Every finding on record at The Crescent

Based on observation, interview, and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 6 residents (Resident #1) reviewed for enteral feedings. 1. LVN A failed to ensure Resident #1 was wearing their abdominal binder (a special belt that is used to secure the feeding tube against the body, preventing the tube from dangling, snagging on clothing, or being accidently pulled out) on 07/30/26. 2. LVN A failed to stop Resident #1's enteral feeding (tube feeding that deliver liquid nutrition directly into the stomach or small intestines) at 7AM on 07/30/26. These failures could place residents at risk for aspiration, stomach bloating, diarrhea, nausea, vomiting, tube dislodgment (accidental shifting, removal, displacement of a medical device-such as feeding tube), and unwanted hospitalization. Findings include: Record review of Resident #1's face sheet, dated 07/30/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: encephalopathy (malfunction of the brain that causes altered mental status, confusion, and memory loss), type 2 diabetes mellitus (when the body has trouble using sugar from the food eaten, leading to too much sugar in the blood), dysphagia (difficulty swallowing), dementia (severe decline in memory, thinking, and reasoning interfering with a person's daily life), dermatitis (skin condition causing redness and itching), benign neoplasm of left breast (non- cancer but abnormal growth of cells in the breast tissue), and mixed receptive-expressive language disorder (a communication condition where a person has trouble understanding what others say and using language to share their own thoughts). Record review of Resident #1's quarterly MDS, dated [DATE], Section C-Cognitive Patterns reflected the resident mental status was a 3, which indicated the resident cognition was severely impaired. Section K-Swallowing/Nutritional status revealed Resident #1 proportion of total calories was received through parenteral or tube feeding was 51%. Record review of Resident #1's Physician Order Summary Report for the month of July 2026 reflected the following orders: -Dated 04/03/26, abdominal binder on each shift to protect peg tube (feeding tube) from dislodging every shift. -Dated 04/03/26, LCS (Low Concentrated Sweets) NAS (No Added Salt) diet pureed texture (smooth, lump-free food with a pudding-like consistency, made by blending or mashing cooked ingredients with added liquids with broth, milk, or juice), regular/thin consistency. -Dated 06/26/26, Enteral feed every shift Isosource 1.5 at 70 ml/hr via feeding tube. To run from 7PM to 7AM daily (may substitute with Jevity [a brand of liquid medical food and tube-feeding formula]). Record review of Resident #1's MAR &TAR for the month of July 2026 revealed the facility was following Physician orders. Record review of Resident #1's Comprehensive Care Plan, dated 04/08/26, reflected resident being care planned for enteral feeding via G-tube (flexible medical device placed through the skin of the abdomen directly into the stomach to deliver nutrition, fluids, and medications) with an intervention to serve diet as ordered. Resident was also being care planned for tube feedings due to dysphagia with an intervention to monitor/document/report any s/sx of: aspiration (foreign material such as formula, stomach acid, or saliva is accidentally inhaled into the airway and lungs instead of down the esophagus [a tube that carries food and liquid from the throat to the stomach]), fever, SOB, and tube dislodgement (accidental shifting, removal, or displacement of a medical device-such as feeding tube). Observation on 07/30/26 at 9:43 AM of medication pass for Resident #1 by LVN A revealed Resident #1 was resting in bed receiving Isosource 1.5 cal (high calorie, nationally complete liquid medical food containing fiber, protein, and fats, designed for tube feeding) at 70 ml/hr via G-tube (flexible medical device placed through the skin of the abdomen directly into the stomach to deliver nutrition, fluids, and medications) . Resident #1 did not have an abdominal binder on. Interview on 07/30/26 at 12:30 PM, LVN A said she had been working at the facility for almost a year on a PRN basis on the morning and evening shifts. LVN A said she forgot to disconnect Resident #1 from her enteral feedings at 7:00 AM. LVN A said although she documented on Resident #1's TAR the resident abdominal binder was intact she failed to assess resident to ensure the abdominal binder was intact and was sorry. LVN A said by not disconnecting Resident #1 from her feedings at 7:00 AM placed the resident at risk of being over fed, bloating, nausea and vomiting. LVN A said if Resident #1's abdominal binder was not in place; this placed the resident at risk of her G-tube being dislodged and the resident would have to go to the hospital to have the tube reinserted. Interview on 07/30/26 at 1:55PM, the DON said by LVN A not disconnecting Resident #1's enteral feeding as ordered by the physician it could place the resident at risk for weight gain. The DON said if the abdominal binder was not in place, it placed Resident #1's G-tube at risk for being dislodged. Record review of the facility policy on Appropriate Use of Feeding Tubes revised December 01/25 reflected in part: .A resident who is fed by enteral means receives the appropriate treatment and services to restore, it possible, oral eating skills and to prevent complications of enteral feeding include but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.Feeding tubes (naso-gastric, gastrostomy, jejunostomy) will be utilized in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #1) reviewed for infection control. LVN A failed to practice Enhanced Barrier Precautions when administering direct care for Resident #1 on 07/30/26. This failure could place residents at risk for acquiring and spreading infections. Findings include: Record review of Resident #1's face sheet, dated 07/30/26, revealed reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1's diagnoses included the following: encephalopathy (malfunction of the brain that causes altered mental status, confusion, and memory loss), type 2 diabetes mellitus (when the body has trouble using sugar from the food eaten, leading to too much sugar in the blood) , dysphagia (difficulty swallowing), dementia (severe decline in memory, thinking, and reasoning interfering with a person's daily life), dermatitis (skin condition causing redness and itching), benign neoplasm of left breast (non- cancer but abnormal growth of cells in the breast tissue), and mixed receptive-expressive language disorder (a communication condition where a person has trouble understanding what others say and using language to share their own thoughts). Record review of Resident #1's quarterly MDS, dated [DATE], Section C-Cognitive Patterns reflected that the resident mental status was a 3, indicating which indicated the resident cognition was severely impaired. Record review of Resident #1's Physician Order Summary Report for the month of July 2026 reflected the following orders: -Dated 04/22/26, Enhanced Barrier Precautions (enteral feedings [{tube feeding}] every shift, follow facility policy. -Dated 06/26/26, Isosource (high calorie, nationally complete liquid medical food containing fiber, protein, and fats, designed for tube feeding) 1.5 at 70 ml/hr from 7PM-7AM daily. Record review of Resident #1's Comprehensive Care Plan, dated 04/22/26, reflected the resident being was care planned for Enhanced barrier Precautions with the intervention to implement Enhanced Barrier Precautions. Observation on 07/30/26 at 9:43 AM of medication pass for Resident #1 by LVN A revealed. there was an EBP signage on the door entrance. Inside of the room at the door entrance was a plastic 3 bins storage container with PPE inside that consisted of gloves sitting on top of the container with disposable gowns inside. Resident #1 was resting in bed receiving Isosource 1.5 cal (high calorie, nationally complete liquid medical food containing fiber, protein, and fats, designed for tube feeding) at 70ml/hr via G-tube (flexible medical device placed through the skin of the abdomen directly into the stomach to deliver nutrition, fluids, and medications). LVN A entered Resident #1's room washed her hands and placed on a pair of gloves but not a disposable gown. LVN A proceeded to administer Resident #1's medications via G-tube. Interview on 07/30/26 at 12:30 PM, with LVN A said she had been working at the facility for almost a year on a PRN basis on the morning and evening shifts. LVN A said she was familiar with EBP. LVN A said EBP should be practiced when providing direct care for residents that who had a G-tube by wearing gown and gloves to prevent the spread of infections to Resident #1. LVN A said she forgot to wear a gown while providing care for Resident #1. Interview on 07/30/26 at 1:50 PM with the Infection Control Nurse Preventionist said residents that who were on EBP consisted of residents with the following: G-tubes, intravenous (into the vein) lines, indwelling Foley catheters, and wounds. The Infection Control Prevention said staff had to wear gowns and gloves when providing direct care for residents with these devices to protect the residents from infections as well as the staff members. Interview on 07/30/26 at 1:55 PM, Interview with the DON said if staff did not practice EBP on residents with artificial devices on their body, it placed the residents at risk for infections. Record review of the facility's policy on Enhanced Barrier Precautions dated December 01, 2025 reflected in part: .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms ( a germ that has developed a resistant to many common antibiotic medications) that employs targeted gown and gloves use during high contact resident care activities.An order for Enhanced Barrier Precautions will be obtained for residents with any of the following: wounds.and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes.even if the resident is not know to be infected or colonized (bacteria living on or in the body without causing an active infection) with MDRO.Implementation of Enhanced Barrier Precautions: make gowns and gloves available immediately near or outside of the resident's room.

Based on interview and record review, the facility failed to permit residents to return to the facility after they were placed on therapeutic leave and failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals for 1 of 8 residents (Resident #11) reviewed for discharge process. The facility failed to ensure Resident #11 was allowed to return to the facility on 7/1/26 after she went out on pass on 6/30/26 resulting in the resident leaving the facility with nowhere to go. The facility failed to develop an effective discharge plan for Resident #11.This failure could place residents at risk of emotional distress, fearfulness and disorientation to discharge. Findings include: Record review of Resident #11's admission Record generated on 7/1/26 revealed she was admitted to the facility on [DATE] with diagnoses of right femur fracture, bipolar disorder (a mental health condition that causes extreme mood swings) and anxiety disorder (mental health conditions characterized by excessive, persistent, and uncontrollable fear or worry that is out of proportion to the actual situation). Resident #11's primary payor source was listed as private pay. (paying for goods or services directly out-of-pocket using personal funds rather than relying on government assistance like Medicare or Medicaid or third-party health insurance). She was [AGE] years old. Record review of Resident #11's Baseline Care Plan dated 4/23/26 revealed Resident #11's initial goal was to discharge to the community with assistance as needed. Record review of Resident #11's Order Summary Report generated on 7/2/26 revealed a physician's order that indicated Resident #11 required nursing home care for 180 days with an order date of 4/23/26. Further review of Resident #11's physician orders revealed an order allowing Resident #11 to go on therapeutic pass (non-medical visit outside of the facility) with medications. Record review of Resident #11's Nursing Facility admission Agreement dated 4/24/26 revealed it was signed by Resident #11 who acknowledged the following information: PASSES. Resident may leave Facility for therapeutic home visits on passes with permission of Resident's Attending Physician and Resident/Resident Representative. Facility administration shall be notified of all passes in advance and Resident shall be signed out at the nurse's station when leaving and upon return.BEDHOLD (a guaranteed reservation for a resident's specific bed when they temporarily leave) POLICY. Upon request, Facility shall hold Resident's bed when Resident is away from Facility for hospitalization or therapeutic home visit, as long as the applicable bedhold fee is paid. The daily bedhold fee is the current daily charge for the Resident bed. If Resident is transferred from Facility, or is on a therapeutic home leave without arranging for a bedhold, Facility shall process the discharge of Resident. If Resident desires to be readmitted after discharge, Resident shall be treated as a new applicant for purposes of admission. Except in an emergency, Resident shall not be transferred or discharged without prior consultation with Resident, Resident's Attending Physician. and written notification describing the reason (s) for the transfer or discharge and Resident right to appeal the transfer or discharge. Record review of Resident #11's admission MDS assessment dated [DATE] revealed Resident #11 had a BIMS score (a short, standardized cognitive screening test used to assess a person's attention, memory, and orientation) of 15, indicating she had no cognitive impairment. She had a PHQ-9 (a standardized, 9-item self-report questionnaire used by healthcare providers to screen for depression, establish provisional diagnoses, and measure the severity of depressive symptoms) score of 7, indicating she had mild depressive symptoms. She used a walker and a wheelchair for mobility and had functional impairment in reach of motion on one side of her lower extremities. She required partial/moderate assistance with bathing, lower body dressing, walking 10 feet, and transfers from chair/bed-to-chair. The assessment indicated she had occasional urinary incontinence and frequent bowel incontinence. Record review of Resident #11's Care Plan Report dated 5/19/26 and revised on 6/5/26 revealed she had a right femur fracture. The goal was listed as, [Resident #11]'s surgical incision will heal without s/sx of infection or breakdown by review date. Interventions included following the physician orders for weight bearing status and review the physical therapy treatment plan. Record review of Resident #11's Nursing Home Transfer and Discharge Notice dated 6/12/26 revealed Resident #11 would be discharged from the facility for not paying her bill for services provided by the facility after reasonable and appropriate notice to pay. The effective date of transfer was 7/30/26. The notice was signed by Resident #11 and the Administrator. Record review of Resident #11's After Visit Summary from a local hospital dated 6/25/26 revealed instructions following posterior hip replacement (a traditional, muscle-sparing surgical technique where a surgeon accesses the hip joint from the back of the body. The damaged ball-and-socket joint is removed and replaced with artificial components) that stated to follow the instructions provided by the hospital physical therapist regarding range of motion and to be careful bending the hip more than 90 degrees for the first 6 weeks. She had a wound incision on her right hip. The After Visit Summary included an X-ray of the right hip dated 6/25/26 which stated the impression as, Status post conversion to total right hip arthroplasty (a surgical procedure where an orthopedic surgeon replaces a diseased or damaged right hip joint with an artificial prosthesis) with expected postoperative findings. Record review of Resident #11's Progress Note dated 6/30/26 at 9:55am written by LVN T stated Resident #11 went out on pass and would return at approximately 4:00pm. Record review of Resident #11's Progress Note dated 7/1/26 at 5:08am revealed Resident #11 had not returned and the resident's responsible party and the DON were notified. Record review of Resident #11's Transfer/Discharge Report dated 7/1/26 revealed Resident #11 had a date of transfer/discharge of 6/30/26 at 9:55am. The report provided a list Resident #11's medications, when the medication was last administered, and the count of medications that were given to the resident on discharge. The document was signed by Resident #11 and an unknown staff member. Record review of Resident #11's Progress Note dated 7/1/26 at 12:36pm written by the Unit Manager stated Resident #11 returned to the facility in stable condition and was notified of discharge. Discharge instructions and medications given and discharge paperwork signed. Pt then left the facility and verbalized she would be back to get her personal belongings. Record review of Resident #11's Progress note dated 7/1/26 at 12:37pm written by the Unit Manager stated Resident #11's nurse practitioner was notified of the resident leaving and an order was given to release the medications excluding narcotics. The Unit Manager reported that an APS case was submitted. In an interview on 7/1/26 at 3:15pm, The BOM said Resident #11 left around lunch time on 6/30/26. She said she saw her get in a bus. She said she did not return and thought she left against-medical-advice. She said they issued her a 30-day notice a few weeks ago and she had until the end of July 2026 to move out. In an interview on 7/1/26 at 3:47pm, LVN O said Resident #11 liked to go out on pass and visit with friends. He said Resident #11 left on 6/30/26. He said he called Resident #11's family member when she did not return to the facility last night during his shift. He said Resident #11 could not be reached by phone. In an interview on 7/1/26 at 4:17pm, the Social Worker stated Resident #11 lived in a homeless shelter prior to her admission. She said her discharge plan included transitional housing. She said she had not seen Resident #11 this week. She said Resident #11 was alert and oriented, could make her own decisions and leave the facility to go out on pass. Surveyor attempted to call Resident #11 by phone with the phone number found in her medical record on 7/1/26 at 4:30pm. The phone number was not in service. In a telephone interview on 7/1/26 at 4:37pm, Resident #11's Family Member stated Resident #11 was at the facility today and the staff kicked her out. She said on 6/30/26, she went to a nearby church. The Family Member stated the bus did not pick her up from the church so she could not make it back to the facility. The Family Member stated she received a call from Resident #11 around 1:00pm on 7/1/26 stating she was at the facility and needed to be picked up. The Family Member stated she refused. The Family Member stated Resident #11 had a recent hip surgery. The Family Member gave the surveyor Resident #11's phone number. In an interview on 7/1/26 at 4:42pm, the Regional Director of Clinical Services stated Resident #11 visited with the DON earlier today and took her medications. He said Resident #11 went out on pass on 6/30/26 and returned around 10:00am on 7/1/26. He said Resident #11 left the facility against-medical-advice. He said Resident #11 packed up her items and left them at the front of the facility in the lobby. He said they made a report to adult protective services because they were worried about her safety in the community. He said she would be allowed to stay if she chose to. He said she had an outstanding balance of about $18,000. In a telephone interview on 7/1/26 at 4:52pm, Resident #11 stated she left the faciity on 6/30/26 to go to a charity shop and visit friends. She said she planned to return to the facility around 4pm but the bus did not pick her up. She said she tried to call the facility but did not get through. She said when she arrived to the facility earlier today on 7/1/26, her belongings were placed in a big box on a dolly in her room. She said a woman came into her room and said she had been discharged . She said she could not believe that they made her leave for something that was outside of her control. She said she met with the Administrator and he asked about a local group home that she previously expressed she was not interested in. She said she pleaded with them to stay at the facility, and they told her she could not stay. She said she told them she had nowhere to go. She said she was sitting at a local store to charge her phone. She said she was unsure where she would go and may go to a local shelter. She said she could take care of her personal care needs. In an interview on 7/1/26 at 5:5pm, the Administrator stated he met with Resident #11 earlier on 7/1/26. He said Resident #11 did not specify whether she wanted to stay at the facility or not. He said they gave her medications and then she left. He said when residents leave out on pass, they were allowed to return to the facility. In an interview on 7/2/26 at 12:10pm, the