interview on 11/7/2017 at 3:45 p.m. with LVN C, she said that on 10/23/2017 (Monday), she worked a double shift and that she came to work at 7:00 a.m. and that CR #1 was still with the same urinary leg bag attached to his leg. LVN C continued saying that at around 11:00 a.m. she saw CR #1 and that he was coming out of the bathroom and told her that he had already emptied his urine leg bag and that he was OK and he then walked to the dining room area. LVN C further said I did not see CR #1 until 4:30 p.m. that's when I found him in bed shivering. I did notice a smell. I offered to change his clothing. CNA E was there. We noticed the blood in the urine when paramedics were entering the room. As we were removing his pants, we noticed the blood in the catheter tube. Further interview at that time, when asked what type of care would nursing provided for CR #1's Foley catheter, LVN C said We would not do anything for him. I have seen him cleaning his catheter with wipes. On 10/22/2017 I asked him if he had taken care of himself and he said 'I got it'. CR #1 refused to have his leg bag changed to drainage bag. When asked if she documented information on nursing notes or care planned or make any notifications to MD or RP that CR #1 refused to have his urine leg changed or that he was cleaning his own catheter, LVN C said No, I did not document or made any notifications on 10/22/2017. LVN C further said On 10/23/2017 I did not do anything for CR #1's catheter care. I took his words for it. In an interview on 11/7/2017 at 3:58 a.m. with LVN C, she said that nurses' responsibilities for residents with urinary catheters were to provide cleaning/ catheter care, assess for patency, empty the catheter bags and then said Probably instead of taking his word, I should have done the catheter care, I should have drained his catheter bag. When residents go to bed, they are supposed to have the drainage bags. Record review at that time with LVN C of CR #1's care plan revealed no information that CR #1 refused any catheter care or that he refused to have the urine drainage bag. Further record review with LVN C revealed that CR #1's care plan did not have information prior to 10/23/2017 that CR #1 would empty his own catheter bag. An entry on CR #1's care plan dated 10/23/2017 (date CR #1 was sent to the hospital) read CR #1 was able to empty his urine bag as needed. Record review of CR #1's Nurses/progress notes dated 10/22/2017 revealed no nurses notes for CR #1 on that date. In an interview on 11/7/2017 at 4:07 p.m. with CNA E, she stated that CR #1 would do a lot for himself and that from her understanding CR #1 would tell the staff I emptied my catheter already. CNA E then said On the day CR #1 went to the hospital, CR #1 told the nurse that he had emptied his catheter. I worked from 2:00 p.m. to 10:00 p.m. when I got to the facility at 2:00 p.m. CR #1 was on his bed and CNA F told me 'CR #1 has been in his bed, he hasn't been feeling well lately. He has not been acting himself. Then later, the charge nurse called me to change him but he refused. The nurse (LVN C) was going to do something because he had a different catheter bag. It was around 3:00 p.m. when he refused, he then started shaking, so I called the nurse, then the nurse was on the phone and then she came and said was going to call the MD because of his oxygen. The nurse then asked me to go and get more nurses. That day, I saw blood in the catheter tube and the catheter on the leg bag. It was a lot of bright red blood. The family came later and said that CR #1 got an emergency surgery due to the amount of blood he lost. In a phone interview on 11/7/2017 at 4:25 p.m. with CNA F, she stated CR #1 wasn't feeling well because he did not eat well. I did not know him well. CR #1 would walk around. I don't remember working with him the day he went to the hospital. I don't remember. In a phone interview on 11/7/2017 at 4:30 p.m. with RN D, she stated that she did not want to speak with surveyor. In a second interview on 11/7/2017 at 5:00 p.m. with LVN C, she stated that on 10/22/2017 (Sunday) CR #1 went to bed with his leg urine bag because he refused to change to a drainage bag. She then said that the next day she came to work at 7:00 a.m. CR #1 was still wearing the leg urine bag. LVN C further said that on 10/23/2017 at around 4:00 p.m. CR #1 was in bed still with the urine leg bag and that the bag had urine and blood. When asked if she had reviewed CR #1's Care Plan, LVN C then said I know, leg urine bags are for walking only, not for bed. If