Receptionist said Resident #11 was allowed to leave the facility out on pass. She said the Housekeeping Supervisor placed Resident #11's belongings in the front lobby. She said Resident #11 returned to the facility in the morning of 7/1/26. She said Resident #11 was upset and mad. She said the Administrator reported that Resident #11 would be discharged . In an interview on 7/2/26 at 12:44pm, the Housekeeping Supervisor said the BOM reported that since Resident #11 had left on 6/30/26 and did not return, she would be discharged . She said she was told to pack Resident #11's belongings. She said Resident #11 returned around 10:00 am on 7/1/26 when they were packing her items. She said she reported Resident #11's return to the BOM and the BOM and DON spoke to the resident. In interviews on 7/2/26 between 1:25pm and 1:45pm, CNA V and CNA N said Resident #11 could independently perform activities of daily living tasks. Surveyor attempted to interview Resident #11's NP on 7/2/26 at 1:22pm but was unsuccessful. In an interview on 7/2/26 at 2:20pm, the DON said Resident #11 admitted to the facility after a fall with a hip fracture. She said was independent with ADL care. She said she went out-on-pass often and could handle her own medical care, including making her own appointments. She said she was not aware Resident #11 had a hip replacement. She said the BOM told her Resident #11 could not stay out overnight. She said when Resident #11 returned to the facility on 7/1/26, they met with her and discussed discharge process. She said they offered to let her stay in a personal care home. She said Resident #11 did not want to hear anything else they had to say and left. She said Resident #11 had a history of homelessness. She said Resident #11 did not qualify for long-term care. In an interview on 7/2/26 at 4:00pm, the BOM said Resident #11 was not on Medicare or Medicaid. She said if a resident had Medicaid, they were allowed to leave the facility for 72 hours while out on pass. She said if residents were at the facility for skilled care then they could not leave for 24 hours because if they leave then that would indicate they could care for themselves. She said the same rule would apply to a private-pay resident. She said they did not know where Resident #11 was and they assumed she would not come back. She said the decision was made to discharge her. She said she could not continue to go out on pass because they did not know what could happen to her and it was putting the resident and the facility in jeopardy. In an interview on 7/2/26 at 4:21pm, the Administrator stated on 7/1/26 in the facility's morning meeting with the IDT, they discussed Resident #11's discharge because she was not at the facility at midnight. He said if she returned then she would have to pay her balance. He said they explained the situation to the resident on 7/1/26. He said Resident #11 was unhoused prior to admission. He said they tried to assist Resident #11 with finding a place to live. Record review of the facility's Therapeutic Leave policy dated 10/2025 read, It is the policy of this facility to allow residents to leave the facility for a non-medical visit, therapy known as therapeutic leave, in accordance with Federal and State guidelines. Each resident will be permitted to return to the facility after therapeutic leave, regardless of payment source. Residents who seek to return to the facility within the bed hold period defined in the state specific plan are allowed to return to their previous room, if available.Not permitting a resident to return following therapeutic leave constitutes a discharge. Because the facility was able to care for the resident prior to therapeutic leave, documentation related to the basis for discharge must clearly show why the facility can no longer care for the resident.

Based on interview and record review, the facility failed to ensure that residents were free of any significant medication errors for 1 of 11 residents (CR #2) reviewed for pharmacy services. -The facility failed to ensure CR #2 received his Hydroxyurea medication (prescription medication used to treat certain cancers) upon admission to the facility and missed 3 doses on 4/24/26, 4/26/26 and 4/28/26. This failure could place residents at risk of not receiving necessary medications and decline in health. Findings include: Record review of CR #2's admission Record generated on 5/14/26 revealed he was admitted to the facility on [DATE] with diagnoses of thrombocytopenia (a medical condition characterized by an abnormally low count of platelets in the blood), chronic myeloproliferative disease (a group of slow-growing blood cancers) and chronic myeloid leukemia (a slow-growing cancer of the bone marrow that causes an overgrowth of white blood cells). He was [AGE] years old. Record review of CR #2's Discharge Instructions from the local hospital dated 4/23/26 revealed an order for CR #2 to start taking Hydroxyurea 500mg on 4/24/26. The order was for 1 capsule by mouth every other day for 30 days. Record review of CR #2's Physician Progress Note completed by MD A on 4/24/26 revealed CR #2 was admitted to the facility with thrombocytopenia and was taking Hydroxyurea. MD A documented that CR #2 was taking Hydroxyurea 500mg, 1 capsule once a day and stated that the medication list was reviewed and reconciled with the patient. Record review of CR #2's Order Summary Report generated on 5/14/26 revealed a physician's order for Hydroxyurea 500mg dated 4/27/26 with instructions for one capsule by mouth every 48 hours related to Thrombocytopenia. Record review of CR #2's Progress Note dated 4/27/26 at 7:45pm written by RN E stated the Oncologist called with an order for Hydroxyurea 500mg every 48 hours. The note read, the order already in place. Pharmacy called to deliver med, also patient's [family member] said that she could go to her pharmacy to get med, she left here to pharmacy. Record review of CR #2's Progress Note dated 4/27/26 at 8:45pm written by RN E stated the pharmacy reported the Hydroxyurea medication would be delivered on the same night (4/27/26). RN E wrote that CR #2's family member could not obtain the medication from the pharmacy. Record review of CR #2's Medication Administration Record dated April 2026 indicated he received one capsule of Hydroxyurea 500mg by mouth on 4/29/26. On 4/27/26, RN C documented that the medication was not administered and referred to a nurse progress note. In a telephone interview on 5/14/26 at 2:16pm, CR #2's family member stated that while in the nursing facility, CR #2 missed his chemotherapy medication for three days. The family member stated they gave him the medication after she brought it to their attention. In an interview on 7/1/26 at 1:33pm, LVN W said she completed CR #2's admission assessment when he arrived to the facility. She said she did not complete the medication review and thought another nurse completed it but could not say who. In an interview on 7/1/26 at 1:52pm, RN C stated she could not remember CR #2. In an interview on 7/1/26 at 4:00pm, the ADON stated if a resident admitted to the facility with an order for chemotherapy medications a family member would bring the medications with them. She said it could take a while for the pharmacy to fill expensive medications. She said she started working at the facility at the end of April 2026 when CR #2 was admitted . In an interview on 7/1/26 at 5:02pm, the ADON said she reviewed CR #2's medical record. She said someone at the facility should have asked for the family member to bring the Hydroxyurea medication to the facility when he was admitted . She said they spoke to the Oncologist on 4/27/26 who gave a new order for the Hydroxyurea to start the medication. She said that was when the facility ordered the medication from the pharmacy. In an interview on 7/2/26 at 11:29am, The Regional Director of Clinical Services said they reviewed clinical information prior to admission and flagged any high-cost medications. Said they usually check with the family members prior to admission to see if they could bring the medication from home. In regard to CR #2, the Regional Nurse Consultant said RN C called the Oncologist after the family member raised the concern that she could not provide the medication to the facility. Surveyor attempted to interview CR #2's NP on 7/2/26 at 1:22pm but was unsuccessful. In an interview on 7/2/26 at 2:20pm, the DON stated she attended CR #2's Circle of excellence meeting, which was a meeting they had with the resident and family member within 48 to 72 hours of admission. She said she could not remember talking about his medications. She said when someone was taking chemotherapy medication they coordinated with the family member before they accept for admission because their insurance would not cover it if it had already been filled. Record review of the facility's policy regarding Medication Administration dated 11/1/25 read, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. Record review of the facility's policy regarding admission of a Resident dated 11/14/25 read, The admission process is intended to obtain all possible information regarding the resident for the development of the comprehensive plan of care, and to assist the resident in becoming comfortable in the facility. Residents are admitted to the facility under orders of the attending physician. Once the resident/family has selected the facility, pre-admission information should be gathered. Preadmission information may include, but is not limited to: History and physical, Discharge summary, Physician's orders, Medication and/or Treatment records. Upon admission, the designated facility staff will obtain information and perform assessments as per their respective departments and as per facility protocol. Information gathered will be placed into the resident's medical record via the facility's means of recordkeeping. Record review of Hydroxyurea Information Sheet on 7/16/16 at 8:58am located at https://medlineplus.gov/druginfo/meds/a682004.html#why read, Hydroxyurea (Hydrea) is used alone or with other medications or radiation therapy to treat a certain type of chronic myelogenous leukemia (CML; a type of cancer of the white blood cells). Hydroxyurea is in a class of medications called antimetabolites. Hydroxyurea treats cancer by slowing or stopping the growth of cancer cells in your body. Take hydroxyurea at around the same time every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take hydroxyurea exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. Your doctor may need to delay your treatment or adjust your dose of hydroxyurea depending on your response to treatment and any side effects that you may experience. Talk to your doctor about how you are feeling during your treatment. Do not stop taking hydroxyurea without talking to your doctor. What should I do if I forget a dose? Take the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one.

Based on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinent care and catheter care, in that:While providing incontinent care to Resident #1 on 07/01/2026, CNA A did not spread the resident's labia. This failure could place residents at-risk for infection and skin breakdown due to improper care practices. Findings included:Record review of Resident #1's face sheet dated 01/02/2026 revealed she was a [AGE] year-old female admitted with the following diagnoses: cardiomyopathy (a disease of the heart muscles that makes if harder for the heart to pump blood to the rest of the body), muscle weakness and abnormalities of gait and mobility.Record review of Resident #1's MDS dated [DATE] revealed her BIMS score was coded 13-indicating memory and thinking. Section GG-Functional abilities indicated she was totally dependent on staff for on her ability to maintain perineal and personal hygiene.Record review of Resident #1's care plan dated 06/19/2026 revealed: Bladder incontinent. Goal: will remain free from skin breakdown due to incontinence. Intervention: clean peri-area with each incontinence episode, monitor and document any possible causes of incontinence bladder infection.In an observation on 07/01/2026 at 11:49 a.m. revealed while providing incontinent care for Resident #1, CNA A did not separate Resident #1's labia. CNA A did not clean either side of the labia separately. In an interview with CNA A on 07/01/2026 at 12: 03 p.m., she said she was trained to wipe both sides of the labia and throw away the wipes and then wipe the middle of the labia with a clean wipe. CNA A said the risk of not following the proper technique was that Resident # 1 could have bacteria infection which could lead to UTI (infection in any part of the urinary tract, which includes the kidneys and bladder). She said if the resident had UTI, that could lead to confusion and hallucinations. She said the resident would be uncomfortable with pain. CNA A said she did not follow the proper steps because she thought she had already separated the labia. In an interview with RN A on 07/01/2026 at 1:12 p.m., she said it was the responsibility of the nursing staff to perform peri care. She said peri care was performed to prevent infection, cross contamination and improve personal hygiene. RN A said if the steps were not correct, the resident might not be clean. She said the risk of not going through all the steps was that there could be infection. She said the most common infections of the peri area were UTI and bladder infection. In an interview with the ADON on 07/01/2026 at 1:26 p.m., she said it was the responsibility of the CNAs' and nurses to assist and perform peri care. She said if the steps were not completed correctly, there was a risk of UTI. She said the resident would be confused. The ADON said she resident would have dark colored urine, pain during urination and frequently wanting to urinate. She said she was not aware that CNA A did not follow the correct incontinent care procedure. She said, she would go through the correct steps with CNA A. In an interview with the DON on 07/01/2026 at 1:38 p.m., she said incontinent care was the responsibility of all nursing staff. She said incontinent care training and check-off was done by DON, ADON and UM. She said if CNA A did not follow the proper steps, there was of UTI and skin breakdown. She said if the UTI was not detected quickly, the resident might be hospitalized .In an interview with the ADM on 07/01/2026 at 1:45 p.m., he said, peri care was done because the resident was incontinent (being unable to voluntary control bodily discharges like urine or feces). He said if the steps were not done correctly, there was a risk of UTI and yeast infection. Record review of the facility's policy titled: Peroneal Care, revised on 12/01/2025 reveals: perineal care refers to the care of the external genitalia and anal area. Section C under: Policy Explanation and Compliance Guidelines stated: Separate the residents' labia with one hand and cleanse perineum with the other hand by wiping in direction from front to back.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 1 resident (Resident #1) reviewed for dietary intake.-The facility incorrectly documented the meal percentage intake for Resident #1. This failure could place all residents at risk for unwanted weight loss and hospitalization. Findings included:Record review of Resident # 1's admission face sheet dated 02/22/2026 revealed she was an [AGE] year-old female who was admitted into the facility on [DATE]. Her diagnoses included: High blood pressure. Hyperlipidemia (high levels of fat in your blood stream), generalized body weakness and abnormality of gait and mobility.Record review of Resident # 1's admission MDS dated [DATE] revealed for section C0500 the resident's BIMS score was uncoded because the MDS was not completed as this was day two of her admission.Record review of Resident # 1's medical providers' notes dated 02/26/2026 written at 09: 48 a.m., that was retrieved at 12:23 p.m., stated proactive health check- evaluate the resident for abdominal pain, headache, loss of taste and sore throat.In an interview with CNA A on 02/24/2026 at 10:12 a.m., she stated Resident #1 ate 76 to 100 percent of her breakfast. She said if a resident does not eat, she would notify the nurse. CNA A stated she did not notify the nurse that Resident # 1 did not eat her breakfast. CNA A said falsification of documentation was when you lie.Record review of the Nutrition - Amount Eaten In an interview with LVN A on 02/24/2026 at 12:34 p.m., she stated CNA A told her Resident # 1 did not eat her breakfast only after the paramedics who came to assess Resident # 1 had left the building. LVN A said, inaccurate documentation of records was writing something in a resident's chart that was not true. She said the consequences of inaccurately documenting Resident # 1's breakfast meal percentage could affect her health in that, she had medication without eating, which could cause her stomach to be upset. She said breakfast was served at 7:30 a.m. LVN A said inaccurate documentation of Resident # 1's meal percentage could affect her weight. In an interview with RN A on 02/24/2026 at 12 :48 p.m., she said inaccurate documentation was writing or saying something that did not happen. If a resident missed a meal, she expected the CNA to notify her. That way she would assess why a resident did not eat. RN A said she would notify the Doctor. RN A said consequences of inaccurately documenting a resident's meal consumption percentage might result in the following: the resident might become weak; the blood sugar might drop. It might also affect certain medications such as those that should not be taken on an empty stomach. There might be failure to thrive.In an interview with LVN B, on 02/24/2026 at 03:26 p.m., she said inaccurately documenting was when someone writes or says something that never happened. LVN B said if a resident's meal percentage was inaccurately documented it would affect the nutritional status, and that would compromise the health's' health. The weight would be affected and the staff involved might be fired.In an interview with RN B on 02/25/2026 at 07:00 a.m., she said inaccurate documentation of records was anything that was inaccurate that was documented on a resident's medical records. If meals documentation was inaccurately documented the nurse would not know how to assess and identify why the resident did not eat. If she knew that the resident did not eat, she would have assessed, offered alternatives and then notify the Doctor. If the primary nurse for Resident # 1 was not notified, the nurse would not assess for failure to eat. RN A said consequences of inaccurate documentation of meal percentage to the Resident # 1's health could be: the residents would become weak, not being able to participate in PT. Resident # 1 might also have weight loss, and they would not know what to tell the Dietician, who might be ordering double portion for the wrong reason. Resident # 1's health might be declining. She said she always asks the nurse aides to tell her which residents ate less than fifty percent of their meals, so she could assess them.In an interview with the ADON on 02/26/2026 at 08:51 a.m., she said inaccurate documentation records was when you document something that you did not perform. The ADON said the consequences would be unexplained weight loss and declining health, malnutrition, medications might not be effective, residents would be weak and thereby unable to attend PT and OT and might have unwanted or returned hospitalization for those that were recently hospitalized . If a resident did not eat a meal, she expects the nurse aide to notify the primary nurse, who would assess and escalate the concern to the Doctor and the Dietician who would assess the resident's appetite. The Dietician might recommend supplements. The staff who recorded the inaccurate meal percentage would be re-educated on falsification of records, and the nurse aide would have to explain why he or she did not report to the primary nurse. In an interview with the DON on 02/26/2026 at 09: 10 a.m., she said inaccurate documentation of record was when you document incorrect information. The DON said, CNA A told her, she documented that Resident # 1 ate sixty-five to one hundred because the resident always ate good. The DON said the inaccurate documentation of Resident # 1's meal could result to weight loss if it continues. She said, she expects the CNAs to notify the charge nurse each time a resident does not eat, so the nurse can offer substitutes.Record review of CNA A's time sheet retrieved on 02/26/2026 revealed that this was the very first time CNA A had ever worked with Resident # 1.In an interview with the ADM on 02/26/2026 at 09:26 a.m., he said inaccurate documentation of records was inappropriately documenting information. He said if meals percentages were falsified indicating that Resident # 1 ate when she did not, this could result to weight loss. He said the staff was re-educated and there were ongoing in-services. Record review of facility's policy of: Documentation in Medical Record Policy Statement: -Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.- Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.- False information shall not be documented.

Based on record review and interview the facility failed to ensure resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practices, to promote healing, prevent infection and prevent new ulcers from developing for 1 (CR #1) of 5 residents reviewed for pressure ulcers. -LVN A failed to transcribe CR #1's new wound treatment order given on 01/29/26 until 02/03/26. This failure could place residents at risk for delay wound healing. Findings: Record review of CR #1's face sheet dated 02/11/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged on 02/10/26. CR #1 diagnoses included: hypoxic encephalopathy (serious brain injury caused by reduced oxygen and blood flow to the brain), cerebral infarction (when blood flow to the brain is blocked), emphysema (group of lung diseases), acute respiratory failure with hypoxia (lack of oxygen), pulmonary edema (excess fluids accumulates in the lungs, making it difficult to breathe), type 2 diabetes mellitus (when the body cannot produce enough insulin {a hormone that regulates blood sugar} to control blood sugars), morbid obesity, dysphagia (difficulty swallowing), hemiplegia (paralysis on one side of the body) and hemiparesis (one sided muscle weakness), seizures, intracranial hemorrhage (type of stroke or trauma where blood leaks into or around the brain), anemia, elevated white blood cell count, myocardial infarction (heart attack), heart failure, pneumonitis (lung infection) due to inhalation of food and vomit, rhabdomyolysis (muscle breakdown) , hyponatremia (low sodium), and gastrostomy (surgical creation of an open into the stomach to insert a feeding tube for direct nutrition, medication, and hydration) , and hypothermia (low body temperature). Record review of CR #1's admission MDS dated [DATE] reflected a BIMS score of 3 indicating that CR #1's cognition was severely impaired. Section GG-Functional Abilities reflected CR #1 was impaired on one side of body to the upper extremity and both sides to the lower extremities. Further review revealed that CR#1 was dependent of toileting and personal hygiene Section M-Skin Condition revealed that CR #1 had no pressure ulcers or injures but was at risk for developing pressure ulcers/injuries. Record review of CR #1's Care Plan dated 01/21/26 revealed that CR #1 was being care planned for pressure ulcer prevention with interventions that included barrier cream, turn and reposition every 2 hours and PRN, use suspension devices (supporting device to elevate a limb of the body to lift off a surface to prevent direct pressure)to reduce pressure on heels and bony prominences (area of the body where a bone lies close to the skin surface). Record review of Clinically Unavoidable Pressure Injury form signed by the NP on 01/25/26 of stage 2 (two) coccyx (small triangular bone at the base of the spine)/ blister. Record review of Wound Care Specialist NP wound treatment order form dated 01/29/26 sacral pressure stage 3 zinc plus collagen powder. Record review of CR #1's Completed Order Summary report dated 02/11/26 reflected the following orders: -Dated 01/28/26 wound treatment: Calcium Alginate every day shift for wound care cleanse wound to sacrum with normal saline or skin cleanser. Pat dry, apply calcium alginate with TRIAD cream (zinc based) to wound bed. Cover with dry dressing. Discontinued 02/03/26 -Dated 02/03/26 wound treatment: every day shift for wound care cleanse wound to sacrum with normal saline or skin cleanser. Pat dry, apply collagen with TRIAD cream (brand name for a sterile, zinc based) to wound bed. Cover with dry dressing. Record reviews of CR #1's MAR & TAR for the month of January 2026 revealed that the facility was following Physician Orders. Record review of CR #1's MAR& TAR for the month of February 2026 reflected the order for zinc plus collagen powder was not initiated until 02/04/26. Interview on 02/11/26 at 12:23PM with the wound care nurse LVN A said CR#1 developed a wound to her sacrum at the NF that was discovered on 01/28/26 measuring 10 x 10cm in redness. LVN A said he done weekly skin assessments on residents every week. LVN A said he notified the family of CR #1, and Wound Care Specialist NP. LVN A said the Wound Care Specialist NP gave an order to treat the wound with calcium alginate. LVN A said he was the nurse that noticed the redness to CR #1's sacrum.Further interview with LVN A said the reason the new wound care treatment order was not transcribed on the day given was because the facility was having some internet issues. LVN A was asked if he could have transcribed the order on paper? LVN A said he did not see the new wound order given on 01/29/26 until 02/03/26. LVN A said he had other obligations one being calling the families about new orders. LVN A said calcium alginate absorbs wound secretions, and zinc was used for moisture- associated along with sweat or urine to protect the skin. LVN A said the surveyor would have to speak with the Wound Care Specialist NP to see what risk it placed CR #1 for regarding delay in new wound treatment. Interview on 02/11/26 at 1:47PM with the Wound Care Specialist NP said she came to the NF once a week on Thursday's. She said she first saw CR #1 on 01/29/26. She said CR #1 had a wound to the sacral area (tailbone). She said she gave an order for zinc plus collagen powder. She said this treatment would not allow the brief to stick to the skin. She said this treatment was a protectant/ barrier like petroleum oil base type of dressing. She said when she documented the treatment wound care form and provided it to the facility, it was an order to be transcribed and carried out. She said she gave the initial order for calcium alginate and this was a basic dressing that could be used until the wound could be further assessed by the clinician. She said calcium alginate was good for drainage and to rebuild the skin. She said she was not aware that the new order she gave on 01/29/26 for zinc plus collagen powder had not been initiated until 02/04/26. She said although there was a delay in initiating the order for zinc plus collagen, it did not place CR #1 at risk for harm and that using calcium alginate would not necessarily make the wound worse but maybe slow the healing process. She said whenever she wrote an order for wound treatment it did not mean she would continue with that same order during the course of treating a wound. The Wound Care Specialist NP said she would give it approximately 2-3 weeks and may have to change the treatment plan pending the wound and how it was healing. Interview on 02/11/26 at 2:25PM with the DON said LVN A was responsible for transcribing treatment orders. The DON said LVN A worked at the facility Monday through Friday and that the facility had another wound care nurse to cover the weekends. The DON said when LVN A received wound care orders from the Wound Care Specialist NP he was supposed to communicate this in the morning meetings. The DON said the ADON shared an office with LVN A. The DON said the ADON was responsible in making sure that all orders including wound care orders were transcribed. The DON said it was both ADON and her that were responsible for ensuring that all orders were being transcribed in a timely manner. The DON said she had designated this task to the ADON because she could not do everything. The DON said she spoke with LVN A after learning there was a delay in transcribing CR #1's treatment order given on 01/29/26. The DON said she had initiated on 02/11/26 a 100% skin audit sweep on residents at the facility with skin breakdown with no further concerns identified. Interview on 02/13/26 at 9:50AM with ADON said she was not aware that LVN A did not transcribe CR #1's new wound care orders given on 01/29/26. The ADON said she tried to help wherever she was needed including verifying orders daily and checking to see if there were any pending orders. The ADON said this was done to avoid any delay in care. The ADON said to be completely honest, the task of overseeing wound care orders was not assigned to her. The ADON said it was important to carry out orders when received to enhance the quality of care. The ADON said she observed CR #1's wound to the sacrum on 02/09/26 and that the wound bed was pink, moist, no odor, or signs and symptoms of infection. Record review of the NF policy on Provision of Quality of Care dated 10/01/25 reflected in part: .Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the resident's choices. Record review of the NF policy on Consulting Physician/Practitioner Orders dated 10/01/25 reflected in part: .For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: call the attending physician to verify the order.follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy and transcribing to the medication or treatment administration record.

Based on interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident (CR #1) of four residents reviewed for infection control.The facility failed to implement enhanced barrier precautions when LVN A entered CR #1's room and administered IV medications without donning appropriate Personal Protective Equipment (PPE). The facility failed to implement infection control prevention when LVN A did not wash or sanitize his hands after entering CR#1's room.The facility failed to implement infection control prevention when LVN A did not sanitize the resident's overbed table.The failure placed CR #1 at risk for infection at the IV site as well as for sepsis, and placed other residents at risk for infection by cross-contamination. Findings include:Record review of CR #1's admission Record (copied 12/04/2025) revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, osteomyelitis (infection of the bone) of his left foot and ankle, Type 2 diabetes, and muscle weakness. CR #1 was discharged to an acute care hospital on [DATE]. Record review of CR #1's Physician Order dated 10/29/2025 revealed he was to receive Cefepime HCl (antibiotic) intravenous solution, 1 gm/50 ml, three times daily until 12/03/2025. Record review of CR #1's November 2025 MAR revealed the IV antibiotic was scheduled, and was administered on 11/05/2025, within one hour before or after 1:00 a.m. The initials were those of LVN A. Record review of the MDS dated [DATE] revealed CR #1 scored 13/15 on the BIMS, indicative of intact cognition. He did not exhibit any behavioral symptoms or resist care during the look-back period (minimum 6 days). CR #1 had limited range-of-motion to both upper and both lower extremities. Record review of CR #1's Care Plan dated 11/23/2025 revealed the resident was on EBP related to wounds and for having a feeding tube. The Care Plan dated 10/25/2025 reflected CR #1 had an infection. Interventions read, in part, .Maintain universal precautions when providing resdient (sic) care. The Care Plan dated 10/25/2025 reflected CR #1 required isolation due to MRSA in his wound. The Care Plan read, in part, .Hand washing to prevent the spread of infection.Provide protective equipment at entrance to room. Review of a video dated 11/05/2025 at 00:42 a.m. revealed CR #1 lying in his bed. A male staff, later identified as LVN A, entered the room. LVN A was wearing a mask. He was not wearing a gown or gloves when he entered the room, and he did not sanitize or wash his hands after entry. He was carrying the bag of intravenous medication. LVN A hung the bag on the IV pole and dropped the tubing onto a chair. LVN A did not sanitize the overbed table before he removed the cap from a syringe of flush, which he then set on the overbed table. Although LVN A was blocking the view of the camera, it appeared that he cleaned the connector, flushed, then connected the medication tubing to the IV connector hub. LVN A then started the flow. He collected the syringe and other discarded items from the overbed table. He moved the overbed table to bedside. He did not sanitize the overbed table. LVN A then exited the room without washing his hands. In an interview on 11/22/2025 at 1:05 p.m., LVN C said when preparing to administer IV medications, the nurse was to check the order, collect the supplies, then confirm the order in the system. The nurse washes hands, don (put on) gloves, then mix the IV medication and prime the tubing. She said the nurse would then check the IV site for any signs of infection. The nurse would then flush the port and administer the medication.In an interview on 11/22/2025 at 4:23 p.m., RN B, the Weekend Supervisor, said if staff did not wear gloves when administering IV medication, it would be an infection control issue. Bacteria could be introduced into the IV tubing. Bacteria in the tubing could cause sepsis and infection in the vein, as well as cellulitis (bacterial infection of the skin's deeper layers). In an interview on 12/04/2025 at 3:44 p.m., LVN C, the facility Infection Preventionist, said residents receiving IV antibiotics would be on EBP. The staff should wash their hands and don a gown and gloves. The overbed table should be sanitized before and after the procedure. Potential problems that could arise could be contamination. She said she could not recall any in-services for IVs, but has conducted in-services regarding isolation. In an interview on 12/04/2025 at 4:33 p.m., the DON said a resident receiving IV antibiotics would be on EBP. She said the staff should wash their hands, then put on a gown and gloves prior to entering the room. The overbed table should be sanitized prior to placing items on it. A complication of not following the guidelines could result in infection. The facility policy Nursing Policy and Procedure Intravenous Therapy - Section 6 (updated 05/2024) read, in part, The delivery of IV therapy provides no margin for error, and one mistake may cause irreparable damage to the Patient. The Policy did not address infection control guidelines. The facility policy Enhanced Barrier Precautions (August 2022) read, in part, .1. Enhanced Barrier Precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include .g. Device care or use (central line .).