residents go to bed with the leg bags, the tubing and the urine bag are not below the bladder, also the bags are smaller. CR #1 would usually drink a lot of coffee, he voided a lot, urine might flow back into the bladder too. I don't remember documenting or notifying the MD or RP when CR #1 refused to change his bag the night of 10/22/2017. In an interview on 11/7/2017 at 5:10 p.m. with the DON, she stated that the day CR #1 went to the hospital she was sick. DON then said that at that time, DON B was responsible for the facility and further said I wasn't too familiar with him. When I came back from my sick day, I was told that he preferred the leg bag for walking. In bed, that would depend on the resident's preference. I was told that he refused. When showed CR #1's care plan and that there was no information that CR #1 refused any catheter care, or refused to have his drainage bag and that the care plan called to have the tubing and the bag below the bladder, the DON said I was told he would empty his own bag and refused care. DON further said that she was not aware about CR #1's incident with the catheter on 10/22/2017 where CR #1's Foley catheter drainage bag had come off from the drainage tube and then said The other DON (DON B) was present that day. I heard that CR #1 went to the hospital but I don't know the specifics. I knew there was a concern that a new catheter was placed but we don't have records or documentation that another catheter was placed. Further interview at that time with the DON, when asked what was the facility responsibility when a resident would refuse to follow the Plan of Care for urine catheters or would refused any care, the DON said I do understand what are you saying, I do understand. In an interview on 11/7/2017 at 5:40 p.m. with the Unit Manager, she stated that she did not remember any information regarding CR #1 refusing any care related to his urine catheter. Unit Manager then said I don't remember much. I do remember going to his room the day he went to the hospital. CR #1 was slightly responsive. His catheter line had a little blood. Don't remember much. Record review on 11/7/2017 at 5:45 p.m. with the Unit Manager revealed that the 24 hour report book dated 10/22/2017 did not have any information regarding CR #1's Foley catheter drainage bag had come off from the drainage tube, or information regarding CR #1 refusing any catheter care or information that CR #1 had refused to have his urine drainage bag replaced. Record review of www. medline.com revealed that Leg bags and drain bags are attached to indwelling or external catheters and used for continuous urinary collection. Catheters and drain bags work with gravity, so make sure the bag is always lower than your bladder. You can use a drain bag either during the night only or throughout the entire day and night. A leg bag can be worn during the day, but you will need to switch to a drain bag for overnight use. Keeping the bag below your bladder will help keep your urine from flowing back into your bladder from the urine collection bag. If your urine flows back into your bladder from your urine collection bag you may get an infection. Resident #2 Record review of Resident #2's medical record revealed she was admitted to the facility on [DATE] and re-admitted on [DATE] with the following [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed she was cognitively intact and had a BIMS score of 14 out of the possible 15. It further revealed she had no signs or symptoms of hallucinations, delusions or other behavioral symptoms. She required limited assistance with her activities of daily living. Resident #2 was continent of bowel and bladder. Record review of Resident #2's Care Plan with target date of 12/20/2017 revealed in part; - Focus: Resident #2 has [DIAGNOSES REDACTED]. -Interventions: Observe/record/report to MD as needed side effects. Administer medications as indicated. Administer [MEDICATION NAME] as per orders. Observe/document for side effects of pain medications. Record review of Resident #2's consolidated Physician's Orders revealed in part; -09/27/2017 [MEDICATION NAME] ([MEDICATION NAME]) 2 mg as needed for anxiety. -09/28/2017 Trazadone HCI tablet 50 mg. Give 1 tablet by mouth at bedtime. -10/30/2017 [MEDICATION NAME] tablet 7.5-325 mg ([MEDICATION NAME]) Give 1 tablet by mouth three times a day for pain. Record review of Telephone order dated 11/3/2017 at 1:50 p.m. revealed orders in part; -Discontinue [MEDICATION NAME], discontinue [MEDICATION NAME] and discontinue