Based on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 8 residents (Resident #1) reviewed for Foley catheter care The facility failed to ensure Resident #1's Foley catheter had a leg strap to prevent being pulled or tugged on. This failure could place residents at risk for unwanted pain, discomfort, and risk of dislodgement or injury. Findings include: Record review of Resident #1's face sheet, dated 11/13/25, reflected a [AGE] year-old female who was admitted to the facility originally on 11/29/24 and readmitted on [DATE]. Resident #1 had diagnoses which included the following: paraplegia (loss of movement typically in the legs, caused by a spinal injury or another condition), ileus (temporary absence of the intestinal muscle contraction that prevents the normal flow of intestinal contents and cause short term blockage), muscle wasting and atrophy ( shrinking of muscle due to lack of use of the muscle), intraspinal abscess (serious infection where pus builds up cause by a bacteria) and granuloma (forming of cells that forms in a response to long time injury or infection, identified by redness, swelling, heat, pain, and loss of function), osteomyelitis (bone infection) of the vertebra lumbar region (bones of the lower back), type 2 diabetes mellitus (when the body does not produce enough insulin or does not use it properly to keep blood sugar levels normal), and depression. Record review of Resident #1's Comprehensive Care Plan, dated 08/27/25 and revised 09/04/25, reflected Resident #1 was being care planned for Foley catheter: Dx of neuromuscular dysfunction (of bladder (when there is nerve damage to the brain, spinal cord that prevents the bladder from functioning properly). The interventions included the following: -Monitor/document for pain/ discomfort due to catheter-Check tubing for kinks each shift Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 13, which indicated the resident's cognition was intact. Section H (Bladder and Bowel) of the MDS was coded 9, which indicated Resident #1 had a catheter. Record review of Resident #1's Physician Order Summary Report for the month of November 2025 reflected the following order: -Dated 08/28/25 Foley catheter 16F/10cc bulb Observation on 11/13/25 at 4:38 PM of Foley catheter care for Resident #1 by the ADON with the assistance of CNA B revealed Resident #1 was not wearing a Foley catheter secured strap. Resident #1's Foley catheter tubing was draining yellow urine. Interview on 11/13/25 at 5:30 PM, RN A said he was Resident #1's nurse. RN A said Resident #1 was supposed to have a secured Foley leg strap to prevent tubing from pulling which could cause injury to the resident that could lead to bleeding. RN A said he was responsible for making sure Resident #1 had a Foley catheter secured strap intact. RN A said the secured strap must have come off. Interview on 11/13/25 at 5:30 PM, Resident #1 said the staff never attached a secure strap to her Foley catheter tubing. Interview on 11/13/25 at 5:35 PM, CNA B said Resident #1's Foley catheter should have had a secure strap to prevent pulling of the Foley catheter tubing and dislodging the Foley catheter. CNA B said she was not assigned to Resident #1 and was just assisting with her care. Interview on 11/13/25 at 5:40 PM, the DON said all residents with Foley catheters should have a leg strap to prevent dislodging the Foley catheter. Record review of the NF policy on Catheter Care, Urinary, revised September 2014, reflected in part: .Ensure that the catheter remains secure with a leg strap to reduce friction and movement at the insertion site. (Note: catheter tubing should be strapped to the resident's inner thigh).

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the transmission of communicable diseases and infections for 1 of 8 Residents (Resident # 1) reviewed for infection control. 1. The ADON and CNA B failed to wear full PPE (disposable gown) when providing Foley catheter care for Resident #1. 2. RN A failed to wear full PPE (disposable gown) when performing Resident #1's wound dressing changes to the sacrum (large bone triangular positioned at the very base of the spine) and RL ischium (the bone that supports the upper body's weight and balance that is located near the pelvis [bone at the base of the spine]). These failures could place residents at the risk of acquiring and spreading multidrug-resistant organisms through contact with staff and other residents that could lead to unwanted infections. Findings include: Record review of Resident #1's face sheet, dated 11/13/25, reflected a [AGE] year-old female who was admitted to the facility originally on 11/29/24 and readmitted on [DATE]. Resident #1 had diagnoses which included the following: paraplegia (loss of movement typically in the legs, caused by a spinal injury or another condition), ileus (temporary absence of the intestinal muscle contraction that prevents the normal flow of intestinal contents and cause short term blockage), muscle wasting and atrophy ( shrinking of muscle due to lack of use of the muscle), intraspinal abscess (serious infection where pus builds up cause by a bacteria) and granuloma (forming of cells that forms in a response to long time injury or infection, identified by redness, swelling, heat, pain, and loss of function), osteomyelitis (bone infection)of the vertebra lumbar region (bones of the lower back), type 2 diabetes mellitus (when the body does not produce enough insulin or does not use it properly to keep blood sugar levels normal), and depression. Record review of Resident #1's Comprehensive Care Plan, dated 08/27/25 and revised 09/04/25, reflected Resident #1 was care planned for EBP as evidence by chronic wound-sacrum & RL ischium with interventions that included the following: -Post EBP on the door to room -Provide Protective Equipment at entrance to door. Record review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 13, which indicated the resident's cognition was intact. Record review of Resident #1's Physician Order Summary Report for the month of November 2025 reflected the following orders: -Dated 08/28/25 Foley Catheter 16 F/10 cc bulb -Dated 09/24/25 Wound Treatment to right buttock cleanse with 1/4 Dakins solution, pat dry, apply santyl (medicated ointment used to remove dead tissue from chronic wounds to promote wound healing) and cover with border dressing every day shift. -Dated 10/07/25 Wound Treatment: Sacral stage 4 pressure: cleanse with Dakins (wound cleanser made from diluted household bleach, baking soda, and water use to treat and prevent infections in various wounds) 1/4 strength pat dry and apply NPWT @ 125 mmhg continuous pressure. As needed if dislodge apply Dakins soaked gauze and apply border dressing. Observation on 11/13/25 at 4:11 PM revealed Resident #1 resting in bed on an air mattress awake looking at her cell phone. There was an Enhanced Barrier Precaution on the outside of the resident's door informing the staff to put on gowns and gloves. There was a PPE storage cart outside of resident doorway with PPE inside that consisted of gown and gloves. Resident #1 had an indwelling Foley catheter hanging on the left side of the bed inside of a privacy bag. Observation on 11/13/25 at 4:38 PM revealed RN A, ADON, and CNA B entered Resident #1's room without placing on a disposable gown and washed their hands with soap and water and donned gloves. The ADON and CNA B proceeded to provide Foley catheter care for Resident #1. When the ADON and CNA B were done providing care, RN A began to change Resident #1's dressings to her wounds which consisted of the sacrum and the right lower ischium/buttock area. Observation of the wound bed to the sacrum being red in color, no odor but a small amount of red drainage was observed. RN A cleaned the wound bed with Dakins solution 1/4 strength cleaning the wound bed from the inside out one wipe at a time. When RN A was done cleaning the sacral wound, he packed the sacral wound with a sponge material, covered it with a translucent tape and attached the wound vac tubing in the center of the dressing. RN A proceeded to clean the right ischium/buttock area with the same solution and in the same fashion, pat dry and applied santyl ointment to the wound bed. The wound bed to the right ischium/buttock area was observed with some black discolored areas in the wound bed with a small amount of red drainage. When RN A was done, he discarded all soiled materials inside of a red biohazard bag, washed hands along with the ADON and CNA B. Interview on 11/13/25 at 5:22 PM, the ADON said the reason she did not place on full PPE when assisting with Foley catheter care and wound care for Resident #1 was due to her being distracted. The ADON said she placed Resident #1 at risk for cross contamination. Interview on 11/13/25 at 5:30 PM, RN A said he was supposed to wear a gown when he changed Resident #1's wounds. RN A said he forgot to put on his disposable gown. RN A said this placed the resident and himself at risk for cross contamination. Interview on 11/13/25 at 5:35PM, CNA B said she forgot to put on the disposable gown. CNA B said placing on full PPE was for infection control. Interview on 11/13/25 at 5:40 PM, the DON said the staff should have been wearing full PPE that consisted of disposable gowns and gloves when providing direct care for Resident #1 due to the resident having wounds and a Foley catheter. The DON said these measures were taken to prevent cross contamination and infection control. The DON said she would be in-servicing the staff. Record review of the facility's policy on Infection Control, dated November 2017, reflected in part: .The facility must establish an infection prevention and control program that must include: a system for prevention, identifying, reporting, investigations, and controlling infections and communicable diseases for all patients, staff, volunteers, visitors, and other individuals. Record review of the facility's policy on Enhanced Barrier Precautions, revised March 2024, reflected in part: .Enhanced Barrier Precautions (EBP) is an infection control intervention to reduce transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and gloves use during high- contact resident care activities.EBP is indicated for residents with any of the following: chronic wound (pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers (open sore on the lower leg, often on the ankle, cause by poor vein function and fluid buildup) and/or indwelling medical devices (.urinary catheter.) even if the resident is not known to be infected or colonized (when germs are present on or in the body without causing illness).with a CDC-targeted MDRO. EBP will be used when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, device care (central line, urinary catheter, feeding tube, tracheostomy (surgical procedure that creates an opening in the neck to place a tube into the windpipe to help a person breathe), wound care.

Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 (Residents #1) reviewed for accidents hazards and supervision.The facility failed to ensure CNA A provided Resident #1 adequate supervision after she provided her with hot water for soup on 04/02/25, in which Resident #1 suffered 2nd/3rd degree burns on her right leg.The facility failed to have appropriate interventions in place to ensure hot water was tested for safe temperatures before being served to residents.These failures resulted in an Immediate Jeopardy (IJ) situation on 10/22/2025. The IJ template was provided to the facility on [DATE] at 6:53PM. While the IJ was removed on 10/23/2025, the facility remained out of compliance at a scope of pattern and a severity level of potential harm with the potential for more than minimal harm that is not an Immediate Jeopardy, due to facility's need of more time to monitor the plan of removal for effectiveness.These failures could place residents at risk of physical harm.Record review of Resident #1's face sheet, dated 10/21/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of anxiety disorder (feeling of worry, fear), Proteus mirabilis (bacterial infection), rheumatoid arthritis (autoimmune disease that cause pain and stiffness in joints), muscle wasting and atrophy (loss of muscle mass and strength), hypertension (elevated blood pressure), and heart failure.Record Review of Resident #1's Significant change MDS assessment dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 15 which indicated she was cognitively intact. Further review of the MDS reflected that Resident #1 had impairment in her upper extremity.Record review of Resident #1's comprehensive care plan, dated 10/21/2025, revealed that it was updated to identify a skin concern of non-pressure wound to right shin with the initiated date of 04/03/2025 and the care plan also identified a focus area of ADL self-care deficit noted resident required total staff assistance with eating initiated 06/24/2025. The care plan did not include interventions for being served hot liquids.Record Review of Resident #1 progress notes dated 04/02/2025 at around 7:33 PM, reflected LVN B was notified by a CNA that Resident #1 poured warmed broth on her body, LVN B noted Resident #1 in supine position crying with burn to leg. LVN B provided Resident #1 with PRN Acetaminophen - Codeine 300-30 mg x 1 tablet, notified DON and MD.Review of Resident #1's skin assessment dated [DATE] reflected non-pressure wound of the right shin undetermined thickness, size of 10 cm length by 17 cm width, area 170 cm2 undermining. Record Review of Resident #1's physician orders reflected an order dated 04/03/2025 Silver Sulfadiazine Cream 1 % Apply to Right shin topically every day shift for Wound Care Apply to wound on right shin.Record Review of Resident #1's progress noted dated 04/04/2025 reflected Resident #1 was assessed by wound nurse practitioner and facility TN. Resident was noted to have cluster of fluid filled blisters to right shin, new order noted for xeroform (wound dressing).Record Review of the facility's Incidents By Incident Type provided on 10/21/2025 for the months of 01/01/2025-10/21/2025 did not reflect Resident #1's burn incident.Record Review of staff in-services reflected on 04/03/2025 was completed with direct care staff on Safety of Hot Liquids by LVN /Nurse Unit Manager. The In-service reflected to Never give a resident any liquid hot enough to cause a burn. If a resident requests a liquid (drink or soup) to be warmed up, then WARMED is all it should be. If you can't hold the container of liquid, then it is too HOT to give to residents. Place on counter out of reach of resident until it cools to warm/room temperature.In an interview conducted on 10/21/2025 at 3:47 PM, Resident #1 stated she wanted her soup hot. She stated CNA A came and brought her some hot water from the coffee pot. She stated CNA A told her This is the water for your soup it is hot and do not waste it. Resident #1 stated it was a 16-ounce cup. She stated she reached for her remote and the water accidentally fell on her leg. Resident #1 stated CNA A came back to check on her and noticed she had wasted the water and started removing the blanket. Resident #1 stated CNA A notified the nurse. Resident #1 stated she was in pain and asked to go to the hospital emergency room, but the nurse did not respond to her request. Resident #1 stated the doctor did not see her until almost a week later. In an interview conducted on 10/21/2025 at 4:15 PM with RP, RP stated Resident #1 received the burn on her right leg. He reported that he was called late in the evening on 04/02/2025 which was much later after the incident had occurred. RP stated he came on April 3rd and took pictures of the burns. He reported that the facility did not send Resident #1 out to the emergency room, stated they would provide treatment for Resident #1 at the facility and that there was no need to send resident out for treatment. RP stated in his opinion the burns were real bad and he sought legal advice. RP stated all treatment was completed at the facility. RP further stated he returned on 04/07/2025 to take more pictures, but the facility did not want him to take pictures. RP forwarded surveyor 4 photos taken on 04/03/2025 (cluster of large blisters on leg), 2 photos taken on 04/07/2025 (leg covered with gauze), and 6 photos taken on 04/08/2025 (showed significant burned skin damage, showed full thickness burn through two layers of skin to indicate a second degree burn ).An interview was attempted with CNA A on 10/21/2025 at 5:14 PM, received voicemail and a message left to return call.An interview was attempted with LVN B on 10/21/2025 at 5:15 PM, received voicemail and a message was left to return call.In an interview conducted with CNA A on 10/22/2025 at 11: 24 AM, CNA A stated the burn incident in April 2025 with Resident #1 was a simple accident. CNA A explained that Resident #1 had asked for either tea, coffee, or soup; however, the CNA could not recall which one. She stated Resident #1 normally ate soup a lot. CNA A stated she obtained hot water from the dispenser in the coffee room next to the nurses' station and advised Resident #1 to let the water cool. CNA A reported she left the room to provide care for another resident and when she returned, Resident #1 had knocked over the cup and the liquid had spilled through the covers. CNA A stated she removed the covers and noted Resdent#1's leg was wet, and Resident #1 was hurting. CNA A stated she notified the LVN B charge nurse, who came to assess Resident #1. CNA A stated Resident #1 did not have any visible marks that day, however the following day, some were noted. CNA A stated an in-service training was completed the next day on Resident #1 use of cup without a handle. CNA A was asked if she normally checked the temperature of liquids before giving them to a resident. CNA A responded that she placed the liquid on the side table to allow it to cool before Resident #1 consumed it. CNA A stated she felt bad about the incident and emphasized that it was not intentional. CNA A advised she had been trained on abuse and neglect, and she stated protocol is to notify the charge nurse of any incidents.Observation on 10/22/2025 at 12:00 pm and 12:07 PM, of the facility's Cafe [NAME] room revealed a hot water and coffee dispenser available to all residents. It further revealed the hot water available to all residents at the coffee station tested by the Nutritional Director was 167.6 degrees Fahrenheit. An interview was attempted two more times with LVN B on 10/22/2025 at 12:29 and 12:40 PM, a voicemail was left to return call.In an interview conducted with LVN C on 10/22/2025 at 12:54 PM. LVN C stated she has been with the facility since September 2024. LVN C reported to be the nurse Unit Manager. LVN C stated she conducted an in-service on handling hot liquids in April 2025 after being instructed to do so due to an incident in which a resident requested a warmed drink and, upon reaching for it, the liquid spilled. LVN C reported that she did not know which resident was involved at that time; she was only informed that an in-service was needed. LVN C stated the protocol for hot liquids is that the liquid cannot be smoking hot. When asked who was responsible for checking the temperature of liquids dispensed from the coffee machine, LVN C stated she could not answer that question and did not know the process or who provided oversight to ensure the water temperature was safe for serving to residents. LVN C stated that if she obtained hot liquid from the kitchen and observed steam, she would not serve it to a resident. When asked what potential harm could occur if a resident were given a liquid that was too hot, LVN C stated that the resident could suffer a natural burn.In an interview conducted with the Nutritional Director on 10/22/2025 at 1:06 PM,. the Nutritional Director stated the dietary department is only responsible for replenishing supplies in the cafe coffee room. He explained that clinical and nursing staff are responsible for monitoring that area, and dietary staff were never assigned that responsibility. He further stated that residents had free access to the cafe coffee room and may enter the area at any time. The Nutritional Director reported that he was not aware of any incidents where a resident burned themselves in that area and did not know of anyone specifically designated to monitor the water temperature in the coffee machine. He explained that the dietary department checks hydration station temperatures in the dining areas each morning but not in the cafe coffee room. When asked about potential harm, he acknowledged that burns could occur if liquid temperatures are too hot, comparing it to someone spilling hot coffee on themselves, like at fast food restaurant. He added that some residents prefer their beverages to be hot. In an interview conducted with the DON on 10/22/2025 at 1:35 PM, the DON stated that nursing staff are responsible for monitoring the cafe coffee station area. She explained that the coffee station is provided so residents can enjoy coffee and tea at their leisure. The DON stated that some residents typically wait for their liquids to cool before drinking them, while some independent residents prefer to take their drinks back to their rooms. The DON reported that she had not received any reports of residents sustaining burns from the coffee area. The DON stated she did not know who services or maintains the coffee machine located in that area. When asked about residents with cognitive impairment accessing the coffee room, the DON responded that if staff observed such residents entering the area, they are expected to intervene to ensure safety. The DON further stated that CNAs should notify a nurse to check the temperature of the hot water if there are any concerns. She said nurses could retrieve the thermometer from the kitchen for that purpose. When asked about the potential harm that could occur if water temperatures are not checked, the DON stated that a resident could sustain a burn if hot liquid were spilled.In an interview conducted with RN Treatment Nurse (TN) on 10/22/2025 at 1:45 PM, TN stated she had not worked at the facility for over two months. When asked if she remembered providing wound care for a resident with a burn in April 2025, she stated that she did recall the incident but could not recall specific details. The TN stated that if surveyors required specific information, they should review her nursing notes in the resident's chart. When asked if the wound had been staged or documented as a burn, the TN responded that it was but clarified that the chart and the wound care physician's notes would reflect the exact classification and treatment provided. She stated that the chart should indicate what treatment was performed and how the physician documented the wound. The TN added that the wound had resolved and healed, and that her main concern at the time was ensuring the wound healed properly.In an interview conducted with CNA K on 10/22/2025 at 5:50 PM, CNA K was asked about her understanding of serving hot liquids to residents. She stated that she warms liquids in the microwave just enough to ensure they are not too hot. When asked how she determines whether a liquid is too hot, CNA K stated that she touches the outside of the cup to assess the temperature. She further explained that she wraps a napkin around the cup to prevent it from being too hot to handle, then places the cup on the resident's table. In an interview conducted with CNA J on 10/22/2025 at 5:54 PM., CNA J stated she has worked for two years at the facility. CNA J reported to remember the incident that happened in April 2025 to Resident #1. CNA J stated they completed an in-service training on hot liquids. CNA J stated the in-service focused more on making sure the residents have an appropriate cup with a handle for hot liquids. CNA J stated they were not told how to test the temperature nor was a thermometer available to test the temperature. She stated she was unaware that a nurse was required to test the temperature of hot liquid prior to the liquid being served to residents. In an additional interview conducted with the DON on 10/22/2025 at 6:01 PM, the DON stated they do not have a temperature log at the nurse's station. She was asked where the nurses record the temperature after checking the hot liquid, she responded there has not been a request to check the temperature of hot liquids.Review of the facility's policy titled Accident/Incidents revealed: An Accident/Incident Report must be completed immediately upon Facility staff becoming aware of the occurrence of an accident/incident (to include medication errors) involving a Patient and, if necessary, the Patient's Care Plan must be updated. Each Accident/Incident Report must be reviewed at the Facility's daily stand-up meeting until all sections of the report are complete. Each Accident/Incident Report for an accident/incident occurring during a month must be signed by the Executive Director and Director of Nursing within 48 hours of the occurrence. A Witness Statement must be completed at the time of the accident/incident. An Accident/Incident Log must be maintained each month in which all accidents/incidents are logged Accidents/Incidents must be reported both internally and externally in accordance with the Reportable Incident Protocol (see Protocol 3-C).This was determined to be an Immediate Jeopardy (IJ) on 10/22/2025, the Administration was notified. The Administrator was provided with the IJ template on 10/22/20255 at 6:53 PM and a plan of removal was requested. The first draft of POR was received on 10/22/2025 at 8:23 PM.The following POR was accepted on 10/23/2025 at 1:00 PM. Plan of removalProblem: F689 Accidents/Supervision Immediate Action:Impact Statement:The facility failed to ensure Resident #1 was free from accidents when Resident #1 suffered 2nd/3rd degree burns after she was provided with hot water to make soup that spilled on her knee Please accept this as a Plan of Removal for the alleged Immediate Jeopardy related to failure to provide supervision to prevent accidents. Systematic Approach:1. Immediate Action Resident #1 was immediately assessed on 4/2/2025 by licensed nurse. Licensed nurse notified physician and initiated treatment plan per order for mild burn to left leg. 4/3/25- Saw by MD wound measurements- 10x17x not measurable/ Surface area 170.00 cm2; open ulceration area of 119.00 cm2 The Executive Director notified the facility Medical Director of the Immediate Jeopardy on 10/22/2025. An emergency QAPI meeting was held on 10/22/2025. On 10/22/2025 DON/Designee immediately initiate hot liquid safety assessment with all facility residents. 38 Facility residents deemed at risk will have appropriate interventions in place per facility hot liquids assessment policy. All facility care plans will be updated as at risk or not at risk with appropriate personalized interventions. DON/Designee will evaluate all patients upon admission and at least quarterly. Maintenance Director removed the coffee machines from the cafe's on 10/23/2025 and put them in storage in an abundance of caution until facility can establish a safe temperature and process for temping hot liquid distributed from the coffee machine for future use. Facility will initiate process for temping On 10/22/2025 DON/Designee in-serviced ALL nursing staff, PRN, new staff, agency on patients at risk, or not at risk for hot liquids per hot liquids assessment. DON/Designee placed binder at each nurse's station for staff to reference to ensure the safety of all patients. DON/Designee will review/update binder daily, weekend supervisor/designee will review/update binder on weekends.Each employee will complete a post-test after their education was completed to ensure staff comprehend in-services.2. Assessment On 10/22/2025 DON/Designee immediately initiate hot liquid safety assessment with all facility residents. Facility residents deemed at risk will have appropriate interventions in place per facility hot liquids assessment policy. All facility care plans will be updated as at risk or not at risk with appropriate personalized interventions. DON/Designee will evaluate all patients upon admission and at least quarterly. Maintenance Director removed the coffee machines from the cafe's on 10/23/2025 and put them in storage in an abundance of caution until facility can establish a safe temperature and process for temping of hot liquid distributed from the coffee machine for future use. On 10/22/2025 DON/Designee in-serviced ALL nursing staff on patients at risk, or not at risk for hot liquids per hot liquids assessment. DON/Designee placed binder at each nurse's station for staff to reference to ensure the safety of all patients. DON/Designee will review/update binder daily, weekend supervisor/designee will review/update binder on weekends. Each employee will complete a post-test after their education was completed to ensure staff comprehend in-services. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. DON/Designee will utilize a staff roster to ensure 100% compliance with education. Licensed nurses and CNA/CMA's will not be allowed to work until in-services completed by DON/Designee. Who will be responsible: Director of Nursing/RDCS Who Will monitor: Executive Director/RVP Target Completion Date 10/22/20253. Monitoring Effective 10/22/2025 DON/Designee will review in daily clinical IDT stand-up new admission, or patients with a change in condition to ensure a hot liquids risk assessment is completed to identity if patient is or is not at risk. Weekend Supervisor/Designee will review weekend admissions to ensure hot liquids assessment is completed timely with appropriate interventions in place for patients deemed at risk.4. Policy and Procedures Policy and procedures were reviewed by [NAME] President of Operations, Director of Regulatory and Compliance, Regional Director of Clinical Services, Executive Director, and Director of Nursing. These policies include Hot Liquids Safety. No policies needed any revisions.Monitored the POR on 10/23/2025 as follows:An observation on 10/23/2025 at 2:30 PM revealed the coffee machine was removed from the cafe and only cold liquids were noted.In an interview on 10/23/2025 at 3 PM, the ED/ADM stated all assessments and in- services were completed and provided surveyors with the plan of removal binder.In an interview on 10/23/2025 at 3:45 PM, the RVP stated he in- serviced the facility ED/ADM and DON, stated that he conducted an in-service training for the Administrator and the Director of Nursing (DON) on the Hot Liquid Safety Policy, reviewing the policy's explanation and compliance guidelines. The RVP stated that he also trained the Administrator and DON on the Hot Liquid Safety Binder, which is to be kept at each nurses' station for staff reference. This binder is intended to ensure the safety of all residents, including those identified as at risk and not at risk for burns related to hot liquids. The RVP reported that both the Administrator and the DON completed the Hot Liquid Safety Policy Quiz, each achieving a score of 100%. He further stated that the Administrator and DON are responsible for training all nursing staff on identifying residents who are at risk or not at risk per the hot liquid assessment, as well as instructing staff on the proper use of the binder. Following the in-service, employees are required to complete a post-test and must achieve a score of at least 90% to demonstrate competency. In an interview on 10/23/2025 at 3:50 PM, the ED/ADM stated that he was in-serviced by the Regional [NAME] President (RVP) on the Hot Liquid Safety Policy and the safe handling of hot liquids with residents. The ED/ADM demonstrated understanding of the policy and was able to explain the required interventions, the purpose of the Hot Liquid Safety Binder, its location, and who is responsible for maintaining and updating it. He stated that he and the Director of Nursing (DON) are responsible for training nursing staff-including RNs, LVNs, CNAs-and all department heads on the policy and procedures related to hot liquid safety. The ED/ADM further stated that all staff are required to complete a post-test following the in-service and must achieve a passing score.In an interview on 10/23/2025 at 4:15 PM, the DON stated she was in serviced by the RVP on Policy for Hot liquids and safely handling hot liquids with the resident. DON stated she and ED/ADM completed in-services with the nurse managers, nursing staff, 2 ADON, Unit Manager, Department Heads to include Dietary, Social Worker, MDS Coordinator, Business Office, Human Resources, Housekeeping, Medical Records, Activity Director, and Admissions Coordinator. DON stated 2 Monitor Hot Liquids Risk Binders were placed at each nurse's station. DON stated assessments will be completed at admission and quarterly. DON stated the DON, ADON, Nurse Unit Manger and weekend supervisor will monitor.Interviews conducted on 10/23/2025 with nurses from 6/2, 2/10, and 10/6 shifts between 4:35 PM -5:40 PM [LVN C, LVN D, LVN E, LVN G, LVN H, and RN I] indicated they participated in the mandatory in service training about Policy for Hot liquids and safely handling hot liquids with the resident. Each stated they completed quizzes following the in-services. They stated they received training on the Hot Liquid Safety Binder of at risk and not at risk binder located at the two nurse's stations. Interviews conducted on 10/23/2025 with 9 CNAs who worked the 6/2, 2/10, and 10/6 shift between 4:00PM-5:48 PM [CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R] indicated they participated in an in-service training on Policy for Hot liquids and safely handling hot liquids with the resident. The CNAs summarized the topic of discussion - stating understanding handling of hot liquids and safety. Each CNA stated they completed the post test with passing scores.Interviews attempted via outbound calls to additional 5 CNAs and 1 RN the calls were unanswered and forwarded to an automated service that prompted to leave a voicemail. A return call was not received prior to the exit on 10/23/2025.Record Review of QAPI meeting attendance sheet (ED/ADM, RVP, DON, Unit Manager, ADON, and Regional Director of Clinical Services).Record Review on 10/23/2025 of the In-Service Training Sheets dated 10/23/2025 reflected all facility staff had been in-serviced on all training topics listed on the plan of removal. About 3 percent of signatures were still needed as those employees had not worked a shift, those employees will reconfirm understanding of the training and sign off prior to working their shift. Record Review on 10/23/2025 of Hot Liquid Evaluation dated 10/23/2025 reflected all 73 residents of the facility had been completed.Record Review of care plans on 10/23/2025 reflected the 38 residents considered at risk from hot liquid evaluation was updated in the comprehensive care plan.The ED/ADM and DON were informed the Immediate Jeopardy was removed on 10/23/25 at 7:20 PM. The facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy and scope of isolated.