Trazadone. -Urinalysis with Culture and Sensitivity, complete blood cell count, comprehensive metabolic panel STAT. Record review of the facility's Laboratory book revealed that there were no Laboratory requisitions for Resident #2 for the month of November 1-7, 2017. Record review of Resident #2's Nurses/progress notes for 11/3/2017 revealed no information related to the new orders dated 11/3/2017. Record review of Resident #2's Medication Administration Record [REDACTED] -[MEDICATION NAME] ([MEDICATION NAME]) 2 mg as needed for anxiety order was not discontinued as ordered. Medication was not administered after 11/3/2017. -Trazadone HCI tablet 50 mg one tablet was not discontinued, but ordered and was administered at 8:00 p.m. on 11/3/2017, 11/4/2017, 11/5/2017 and 11/6/2017. -[MEDICATION NAME] tablet 7.5-325 mg ([MEDICATION NAME]) Give 1 tablet by mouth three times a day was not discontinued as ordered and was administered on 11/4/17 at 4:00 p.m., 11/5/17 at 8:00 a.m., 11/5/17 at 4:00 p.m. and 11/7/17 at 12:00 p.m.). Resident #2 refused to take the medication 8 times from 11/3/17 to 11/7/17. In an observation and interview on 11/7/2017 at 1:20 p.m. with Resident #2 she stated I want to stop all medications that are affecting me emotionally. Some medications are affecting my nerves. I want to decrease the dose on the medications. I am becoming over emotional, I just cry without reason. Further observation at that moment revealed Resident #2 started wiping tears from her eyes. Resident #2 then said I take pain medications but I don't want to take pain medications anymore. I go to therapy and I do arm and weight exercises. Therapy is helping me to control the pain. I went to the head nurse the day before yesterday (did not say name). I told her my problem. She told me that she was going to call the MD. I get pain medications every 4 hours. I feel that the pain medications and the other medications are affecting my emotional status because lately I feel over emotional. I feel like I cry more and more daily. Today, I told the lady passing the medications to remove the pain medication. I don't want it. It's [MEDICATION NAME]. It's been worse this last days. Continued observation during interview, Resident #2 was crying intermittently. In an interview on 11/7/2017 at 1:50 p.m. LVN A stated that Resident #2 told her just recently that she wanted the pain medication [MEDICATION NAME] discontinued because she was getting forgetful. LVN A further said She just told me about it. I will call the MD. Further interview with LVN A, when asked about Resident #2's Telephone order dated 11/3/2017, orders to discontinue [MEDICATION NAME] and Trazadone, LVN A stated that she was not aware of those orders. In an interview on 11/7/2017 at 2:30 p.m. with MA B, she stated that during the morning medication administration at around 8:00 a.m., Resident #2 refused [MEDICATION NAME] and that she reported to LVN A at around 9:00 a.m. MA B then said Resident #2 refused again the medication [MEDICATION NAME] at 12:00 p.m. and I told LVN A again and LVN A convinced Resident #2 to take the medication this time. Since 9:00 a.m. I reported to LVN A that Resident #2 reported that she felt that the [MEDICATION NAME] was making her forgetful. It has been few days that Resident #2 has been refusing the [MEDICATION NAME], Resident #2 reports feeling dizzy and forgetful. My job is to report this information to the nurse right away and that's what I had been doing. In an interview on 11/7/2017 at 3:00 p.m. with the Unit Manager, she stated that she was not aware of Resident #2's new Telephone orders dated 11/3/2017 to discontinue the medications [MEDICATION NAME], Trazadone and the STAT laboratory orders. The Unit Manager further said The nurse who wrote the order, was the nurse responsible to carry out the orders and remove the first 2 copies of the telephone orders, then the copies needed to be placed in a box located at the nursing station. We review all new telephone orders daily, we make sure that orders are followed on Point Click Care. If the nurse did not remove the copies of the Telephone orders, like in this case, I will not know that there were new orders. Unit Manager further said that she did not know which RN obtained the new orders for Resident #2 or why the orders were not carried out. Unit Manager then said that she worked with Resident #2 on 11/1/2017 and that she had to call the MD because Resident #2 was having crying episodes and that the MD said he was going to come to visit Resident #2. Record review of