Based on observations, interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that 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 in accordance with State law through established procedures for one of five residents (Resident #1) reviewed for abuse and neglect . The facility failed to report to Health and Human Services an incident of potential neglect for Resident #1 within 24 hours, when Resident #1 was left unattended with a hot cup of liquid which resulted in Resident #1 sustaining second degree burns to her right leg and pain.This failure could place residents at risk of abuse, neglect, pain, and diminished quality of life.Record review of Resident #1's face sheet, dated 10/21/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of anxiety disorder (feeling of worry, fear), Proteus mirabilis (bacterial infection), rheumatoid arthritis (autoimmune disease that cause pain and stiffness in joints), muscle wasting and atrophy (loss of muscle mass and strength), hypertension (elevated blood pressure), and heart failure.Review of Resident #1's Significant change MDS assessment dated [DATE] reflected Resident #1 was assessed to have a BIMS score of 15 which indicated she was cognitively intact. Further review of the MDS reflected that Resident #1 had impairment in her upper extremity.Record review of Resident #1's care plan, dated 10/21/2025, revealed that it was updated to identify a skin concern of non-pressure wound to right shin with the initiated date of 04/03/2025 and the care plan also identified a focus area of ADL self-care deficit noted resident required total staff assistance with eating initiated 06/24/2025.Record Review of the facility's Incidents By Incident Type on 10/21/2025 for the months of 01/01/2025-10/21/2025 did not reflect Resident #1's burn incident.Record review of TULIP (online system for intakes regarding facility reported incidents and complaints in nursing facilities) for dates 4/02/25 through 10/21/25 indicated the facility had not reported to the state agency Resident #1's burn with injury on 04/02/25.Record Review of Resident #1 progress notes dated 04/02/2025 at around 7:33 PM, reflected LVN B was notified by a CNA that Resident #1 poured warmed broth on her body, LVN B noted Resident #1 in supine position crying with burn to leg. LVN B provided Resident #1 with PRN Acetaminophen - Codeine 300-30 mg x 1 tablet, notified DON and MD. The notes further noted that the area formed with blisters, cream applied.Record Review of Resident #1's physician orders reflected an order dated 04/03/2025 Silver Sulfadiazine Cream 1 % Apply to Right shin topically every day shift for Wound Care Apply to wound on right shin.An observation and interview conducted on 10/21/2025 at 3:47 PM, Resident #1 stated she did have an incident on 04/02/2025 where hot soup accidentally fell on her leg causing her a burn and pain. Resident was noted to have significant area of discolored skin to her right shin, that resulted from the burn. Resident #1 stated she was in pain and asked to go to the hospital emergency room, but the nurse did not respond to her request. Resident #1 stated the doctor did not see her until almost a week later. An observation / review of photos dated 04/03/2025 and 04/07/2025 conducted on 10/21/2025 at 4:23 PM, revealed Resident #1's burn on her right leg showed full thickness burn through two layers of skin to indicate a second-degree burn.An interview was attempted with CNA A on 10/21/2025 at 5:14 PM, received voicemail and a message left to return call.An interview was attempted with LVN B on 10/21/2025 at 5:15 PM, received voicemail and a message was left to return call.In an interview conducted with CNA A on 10/22/2025 at 11: 24 AM, CNA A stated the burn incident in April 2025 with Resident #1 was a simple accident. CNA A explained that Resident #1 had asked for either tea, coffee, or soup; however, the CNA could not recall which one. She stated Resident #1 normally ate soup a lot. CNA A stated she obtained hot water from the dispenser in the coffee room next to the nurses' station and advised Resident #1 to let the water cool. CNA A reported she left the room to provide care for another resident and when she returned, Resident #1 had knocked over the cup and the liquid had spilled through the covers. CNA A stated she removed the covers and noted Resdent#1's leg was wet, and Resident #1 was hurting. CNA A stated she notified the LVN B charge nurse, who came to assess Resident #1. CNA A stated Resident #1 did not have any visible marks that day, however the following day, some marks were noted. An interview was attempted two more times with LVN B on 10/22/2025 at 12:29 and 12:40 PM, a voicemail was left to return call.In an interview conducted on 10/23/2025 at 4:11 PM, the ED/ADM stated he was responsible for reporting incidents to HHSC. He stated in the absence of the ED/ADM the DON or other Regional Staff would take on the responsibility. ED/ADM stated he does not know why the incident was not reported by the facility, he noted at the time of the incident there was a different ADM. ED/ADM stated not reporting incidents was potential for additional harm to residents.In an interview conducted on 10/23/2025 at 4:33 PM, the DON stated the ED reports incidents to HHSC. The DON stated if the ED is out, she will report to HHSC. The DON stated the incident happened prior to her being hired at the facility. The DON stated the potential harm for not reporting incidents to HHSC could leave residents at risk for more harm.Review of facility's Abuse Prevention-Reporting Protocol dated June 2013 reflected:1. The Abuse Prevention Coordinator will:a. Immediately (within 24 hours) report to The Department of Aging and Disability Services (DADS) and other appropriate authorities incidents of Patient Abuse as required under applicable regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to The Department of Aging and Disability Services (DADS) and other appropriate authorities as required under applicable regulations and regulatory guidance. b. Immediately (within 24 hours) suspend the employee for an abuse allegation until an investigation is completed. Review of facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated April 2021 reflected: 1. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.2. Investigate and report any allegations within timeframes required by federal requirements.Record review of the Long-Term Care Regulation Provider Letter Title Abuse, Neglect Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility Must Report to the Health and Human Services Commission reflected:Type of Incident to Report Neglect (Incident with or without serious bodily injury) When to report:Immediately, but not later than two hours after the incident occurs or is suspected.

Based on observation, interview and record review the facility failed to report an alleged violation involving abuse or resulting in serious bodily injury immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures; that 1(CR#1) of 9 residents had been abused by CNA A, which resulted in injury.The facility staff failed to immediately report abuse to the Abuse Coordinator, the State Survey Agency and Law Enforcement. An Immediate Jeopardy (IJ) situation was identified on 06/26/2025. While the IJ was removed on 6/27/2025., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of continued abuse. Findings include:Record review of CR#1's undated face sheet reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. CR#1 had diagnoses which included toxic encephalopathy (a neurological disorder that occurs with brain is exposed to toxic substances, such as heavy metals or neurotoxic solvents over a period of time) and had a cystostomy catheter (tube inserted through the abdomen into the bladder).Record review of CR#1's Orders revealed, Wound Treatment-Xeroform (dressing) everyday shift cleanse wound to left hand with Normal Saline or skin cleanser. Pat dry. Apply Xeroform to wound. Cover with dry dressing. Start Date-06/22/2025. Record review of CR#1's care plan, dated 6/17/2025, revealed the following:Focus: [CR#1] has an ADL self-care performance deficit r/t. Date initiated 5/2/2025Goal: [CR#1] will maintain currently level of function in through the review date.Interventions: [CR#1] Transfer: Resident is totally dependent of staff for transferring. Date initiated: 5/27/2025Record review of WCD notes, dated 6/24/2025, revealed a skin tear wound of the left forearm. Wound size 2.2x1x0.3. Primary dressing Xeroform gauze apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Record Review of the Nursing Board certificates received from ED for the current staff: DON, RN A, LVN A and CNA A. Each document contained a handwritten termination date and time on the upper righthand corner of each document.Record review of CR#1's admission MDS dated [DATE], revealed CR#1 has a BIMS Score of 12, which indicated moderate cognitive impairment. CR#1 used a wheelchair as a mobility device; required 2 or more helpers to complete to assist with transferring from wheelchair or bed.Record review of nursing notes, revealed there were no notes documented on 6/21/2025 regarding CR#1's injuries. During an observation and interview on 6/24/25 at 9:15 AM, CR#1 was seated in his wheelchair at the entrance of his room and was observed with a bandage on his left forearm that had a small amount of blood on it. It had a written date of 6/24/2025. CR#1 was alert, orientated to person, place and event. CR#1 stated the injury occurred when CNA A tried putting him in bed by herself by pulling his arms to lift him out of the wheelchair. CR#1 stated he told CNA A he did not want to go to bed, but she insisted anyway and continued to pull on his arms. CR#1 stated CNA A told him she could put him in bed by herself and he told her it would take two people, but he was not ready to go to bed. He stated CNA A told him if she didn't put him in bed then he would be there all night even if he pooped on himself, and she would not bring him any food. He stated CNA A insisted on putting him in bed by herself and he told her he was unable to assist her due to how he was feeling. CR#1 stated during her pulling on his arms by herself, CNA A injured his left arm. CR#1 continued to tell CNA A not to pick him up by herself because it took two people. He stated she did not listen, but when she realized she couldn't she went and got CNA B. CR#1 stated he told LVN what occurred when she came to his room. He stated CNA A was rough with him.Record review of text received from LVN A from her telephone reveals that the 911 call was made on 6/22/25 at 4:21pm. Record review of nursing notes, by WCN A, dated 6/22/25 at 6:38 PM, revealed Received report resident has skin tear to left hand. Assessment done verbally denied pain and discomfort. Physician informed, order in place. Wound care done at this time, tolerated well. Offloads reposition and safety noted. RP updated remain stable. Will continue plan of care. Record review of nursing notes, by RN A, dated 6/22/25 at 6:58 PM, for effective date 6/21/25 at 3:30 PM revealed the following note: Received report from the outgoing nurse that patient voiced concern regarding a CNA's approach during care. Patient reported that the assigned CNA was not gentle and continued to insist that he perform tasks independently, despite the patient stating he felt too weak and required two-person assistance. CNA reportedly attempted care initially alone, but eventually called for a second staff member to assist. During assessment, patient was noted with an existing bruise to the left upper arm that appeared to have reopened, resulting in a small amount of blood observed on the bedsheet. It remains unclear when the original injury occurred. Patient continued to express that the CNA was rough during care. Writer obtained statements from the involved CNA and requested the primary nurse to initiate an incident report for documentation and follow-up. Patient was repositioned and made comfortable in bed. The DON was notified of the incident and ongoing concerns. Will continue to monitor patient closely and follow up as needed.In a telephone interview on 6/24/2025 at 11:22 AM, LVN A stated she became aware of the incident by CR#1 on Saturday 6/21/2025 around 4:15PM-4:30PM while she was doing her rounds. She stated when she got to CR#1's room he was in bed which was unusual for him since he went to bed after dinner. LVN A went into the room, and she stated CR#1 looked as if he was crying. LVN A stated FM A informed her additional things that were going on like CR#1 had been treated mean and CR#1 stated CNA A hurt him. LVN A stated CR#1 told her CNA A told him if he didn't go to bed, she would let him sit in poop and would refuse to change him or feed him for the rest of the shift. LVN A stated CNA A attempted to transferred him from the wheelchair to the bed, which was an improper transfer as CR#1 was a 2 person assist. LVN A stated CR#1 told her CNA A tossed him in bed. After speaking with CR#1, LVN A stated she immediately notified RN A and told her to come to CR#1's room because he had a complaint and told her who the two CNA's (CNA A and CNA B) involved were. LVN A stated RN A arrived at CR#1's room, where he repeated what happened to him. RN A told LVN A to locate the WCN; however, she had gone home for the day, so LVN A stated she washed the wound and put a bandage on it until CR#1 could be seen Sunday 6/22/25 by WCN A. LVN A stated she telephoned the DON who told her she would call her back. LVN A stated the DON called back and only wanted to speak with RN A. LVN A stated during a telephone conversation between the DON and RN A she interrupted and told the DON and RN A that CNA A's actions were abuse and the abuse coordinator, ED needed to be called along with a report to the staff. She stated the DON said those words (Abuse) would result in severe consequences to her and never use that word in her facility again. LVN A stated the DON told her she didn't need to do anything as the situation would be handled. RN A told LVN A the situation was being taken care of and instructed her to leave for today (6/21/25) as her shift was ending; and return tomorrow (6/22/25) to complete documentation. LVN stated when she arrived for her shift the next day, 6/22/25, she viewed the nursing schedule and observed CNA A was scheduled to work and on 700 hall, which meant she would care for CR#1. LVN stated she called the DON and told her CNA A was scheduled to provide care to CR#1 when she abused him yesterday. LVN A stated she told the DON she was not going to work with CNA A and she was going to document in the nursing notes and file a police report. LVN A stated she requested the administrator's telephone number to report it and neither the DON nor RN A would provide it to her. She stated she obtained the ED's number from another staff member. LVN A stated FM A and FM B came to the facility to visit CR#1 and she was told by RN A she was not allowed to engage in the conversation with the family nor come into CR#1's room. LVN A stated on 6/22/25 she telephoned the ED and was informed she was suspended for not documenting timely, calling on 6/21/25 within 2 hours of being aware of the abuse and due to an immediate investigation. LVN A stated she tried to document in the nursing notes anyway, but her sign in and password were deactivated, which prompted her to call the police and make a report. In a telephone interview on 6/24/2025 at 1:54 PM, RN A stated on the afternoon of 6/21/2025, LVN A called her and said CR#1 had a complaint. She stated she arrived at CR#1's room and observed his left forearm with blood on it. RN A stated CR#1 told her his left arm was injured during a transfer with another nursing staff. CR#1 told her he told CNA A he was a 2-person assist because she attempted to transfer him alone. CNA A called another aide (CNA B) to the room, and both CNAs transferred him to the bed. She stated CR#1 had an old bruise on his arm and she believed it re-opened during the transfer and the bruise began to bleed, which explains the blood on his bed sheet. She stated it was a healing bruise that opened. RN A stated she required a statement from both CNA's due to the wound. RN A stated she told LVN A to call WCN A to look at CR#1's wound. RN A stated CR#1 never told her CNA A was rough with him and admitted during her interview with him she didn't ask. RN A stated LVN A told her CNA A did not handle CR#1 correctly, but admitted she never asked LVN A to clarify rough. RN A stated on 6/22/25, LVN A told her CNA A should not work the 700 hall with CR#1 because she didn't treat CR#1 right yesterday (6/21/2025) because she was rough. RN A stated CR#1 told her he told CNA A to get someone to assist. RN A stated she was informed the resident was transferred safely by the CNA's but could not recall how the resident should be transferred. RN A stated she met with CR#1's family on Sunday 6/22/25 with both CNA's, A and B. RN A stated CR#1 told his family, through speaking Spanish, that one CNA B was nice and CNA A wasn't nice. She stated she did not report the incident or what CR#1 stated to his family or to the abuse coordinator, administrator, even though she knew who the abuse coordinator was. RN A stated she reported it to the DON instead. In a telephone interview on 6/24/2025 at 6:00pm with WCN A, she stated she was called to CR#1's room to look at his arm on Sunday 6/22/25 because the wound occurred on (Saturday), 6/21/2025. She stated CR#1's wound was covered on Sunday when she observed it. The WCN stated CR#1 told her staff gave him a skin tear and did not mention a name. When asked if she had attempted to probe the resident for more information, she stated, I was there to do my job, so I didn't ask any further question. WCN A stated she was aware she was a mandatory reporter and did not report the incident to the abuse coordinator. In an interview on 6/24/2025 at 6:15 PM, the DON stated on Saturday evening 6/21/25, she received a call from LVN A regarding CNA A and had an issue with her. The DON stated she called the supervisor to find out what occurred. She stated CNA A reported she asked LVN A to assist her in transferring a resident to bed because he was a two person assist. The DON stated LVN A refused, and CNA A got CNA B to assist. The DON stated she called RN A to find out what was going on and RN A stated the resident had an old wound that was opened during the transfer. The DON initially stated she never received a call from LVN A on Sunday, 6/22/25; then stated LVN A telephoned her on Sunday, 6/22/2025 afternoon between 3:00PM - 3:30PM and told her she would not work with CNA A because she was rough to a resident when she attempted to transfer CR#1 to the bed alone on yesterday (6/21/2025) and demanded CNA A be sent home. The DON stated she told LVN A she did not make those type of demands. Shortly after the call with LVN A, the DON stated she received a call from the ED and was informed LVN A was alleging abuse. She stated on Sunday (6/22/2025) LVN A reported abuse to the ED (abuse coordinator). The ED suspended LVN A and CNA A. The DON stated she spoke with CR#1 yesterday (6/23/2025) and he told her his weekend was good. The DON stated she asked CR#1 if anything happened this weekend he needed to talk about, and CR#1 told her no. The DON stated she did not asked CR#1 if CNA A was rough with him because he told her his weekend was good. The DON stated she did not speak with the FM's and did not file any report with the state. The DON stated she could not think of a negative outcome regarding this incident; however, she said after LVN A mentioned abuse it was a reportable incident. In an interview on 6/24/2025 at 6:52 PM, the ED stated on Saturday, 6/21/25, she received a phone call from CNA A, who stated CR#1 said he received a skin tear during a transfer with CNA A. She stated she spoke with RN A who stated the resident had an old bruise, which opened during a transfer to the bed by CNA's. She stated the RN told her WCN A was notified to look at the wound. The ED stated on Sunday, 6/22/25, around 2:30PM - 2:45PM, she received a call from LVN A claiming CNA A abused CR#1 yesterday (6/21/2025) afternoon. The ED stated she received information CR#1's FMs were visiting him. She stated she told the receptionist to go to CR#1's room and keep her on facetime so she could speak with the FM's. She stated she was informed by the FMs a CNA was rough with CR#1 yesterday (6/21/2025) and injured his arm while trying to put him in bed by herself. The ED stated during this time she directed RN A to bring in both CNAs (A & B) to identify which ones completed the transfer. She stated CR#1 identified CNA A as being rough with him and CNA B as being nice. The ED stated at this time the LVN and CNA A were suspended immediately and asked to leave the building. The ED stated LVN A told her she called and filed a police report and called in a report to the state survey agency. She stated FM B stated he called the police. The ED stated she reported the incident when she found out about it on Sunday, 6/22/2025. She stated the provider letter stated reports of abuse were to be reported within 2 hours. The negative outcome was other residents could be subjected to abuse because the alleged perpetrator could be providing care to other residents as well. She stated this was why she immediately suspended LVN A because she had an obligation to report. The ED stated as soon as she became aware of the incident she called in a report to the state (Intake#1018590). Based on the initial interviews with staff involved she placed each on suspension, then terminated them. She stated it had only been 2 days since the incident and the provider investigation report has not been submitted to state. In a telephone interview on 7/1/2025 at 1:08 PM, SPO stated he received a call on 6/22/2025 regarding an abuse on an elderly resident. He stated he responded to the facility around 4:00 PM to take a report. Upon arrival, he met the family in the entrance area and walked to the resident room with them. He spoke with LVN A who stated a resident was abused by CNA A and she was working and had access to resident(s). He stated LVN A stated CNA A injured the resident's left arm. He stated he spoke with the resident who stated CNA A was rough with him by putting him in bed roughly. He stated he was unable to locate the CNA for an interview. He stated he spoke with CR#1's family who stated they didn't want to press charges; however, they wanted to wait to see what the facility's response would be. stated FMs A and B said if the facility did not address the issue, then they would press charges. He stated he took photos of the resident's left arm and entered them into evidence. Record review of the facility's abuse Policy revealed the following:8. Any person observing an incident of Patient Abuse or suspecting Patient Abuse must immediately report such incidents to the Charge Nurse. The following information should be reported to the Charge Nurse: a. The name of the Patient involved; b. The date and time that the incident occurred; c. Where the incident took place; d. The name(s) of the person(s) committing the incident, if known; e. The name(s) of any witnesses to the incident; f. The type of abuse that was committed (i.e., verbal, physical, sexual, etc.); and g. Other information that may be requested by the Charge Nurse. 9. The Charge Nurse will immediately examine the Patient and notify the Abuse Prevention Coordinator upon receiving reports of mental, physical or sexual abuse. Findings of the examination will be recorded in the Patient's medical record. (Protection) This was determined to be an Immediate Jeopardy (IJ) was identified on 06/26/2025. The ED was notified and provided with the IJ template on 6/26/2025 at 12:10pm. The following Plan of Removal submitted by the facility was accepted on 6/27/2025 at 2:53pm. 06/27/25 Plan of Removal F609 Facility Name and ID: Impact Statement On 06/27/2025 the facility was cited for immediate jeopardy related to an incident on 06/21/2025 the facility staff failed to report abuse immediately, but no later than 2 hours to the Administrator, State Survey Agency, and Law Enforcement. The facility failed to report abuse immediately, but no later than 2 hours to the Administrator, State Survey Agency, and Law Enforcement. Immediate Action:Please accept this as our Plan of Removal for the Immediate Jeopardy related to F609 Reporting of Alleged Allegation. The Executive Director notified the Medical Director of Immediate Jeopardy on 6/27/25 at 1:00pm. The facility held an Emergency QAPI Meeting. Director of Nursing, LVN A, RN A, and CNA A were terminated on 6/25/2025 for failure to immediately report abuse to the Abuse Coordinator. 1:1 education on Policy and Procedure Abuse and Neglect, including immediate reporting to Abuse Coordinator and timely reporting per HHSC guidelines was immediately provided Executive Director, ADON, Unit Manager by Senior Executive Director. Completion Date: 06/27/2025 AssessmentAn emergency QAPI meeting was held on 06/27/2025 which was inclusive of a review of our policies/protocols Abuse and Neglect, they were found to be sufficient. Staff in- services, to include all facility employees, were started on Abuse and Neglect, including immediate notification to the Abuse Coordinator. Staff will not be allowed to start on the floor or give care until this training has been completed. All new facility staff will receive the in-services as part of the onboarding orientation process prior to working in the facility. All facility staff members completed a posttest after their education was completed to ensure staff were able to identify abuse and neglect, and proper reporting procedures. If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. A staff roster was utilized to ensure 100% of staff were in-serviced and tested. In-services were deemed to be effective by the in-services post test scores and verbalization of understanding by all facility staff. Who will be responsible: Executive Director The in-services with all staff will be completed by 06/25/2025. All staff were in-serviced 06/25/2025. Facility leadership completed safe surveys on all current facility patients to ensure they were free from abuse and neglect, no negative findings. Completion Date 06/25/2025 Facility Monitoring Residents will continue to receive safe surveys daily for 7 days, including weekends by facility leadership Manager on Duty, and twice weekly for the next 4 weeks to ensure residents remain free from abuse and neglect. Facility leadership will continue with daily and PRN rounds to ascertain any signs and symptoms of abuse and neglect. Any negative findings will be immediately reported to the Abuse Coordinator. Beginning 06/25/2025 no staff will be allowed to work until the required in servicing has been completed. Who will be responsible: Facility Leadership Who will do monitoring: Executive Director Completed on date: 06/27/2025 Policy and Procedures Policy and procedures were reviewed by Senior Executive Director, Regional Director of Clinical Services, Executive Director. These policies include Abuse and Neglect. No policies needed any revisions.Interviews on 6/26/2025 & 6/27/2025 from 2:45 PM - 5:20 PM, with multiple staff across multiple shifts. Interview conducted with the ED, ADON, RN B, RN C, RN D, RN E and RN F; LVN B, LVN C, and LVN E; CNA C, CNA D, CNA E, CNA F, CNA G and CNA H. All staff stated they were in-serviced and reviewed the facility's policy on abuse and neglect, and exploitation. According to the in-services completed, staff were given a posttest on identifying abuse and neglect, behaviors of residents who may exhibit signs of abuse, identifying any marks or bruises and neglect. The staff were expected to get a score of 90%. Record Review revealed all staff received a 90% or above on the post test. Each stated they have an obligation to reporting abuse immediately. Each were able to identify 3 types of abuse and neglect and the name of the abuse coordinator. Each staff member was able to tell where the abuse coordinator's information throughout the facility. The ED, ADON and LVN D were in-serviced 1:1 by the SED on Policy and Procedure Abuse and Neglect, including immediate reporting to Abuse Coordinator per HHSC guidelines. The ED was informed the Immediate Jeopardy was removed on 6/27/2025 at 6:00 PM The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to implement the abuse protocol that prohibit and prevent abuse, neglect, and exploitation of residents 1 (CR#1) of 9 residents reviewed for abuse. The facility failed to prevent abuse, report the abuse allegation immediately to the Abuse Coordinator, and failed to protect the residents as the alleged perpetrator was allowed to continue to work. CR#1 reported he was physically abused on his arm by CNA A on 6/21/2025 around 2:30pm, which was the time CNA A started her afternoon shift. An Immediate Jeopardy (IJ) situation was identified on 06/26/2025. While the IJ was removed on 6/27/2025., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of physical harm, emotional distress, mental anguish and death from possible abuse and neglect.Findings Include: Record review of the facility's Abuse Protocol policy, dated April 2019, revealed the following:7. The following definitions are provided to assist our Facility's staff members in recognizing incidents of Patient Abuse:a. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all Patient/Resident, irrespective of any physical or mental condition, cause physical harm, pain, or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.b. Taking or using photographs or recordings in any manner that would demean or humiliate a Patient. This includes using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep or distribute photographs and recordings on social media.c. Misappropriation of Patient property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a Patient's belongings or money without the Patient's consent.d. Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to Patient or their families, or within their hearing distance, to describe Patient, regardless of their age, ability to comprehend, or disability.e. Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault, or any nonconsensual sexual contact of any type with the Patient.f. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment.g. Involuntary seclusion is defined as separation of a Patient from other Patient's or from his or her room against the Patient will, or the will of the Patient's legal guardian or representative. (Note: temporary monitored separation from other Patient's will not be considered involuntary seclusion and may be permitted when used as a therapeutic intervention to reduce agitation as determined by the Medical Director, and/or the Director of Nursing, and such action is consistent with the Patient's Care Plan).h. Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. (Identifying)i. Adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof.j. Exploitation means taking advantage of a Patient for personal gain through the use of manipulation, intimidation, threats, or coercion.k. Mistreatment means inappropriate treatment or exploitation of a Patient.l. Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a Patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.m. Person-centered-care means to focus on the Patient as the locus of control and support the Patient in making their own choices and having control over the daily lives.8. Any person observing an incident of Patient Abuse or suspecting Patient Abuse must immediately report such incidents to the Charge Nurse. The following information should be reported to the Charge Nurse:a. The name of the Patient involved;b. The date and time that the incident occurred;c. Where the incident took place;d. The name(s) of the person(s) committing the incident, if known;e. The name(s) of any witnesses to the incident;f. The type of abuse that was committed (i.e., verbal, physical,sexual, etc.); andg. Other information that may be requested by the Charge Nurse.9. The Charge Nurse will immediately examine the Patient and notifythe Abuse Prevention Coordinator upon receiving reports of mental,physical or sexual abuse. Findings of the examination will berecorded in the Patient's medical record. (Protection)Record review of CR#1's undated face sheet reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. CR#1 had diagnoses which included toxic encephalopathy (a neurological disorder that occurs with brain is exposed to toxic substances, such as heavy metals or neurotoxic solvents over a period of time) and had a cystostomy catheter (tube inserted through the abdomen into the bladder).Record review of CR#1's Orders revealed, Wound Treatment-Xeroform (dressing) everyday shift cleanse wound to left hand with Normal Saline or skin cleanser. Pat dry. Apply Xeroform to wound. Cover with dry dressing. Start Date-06/22/2025. Record review of CR#1's care plan, dated 6/17/2025, revealed the following:Focus: [CR#1] has an ADL self-care performance deficit r/t. Date initiated 5/2/2025Goal: [CR#1] will maintain currently level of function in through the review date.Interventions: [CR#1] Transfer: Resident is totally dependent of staff for transferring. Date initiated: 5/27/2025Record review of WCD notes, dated 6/24/2025, revealed a skin tear wound of the left forearm. Wound size 2.2x1x0.3. Primary dressing Xeroform gauze apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Record Review of the Nursing Board certificates received from ED for the current staff: DON, RN A, LVN A and CNA A. Each document contained a handwritten termination date and time on the upper righthand corner of each document. Record review of CR#1's admission MDS dated [DATE], revealed CR#1 has a BIMS Score of 12, which indicated moderate cognitive impairment. CR#1 used a wheelchair as a mobility device; required 2 or more helpers to complete to assist with transferring from wheelchair or bed.Record review of nursing notes, revealed there were no notes documented on 6/21/2025 regarding CR#1's injuries. Record review of TULIP did not reflect the facility reported the violation/incident to the Administrator, state agency and to all other required agencies within specified timeframes, regarding the abuse violation described on 6/21/2025.During an observation and interview on 6/24/25 at 9:15 AM, CR#1 was seated in his wheelchair at the entrance of his room and was observed with a bandage on his left forearm that had a small amount of blood on it. It had a written date of 6/24/2025. CR#1 was alert, orientated to person, place and event. CR#1 stated the injury occurred when CNA A tried putting him in bed by herself by pulling his arms to lift him out of the wheelchair. CR#1 stated he told CNA A he did not want to go to bed, but she insisted anyway and continued to pull on his arms. CR#1 stated CNA A told him she could put him in bed by herself and he told her it would take two people, but he was not ready to go to bed. He stated CNA A told him if she didn't put him in bed then he would be there all night even if he pooped on himself, and she would not bring him any food. He stated CNA A insisted on putting him in bed by herself and he told her he was unable to assist her due to how he was feeling. CR#1 stated during her pulling on his arms by herself, CNA A injured his left arm. CR#1 continued to tell CNA A not to pick him up by herself because it took two people. He stated she did not listen, but when she realized she couldn't she went and got CNA B. CR#1 stated he told LVN what occurred when she came to his room. He stated CNA A was rough with him.Record review of text received from LVN A from her telephone reveals that the 911 call was made on 6/22/25 at 4:21pm. Record review of nursing notes, by WCN A, dated 6/22/25 at 6:38 PM, revealed Received report resident has skin tear to left hand. Assessment done verbally denied pain and discomfort. Physician informed, order in place. Wound care done at this time, tolerated well. Offloads reposition and safety noted. RP updated remain stable. Will continue plan of care. Record review of nursing notes, by RN A, dated 6/22/25 at 6:58 PM, for effective date 6/21/25 at 3:30 PM revealed the following note: Received report from the outgoing nurse that patient voiced concern regarding a CNA's approach during care. Patient reported that the assigned CNA was not gentle and continued to insist that he perform tasks independently, despite the patient stating he felt too weak and required two-person assistance. CNA reportedly attempted care initially alone, but eventually called for a second staff member to assist. During assessment, patient was noted with an existing bruise to the left upper arm that appeared to have reopened, resulting in a small amount of blood observed on the bedsheet. It remains unclear when the original injury occurred. Patient continued to express that the CNA was rough during care. Writer obtained statements from the involved CNA and requested the primary nurse to initiate an incident report for documentation and follow-up. Patient was repositioned and made comfortable in bed. The DON was notified of the incident and ongoing concerns. Will continue to monitor patient closely and follow up as needed. In a telephone interview on 6/24/2025 at 11:22 AM, LVN A stated she became aware of the incident by CR#1 on Saturday 6/21/2025 around 4:15PM-4:30PM while she was doing her rounds. She stated when she got to CR#1's room he was in bed which was unusual for him since he went to bed after dinner. LVN A went into the room, and she stated CR#1 looked as if he was crying. LVN A stated FM A informed her additional things that were going on like CR#1 had been treated mean and CR#1 stated CNA A hurt him. LVN A stated CR#1 told her CNA A told him if he didn't go to bed, she would let him sit in poop and would refuse to change him or feed him for the rest of the shift. LVN A stated CNA A