Resident #2's Nurses/progress notes dated 11/1/2017 at 2:18 p.m. signed by Unit Manager revealed in part; Called MD in regards to Resident #2's intermitted crying. MD stated that he will look over medication list and follow up . Further record review of the Nurses/progress notes on 11/3/2017 revealed no information regarding new Telephone orders. In an interview on 11/7/2017 at 3:22 p.m. with the DON, she stated that the RN who obtained Resident #2's Telephone order dated 11/3/2017 was a DON B, who was in training because today was her last day of work. DON then said I trained DON B for 3 weeks and he just did not come today. He did not call and did not show up to work. I can't find any information about why the order was given. He did not write any nursing notes. When new orders are obtained, the information is written on the 24 hour book. He did not write anything. He was supposed to remove the first two copies of the Telephone order so the Unit Manager can follow up with the order and he did not do it either. He was also supposed to fill out the Laboratory requisition form and call the laboratory to notify of the STAT orders. When asked if she was aware of Resident #2 having crying episodes and that she had been refusing to take the [MEDICATION NAME], the DON said I was told of only one episode of crying. I was just told today that she refused the [MEDICATION NAME]. LVN A is following up with the MD. Record review of the facility Policy and Procedure with title Catheter Care, Urinary revised April 2010 revealed in part; .Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. 1.- Review the resident's care plan to assess for any special needs of the resident. 3.- The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back in to the urinary bladder. 2.- Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag. Documentation: The following information should be recorded in the resident's medical record: 1.- The date and time that catheter care was given, 3.- If the resident refused the procedure, the reason (s) why and the intervention taken. Reporting: Notify the supervisor if the resident refuses the procedure. 2.- Report other information in accordance with facility policy and professional standards of practice . Record review of the facility Policy and Procedure with title Change in a Resident's Condition or Status Protocol for notifying attending Physician revised August 2009 revealed in part; .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician when . a refusal of treatment Record review of the facility Policy and Procedure with title Laboratory and Diagnostic Test Results - Clinical Protocol revised April 2007 revealed in part; The physician will identify and order diagnostic and laboratory testing based on diagnostic and monitoring needs. 2.- The staff will process test requisitions and arrange for test . Record review of the facility Policy and Procedure with title Physician Medication Orders revised April 2010 revealed in part; Medications shall be administered only upon the written order Further record review revealed no information on how the facility would monitor that medications were administered as ordered by the MD. The facility's census report dated 11/7/2017 revealed 26 residents on the 400 Hall and Record review of the facility's CMS 672 dated 11/7/2017 revealed 9 residents with Indwelling or external catheters.

Based on interview and record review, the facility failed to ensure residents with indwelling catheters received appropriate treatment and services to prevent complications for 1 of 6 residents reviewed for Foley catheters. (CR #1). - The facility failed to follow CR #1's Physician's Orders to have his Foley Catheter to bedside drainage and provide catheter care every shift. - In addition, the facility failed to ensure CR #1's catheter bag and tubing were positioned below his bladder per the resident's care plan. CR #1 was sent to the hospital and was found with the Foley catheter in the prostatic urethra and urinary tract infection. These failures affected one former resident and could place nine residents with indwelling Foley catheters in the facility at risk for discomfort, urinary tract infections, and hospitalization . Findings included: Intake TX 778 / # 4 Record review of CR #1's medical record revealed he was admitted to the facility on [DATE] and re-admitted on [DATE] with the following [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of CR #1's admission MDS assessment dated [DATE] revealed he had a BIMS score of 1 out of the possible 15, indicating severe cognitive impairment. He required supervision with set up for bed mobility, transfer, walking, dressing, toilet use and required limited assistance of one person for personal hygiene. CR #1 had an indwelling catheter and was frequently incontinent of bowel. Record review of CR #1's Care Plan initiated on 10/01/2017 revealed in part; - Focus: CR #1 has Indwelling Catheter related to [MEDICAL CONDITION] (Foley catheter is a flexible tube which a clinician passes through the urethra and into the bladder to drain urine. It is the most common type of indwelling urinary catheter). -Interventions: Position catheter bag and tubing below the level of the bladder. Check for patency and urinary output every shift. Record review of CR #1's consolidated Physician's Orders revealed in part; -10/02/2017 Foley Catheter 16FR 10cc bulb to bedside drainage, for [DIAGNOSES REDACTED]. -10/02/2017 Record Foley catheter output every shift. -10/02/2017 Foley Catheter care every shift and as needed. Record review of CR #1's Medication Administration Record/Treatment Administration Record dated October 2017 revealed that on 9/22/2017 during 10 p.m. and 6:00 a.m. shift no output was recorded. Record review of CR #1's Nurses/progress notes revealed in part; - 10/23/2017 at 4:40 p.m. .Observed CR #1 in bed shivering, refused for leg bag to be changed to regular Foley bag and pericare. Vital signs: Temperature: 100.1 degrees (Fahrenheit), Pulse 110 beat per minute and 66% (oxygen) room air. Administered 3 liters of oxygen as needed. Called MD and RP immediately. Received verbal orders for laboratory work and as needed pain medication. While on the phone talking to RP, the aide by CR #1's bed side yelled out that CR #1 was not responding but upon arrival to the room, CR #1 was noticed breathing but shallow. Immediately called for crash cart, 911 and notified MD. Vital signs Temperature 100.1 degrees (Fahrenheit), Pulse 74 beat per minute, blood sugar 115, respirations 22, blood pressure 64/40 and 77 % (oxygen) room air. Noticed blood in leg bag, immediately changed to regular bag and 911 crew arrived . Signed by LVN C. -10/23/2017 at 6:41 p.m. CR #1 refused for leg bag to be changed to regular Foley bag (drainage bag) and pericare about 4:31 p.m Signed by LVN C. -10/23/2017 at 6:43 p.m. CR #1 was sent to ER for evaluation and treatment for [REDACTED]. CR #1 was picked up by 911 . Signed by LVN C. Record review of CR #1's hospital History and Physical dated 10/23/2017 revealed in part; CR #1 sent to emergency room because of his altered mental status. His heart rate was in 130s, blood pressure was 80 systolic. CR #1 was confused on arrival. He was found to be hypotensive, blood pressure was 85/50. Temperature was 99.9. CR #1 was admitted to the hospital. CT (computed tomography ) scan of the abdomen and pelvis done, which shows Foley catheter in the prostatic urethra (The portion of the urethra that is within the prostate is called the prostatic urethra). CR #1 had blood in the urine. CR #1 was taken to the Operation Room. He had a cystoscopy done (is a test that allows your doctor to look at the inside of your bladder and urethra). The 3-way Foley catheter was placed (A 3-way catheter is a style of catheter that ends in three separate prongs instead of a single or double tube. It is used to treat bladder infections and other conditions that require a medical professional to introduce something into the bladder as well as drain it). Impression and Plan: CR #1 had a urinary tract infection. He was treated with intravenous fluids and antibiotics. In an interview on 11/7/2017 at 3:35 p.m. with LVN C, she stated that on 10/23/2017 at around 4:30 p.m. CR #1 was on his bed and was noted to be shivering. LVN C then said I then asked him if he was OK, and he did not respond. Then he said he was not doing well, that he did not feel good. I then checked his vital signs. A day before, on 10/22/2017, a Sunday, during change of shift at 2:00 p.m. I got report that CR #1's Foley catheter drainage bag had come off from the drainage tube. RN D did not really say how the drainage bag had come off from the drainage tube. The nurse (RN D), told me that as a result, she placed a leg bag (Urinary Leg bags are used to collect urine during the day and are secured to the leg) to CR #1. LVN C then said that in the evening around 11:00 p.m. she saw CR #1 coming out of the bathroom and that he told LVN C that he had already emptied his urine leg bag. LVN C further said CR #1 would always walk with his urinary drainage bag hanging on the walker. He would go to the bathroom by himself and would empty his urinary drainage bag by himself. Continued interview on 11/7/2017 at 3:45 p.m. with LVN C, she said that on 10/23/2017 (Monday), she worked a double shift and that she came to work at 7:00 a.m. and that CR #1 was still with the same urinary leg bag attached to his leg. LVN C continued saying that at around 11:00 a.m. she saw CR #1 and that he was coming out of the bathroom and told her that he had already emptied his urine leg bag and that he was OK and he then walked to the dining room area. LVN C further said I did not see CR #1 until 4:30 p.m. that's when I found him in bed shivering. I did notice a smell. I offered to change his clothing. CNA E was there. We noticed the blood in the urine when paramedics were entering the room. As we were removing his pants, we noticed the blood in the catheter tube. Further interview at that time, when asked what type of care would nursing provided for CR #1's Foley catheter, LVN C said We would not do anything for him. I have seen him cleaning his catheter with wipes. On 10/22/2017 I asked him if he had taken care of himself and he said 'I got it'. CR #1 refused to have his leg bag changed to drainage bag. When asked if she documented information on nursing notes or care planned or make any notifications to MD or RP that CR #1 refused to have his urine leg changed or that he was cleaning his own catheter, LVN C said No, I did not document or made any notifications on 10/22/2017. LVN C further said On 10/23/2017 I did not do anything for CR #1's catheter care. I took his words for it. In an interview on 11/7/2017 at 3:58 a.m. with LVN C, she said that nurses' responsibilities for residents with urinary catheters were to provide cleaning/ catheter care, assess for patency, empty the catheter bags and then said Probably instead of taking his word, I should have done the catheter care, I should have drained his catheter bag. When residents go to bed, they are supposed to have the drainage bags. Record review at that time with LVN C of CR #1's care plan revealed no information that CR #1 refused any catheter care or that he refused to have the urine drainage bag. Further record review with LVN C revealed that CR #1's care plan did not have information prior to 10/23/2017 that CR #1 would empty his own catheter bag. An entry on CR #1's care plan dated 10/23/2017 (date CR #1 was sent to the hospital) read CR #1 was able to empty his urine bag as needed. Record review of CR #1's Nurses/progress notes dated 10/22/2017 revealed no nurses notes for CR #1 on that date. In an interview on 11/7/2017 at 4:07 p.m. with CNA E, she stated that CR #1 would do a lot for himself and that from her understanding CR #1 would tell the staff I emptied my catheter already. CNA E then said On the day CR #1 went to the hospital, CR #1 told the nurse that he had emptied his catheter. I worked from 2:00 p.m. to 10:00 p.m. when I got to the facility at 2:00 p.m. CR #1 was on his bed and CNA F told me 'CR #1 has been in his bed, he hasn't been feeling well lately. He has not been acting himself. Then later, the charge nurse called me to change him but he refused. The nurse (LVN C) was going to do something because he had a different catheter bag. It was around 3:00 p.m. when he refused, he then started shaking, so I called the nurse, then the nurse was on the phone and then she came and said was going to call the MD because of his oxygen. The nurse then asked me to go and get more nurses. That day, I saw blood in the catheter tube and the catheter on the leg bag. It was a lot of bright red blood. The family came later and said that CR #1 got an emergency surgery due to the amount of blood he lost. In a phone interview on 11/7/2017 at 4:25 p.m. with CNA F, she stated CR #1 wasn't feeling well because he did not eat well. I did not know him well. CR #1 would walk around. I don't remember working with him the day he went to the hospital. I don't remember. In a phone interview on 11/7/2017 at 4:30 p.m. with RN D, she stated that she did not want to speak with surveyor. In a second interview on 11/7/2017 at 5:00 p.m. with LVN C, she stated that on 10/22/2017 (Sunday) CR #1 went to bed with his leg urine bag because he refused to change to a drainage bag. She then said that the next day she came to work at 7:00 a.m. CR #1 was still wearing the leg urine bag. LVN C further said that on 10/23/2017 at around 4:00 p.m. CR #1 was in bed still with the urine leg bag and that the bag had urine and blood. When asked if she had reviewed CR #1's Care Plan, LVN C then said I know, leg urine bags are for walking only, not for bed. If residents go to bed with the leg bags, the tubing and the urine bag are not below the bladder, also the bags are smaller. CR #1 would usually drink a lot of coffee, he voided a lot, urine might flow back into the bladder too. I don't remember documenting or notifying the MD or RP when CR #1 refused to change his bag the night of 10/22/2017. In an interview on 11/7/2017 at 5:10 p.m. with the DON, she stated that the day CR #1 went to the hospital she was sick. DON then said that at that time, DON B was responsible for the facility and further said I wasn't too familiar with him. When I came back from my sick day, I was told that he preferred the leg bag for walking. In bed, that would depend on the resident's preference. I was told that he refused. When showed CR #1's care plan and that there was no information that CR #1 refused any catheter care, or refused to have his drainage bag and that the care plan called to have the tubing and the bag below the bladder, the DON said I was told he would empty his own bag and refused care. DON further said that she was not aware about CR #1's incident with the catheter on 10/22/2017 where CR #1's Foley catheter drainage bag had come off from the drainage tube and then said The other DON (DON B) was present that day. I heard that CR #1 went to the hospital but I don't know the specifics. I knew there was a concern that a new catheter was placed but we don't have records or documentation that another catheter was placed. Further interview at that time with the DON, when asked what was the facility responsibility when a resident would refuse to follow the Plan of Care for urine catheters or would refused any care, the DON said I do understand what are you saying, I do understand. In an interview on 11/7/2017 at 5:40 p.m. with the Unit Manager, she stated that she did not remember any information regarding CR #1 refusing any care related to his urine catheter. Unit Manager then said I don't remember much. I do remember going to his room the day he went to the hospital. CR #1 was slightly responsive. His catheter line had a little blood. Don't remember much. Record review on 11/7/2017 at 5:45 p.m. with the Unit Manager revealed that the 24 hour report book dated 10/22/2017 did not have any information regarding CR #1's Foley catheter drainage bag had come off from the drainage tube, or information regarding CR #1 refusing any catheter care or information that CR #1 had refused to have his urine drainage bag replaced. Record review of www. medline.com revealed that Leg bags and drain bags are attached to indwelling or external catheters and used for continuous urinary collection. Catheters and drain bags work with gravity, so make sure the bag is always lower than your bladder. You can use a drain bag either during the night only or throughout the entire day and night. A leg bag can be worn during the day, but you will need to switch to a drain bag for overnight use. Keeping the bag below your bladder will help keep your urine from flowing back into your bladder from the urine collection bag. If your urine flows back into your bladder from your urine collection bag you may get an infection. Record review of the facility Policy and Procedure with title Catheter Care, Urinary revised April 2010 revealed in part; .Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. 1.- Review the resident's care plan to assess for any special needs of the resident. 3.- The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back in to the urinary bladder. 2.- Maintain clean technique when handling or manipulating the catheter, tubing or drainage bag. Documentation: The following information should be recorded in the resident's medical record: 1.- The date and time that catheter care was given, 3.- If the resident refused the procedure, the reason (s) why and the intervention taken. Reporting: Notify the supervisor if the resident refuses the procedure. 2.- Report other information in accordance with facility policy and professional standards of practice . Record review of the facility Policy and Procedure with title Change in a Resident's Condition or Status Protocol for notifying attending Physician revised August 2009 revealed in part; .The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician when . a refusal of treatment The facility's CMS 672 dated 11/7/2017 revealed 9 residents with Indwelling or external catheters.