attempted to transferred him from the wheelchair to the bed, which was an improper transfer as CR#1 was a 2 person assist. LVN A stated CR#1 told her CNA A tossed him in bed. After speaking with CR#1, LVN A stated she immediately notified RN A and told her to come to CR#1's room because he had a complaint and told her who the two CNA's (CNA A and CNA B) involved were. LVN A stated RN A arrived at CR#1's room, where he repeated what happened to him. RN A told LVN A to locate the WCN; however, she had gone home for the day, so LVN A stated she washed the wound and put a bandage on it until CR#1 could be seen Sunday 6/22/25 by WCN A. LVN A stated she telephoned the DON who told her she would call her back. LVN A stated the DON called back and only wanted to speak with RN A. LVN A stated during a telephone conversation between the DON and RN A she interrupted and told the DON and RN A that CNA A's actions were abuse and the abuse coordinator, ED needed to be called along with a report to the staff. She stated the DON said those words (Abuse) would result in severe consequences to her and never use that word in her facility again. LVN A stated the DON told her she didn't need to do anything as the situation would be handled. RN A told LVN A the situation was being taken care of and instructed her to leave for today (6/21/25) as her shift was ending; and return tomorrow (6/22/25) to complete documentation. LVN stated when she arrived for her shift the next day, 6/22/25, she viewed the nursing schedule and observed CNA A was scheduled to work and on 700 hall, which meant she would care for CR#1. LVN stated she called the DON and told her CNA A was scheduled to provide care to CR#1 when she abused him yesterday. LVN A stated she told the DON she was not going to work with CNA A and she was going to document in the nursing notes and file a police report. LVN A stated she requested the administrator's telephone number to report it and neither the DON nor RN A would provide it to her. She stated she obtained the ED's number from another staff member. LVN A stated FM A and FM B came to the facility to visit CR#1 and she was told by RN A she was not allowed to engage in the conversation with the family nor come into CR#1's room. LVN A stated on 6/22/25 she telephoned the ED and was informed she was suspended for not documenting timely, calling on 6/21/25 within 2 hours of being aware of the abuse and due to an immediate investigation. LVN A stated she tried to document in the nursing notes anyway, but her sign in and password were deactivated, which prompted her to call the police and make a report. In a telephone interview on 6/24/2025 at 1:54 PM, RN A stated on the afternoon of 6/21/2025, LVN A called her and said CR#1 had a complaint. She stated she arrived at CR#1's room and observed his left forearm with blood on it. RN A stated CR#1 told her his left arm was injured during a transfer with another nursing staff. CR#1 told her he told CNA A he was a 2-person assist because she attempted to transfer him alone. CNA A called another aide (CNA B) to the room, and both CNAs transferred him to the bed. She stated CR#1 had an old bruise on his arm and she believed it re-opened during the transfer and the bruise began to bleed, which explains the blood on his bed sheet. She stated it was a healing bruise that opened. RN A stated she required a statement from both CNA's due to the wound. RN A stated she told LVN A to call WCN A to look at CR#1's wound. RN A stated CR#1 never told her CNA A was rough with him and admitted during her interview with him she didn't ask. RN A stated LVN A told her CNA A did not handle CR#1 correctly, but admitted she never asked LVN A to clarify rough. RN A stated on 6/22/25, LVN A told her CNA A should not work the 700 hall with CR#1 because she didn't treat CR#1 right yesterday (6/21/2025) because she was rough. RN A stated CR#1 told her he told CNA A to get someone to assist. RN A stated she was informed the resident was transferred safely by the CNA's but could not recall how the resident should be transferred. RN A stated she met with CR#1's family on Sunday 6/22/25 with both CNA's, A and B. RN A stated CR#1 told his family, through speaking Spanish, that one CNA B was nice and CNA A wasn't nice. She stated she did not report the incident or what CR#1 stated to his family or to the abuse coordinator, administrator, even though she knew who the abuse coordinator was. RN A stated she reported it to the DON instead. In an interview on 6/24/2025 at 6:15 PM, the DON stated on Saturday evening 6/21/25, she received a call from LVN A regarding CNA A and had an issue with her. The DON stated she called the supervisor to find out what occurred. She stated CNA A reported she asked LVN A to assist her in transferring a resident to bed because he was a two person assist. The DON stated LVN A refused, and CNA A got CNA B to assist. The DON stated she called RN A to find out what was going on and RN A stated the resident had an old wound that was opened during the transfer. The DON initially stated she never received a call from LVN A on Sunday, 6/22/25; then stated LVN A telephoned her on Sunday, 6/22/2025 afternoon between 3:00PM - 3:30PM and told her she would not work with CNA A because she was rough to a resident when she attempted to transfer CR#1 to the bed alone on yesterday (6/21/2025) and demanded CNA A be sent home. The DON stated she told LVN A she did not make those type of demands. Shortly after the call with LVN A, the DON stated she received a call from the ED and was informed LVN A was alleging abuse. She stated on Sunday (6/22/2025) LVN A reported abuse to the ED (abuse coordinator). The ED suspended LVN A and CNA A. The DON stated she spoke with CR#1 yesterday (6/23/2025) and he told her his weekend was good. The DON stated she asked CR#1 if anything happened this weekend he needed to talk about, and CR#1 told her no. The DON stated she did not asked CR#1 if CNA A was rough with him because he told her his weekend was good. The DON stated she did not speak with the FM's and did not file any report with the state. The DON stated she could not think of a negative outcome regarding this incident; however, she said after LVN A mentioned abuse it was a reportable incident. In an interview on 6/24/2025 at 6:52 PM, the ED stated on Saturday, 6/21/25, she received a phone call from CNA A, who stated CR#1 said he received a skin tear during a transfer with CNA A. She stated she spoke with RN A who stated the resident had an old bruise, which opened during a transfer to the bed by CNA's. She stated the RN told her WCN A was notified to look at the wound. The ED stated on Sunday, 6/22/25, around 2:30PM - 2:45PM, she received a call from LVN A claiming CNA A abused CR#1 yesterday (6/21/2025) afternoon. The ED stated she received information CR#1's FMs were visiting him. She stated she told the receptionist to go to CR#1's room and keep her on facetime so she could speak with the FM's. She stated she was informed by the FMs a CNA was rough with CR#1 yesterday (6/21/2025) and injured his arm while trying to put him in bed by herself. The ED stated during this time she directed RN A to bring in both CNAs (A & B) to identify which ones completed the transfer. She stated CR#1 identified CNA A as being rough with him and CNA B as being nice. The ED stated at this time the LVN and CNA A were suspended immediately and asked to leave the building. The ED stated LVN A told her she called and filed a police report and called in a report to the state survey agency. She stated FM B stated he called the police. The ED stated she reported the incident when she found out about it on Sunday, 6/22/2025. She stated the provider letter stated reports of abuse were to be reported within 2 hours. The negative outcome was other residents could be subjected to abuse because the alleged perpetrator could be providing care to other residents as well. She stated this was why she immediately suspended LVN A because she had an obligation to report.In a telephone interview on 7/1/2025 at 1:08 PM, SPO stated he received a call on 6/22/2025 regarding an abuse on an elderly resident. He stated he responded to the facility around 4:00 PM to take a report. Upon arrival, he met the family in the entrance area and walked to the resident room with them. He spoke with LVN A who stated a resident was abused by CNA A and she was working and had access to resident(s). He stated LVN A stated CNA A injured the resident's left arm. He stated he spoke with the resident who stated CNA A was rough with him by putting him in bed roughly. He stated he was unable to locate the CNA for an interview. He stated he spoke with CR#1's family who stated they didn't want to press charges; however, they wanted to wait to see what the facility's response would be. stated FMs A and B said if the facility did not address the issue, then they would press charges. He stated he took photos of the resident's left arm and entered them into evidence. This was determined to be an Immediate Jeopardy (IJ) was identified on 06/26/2025. The ED was notified and provided with the IJ template on 6/26/2025 at 12:10pm. The following Plan of Removal submitted by the facility was accepted on 6/27/2025 at 2:53pm. 06/27/25Plan of RemovalF607Facility Name and ID:Impact StatementOn 06/27/2025 the facility was cited for immediate jeopardy related to incident on 06/21/2025. Staff failed to notify the Abuse Coordinator of allegation of physical abuse, notify HHSC within 2 hours and initiating an investigation after CR#1 reported to LVN A he was abused and threatened by CNA A during a transfer from his wheelchair to his bed. Staff failed to notify the abuse coordinator immediately leaving residents at risk for further abuse/neglect.Immediate Action:Please accept this as our Plan of Removal for the Immediate Jeopardy related to F607 Implement Abuse Policies. The Executive Director notified the Medical Director of Immediate Jeopardy on 6/27/25 at 1:00pm. The Facility held an Emergency QAPI Meeting. The Director of Nursing, LVN A, RN A, and CNA A were terminated on 6/25/2025 for failure to immediately report abuse to the Abuse Coordinator.1:1 education on Policy and Procedure Abuse and Neglect, including immediate reporting to Coordinator and immediately reporting per HHSC guidelines was immediately provided Executive Director, ADON, Unit Manager by Senior Executive Director. Completion on Date: 06/27/2025AssessmentAn emergency QAPI meeting was held on 06/25/2025 which was inclusive of a review of our policies/protocols Abuse and Neglect, they were found to be sufficient.Staff in- services, to include all facility employees, were started on Abuse and Neglect, including immediate notification to the Abuse Coordinator. Staff will not be allowed to start on the floor or give care until this training has been completed.All new facility staff will receive the in-services as part of the onboarding orientation process prior to working in the facility.All facility staff members completed a posttest after their education was completed to ensure staff were able to identify abuse and neglect, and proper reporting procedures.If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. A staff roster was utilized to ensure 100% of staff were in-serviced and tested.In-services were deemed to be effective by the in-services post test scores and verbalization of understanding by all facility staff. Who will be responsible: Executive Director The in-services with all staff will be completed by 06/25/2025. All staff were in-serviced 06/25/2025. Facility leadership completed safe surveys on all current facility patients to ensure they were free from abuse and neglect, no negative findings.Completion Date 06/25/2025Facility MonitoringResidents will continue to receive safe surveys daily for 7 days, including weekends by facility leadership Manager on Duty, and twice weekly for the next 4 weeks to ensure residents remain free from abuse and neglect. Facility leadership will continue with daily and PRN rounds to ascertain any signs and symptoms of abuse and neglect. Any negative findings will be immediately reported to the Abuse Coordinator. Beginning 06/25/2025 no staff will be allowed to work until the required in servicing has been completed.Who will be responsible: Facility Leadership Who will do monitoring: Executive Director Completed on date: 06/27/2025 Policy and Procedures Policy and procedures were reviewed by Senior Executive Director, Regional Director of Clinical Services, Executive Director. These policies include Abuse and Neglect. No policies needed any revisions.Interviews on 6/26/2025 & 6/27/2025 from 2:45 PM - 5:20 PM, with multiple staff across multiple shifts. Interview conducted with the ED, ADON, RN B, RN C, RN D, RN E and RN F; LVN B, LVN C, and LVN E; CNA C, CNA D, CNA E, CNA F, CNA G and CNA H. All staff stated they were in-serviced and reviewed the facility's policy on abuse and neglect, and exploitation. According to the in-services completed, staff were given a posttest on identifying abuse and neglect, behaviors of residents who may exhibit signs of abuse, identifying any marks or bruises and neglect. The staff were expected to get a score of 90%. Record Review revealed all staff received a 90% or above on the post test. Each stated they have an obligation to reporting abuse immediately. Each were able to identify 3 types of abuse and neglect and the name of the abuse coordinator. Each staff member was able to tell where the abuse coordinator's information throughout the facility. The ED, ADON and LVN D were in-serviced 1:1 by the SED on Policy and Procedure Abuse and Neglect, including immediate reporting to Abuse Coordinator per HHSC guidelines. The ED was informed the Immediate Jeopardy was removed on 6/27/2025 at 6:00 PM The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations of abuse were thoroughly investigated, to prevent further potential abuse or mistreatment while the investigation was in progress, and report the result of all investigations to other officials in accordance with State law, including to the State Survey Agency within 5 working days of the incident for 1 (CR#1) of 9 residents reviewed for abuse.The facility failed to ensure resident(s) was/were free from physical/mental abuse and neglect when CR#1 reported he was abused by CNA A and received an injury. The facility staff failed to immediately report the incident to the Abuse Coordinator (ED), suspend staff, and being an investigation of the incident promptly.The facility failed to prevent CNA A from having access to CR#1 and other residents after an allegation of abuse was reported.An Immediate Jeopardy (IJ) situation was identified on 06/26/2025. While the IJ was removed on 6/27/2025., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed resident(s) involved in abuse incidents at risk of continued abuse, mistreatment, further injury, pain and physical and emotional distress contributing to further serious injuries. The findings include:Record review of CR#1's undated face sheet reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. CR#1 had diagnoses which included toxic encephalopathy (a neurological disorder that occurs with brain is exposed to toxic substances, such as heavy metals or neurotoxic solvents over a period of time) and had a cystostomy catheter (tube inserted through the abdomen into the bladder).Record review of CR#1's Orders revealed, Wound Treatment-Xeroform (dressing) everyday shift cleanse wound to left hand with Normal Saline or skin cleanser. Pat dry. Apply Xeroform to wound. Cover with dry dressing. Start Date-06/22/2025.Record review of CR#1's care plan, dated 6/17/2025, revealed the following:Focus: [CR#1] has an ADL self-care performance deficit r/t. Date initiated 5/2/2025Goal: [CR#1] will maintain currently level of function in through the review date.Interventions: [CR#1] Transfer: Resident is totally dependent of staff for transferring. Date initiated: 5/27/2025Record review of WCD notes, dated 6/24/2025, revealed a skin tear wound of the left forearm. Wound size 2.2x1x0.3. Primary dressing Xeroform gauze apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Record Review of the Nursing Board certificates received from ED for the current staff: DON, RN A, LVN A and CNA A. Each document contained a handwritten termination date and time on the upper righthand corner of each document.Record review of CR#1's admission MDS dated [DATE], revealed CR#1 has a BIMS Score of 12, which indicated moderate cognitive impairment. CR#1 used a wheelchair as a mobility device; required 2 or more helpers to complete to assist with transferring from wheelchair or bed. Record review of nursing notes, revealed there were no notes documented on 6/21/2025 regarding CR#1's injuries. During an observation and interview on 6/24/25 at 9:15 AM, CR#1 was seated in his wheelchair at the entrance of his room and was observed with a bandage on his left forearm that had a small amount of blood on it. It had a written date of 6/24/2025. CR#1 was alert, orientated to person, place and event. CR#1 stated the injury occurred when CNA A tried putting him in bed by herself by pulling his arms to lift him out of the wheelchair. CR#1 stated he told CNA A he did not want to go to bed, but she insisted anyway and continued to pull on his arms. CR#1 stated CNA A told him she could put him in bed by herself and he told her it would take two people, but he was not ready to go to bed. He stated CNA A told him if she didn't put him in bed then he would be there all night even if he pooped on himself, and she would not bring him any food. He stated CNA A insisted on putting him in bed by herself and he told her he was unable to assist her due to how he was feeling. CR#1 stated during her pulling on his arms by herself, CNA A injured his left arm. CR#1 continued to tell CNA A not to pick him up by herself because it took two people. He stated she did not listen, but when she realized she couldn't she went and got CNA B. CR#1 stated he told LVN what occurred when she came to his room. He stated CNA A was rough with him.Record review of text received from LVN A from her telephone reveals that the 911 call was made on 6/22/25 at 4:21pm.Record review of nursing notes, by WCN A, dated 6/22/25 at 6:38 PM, revealed Received report resident has skin tear to left hand. Assessment done verbally denied pain and discomfort. Physician informed, order in place. Wound care done at this time, tolerated well. Offloads reposition and safety noted. RP updated remain stable. Will continue plan of care.Record review of nursing notes, by RN A, dated 6/22/25 at 6:58 PM, for effective date 6/21/25 at 3:30 PM revealed the following note: Received report from the outgoing nurse that patient voiced concern regarding a CNA's approach during care. Patient reported that the assigned CNA was not gentle and continued to insist that he perform tasks independently, despite the patient stating he felt too weak and required two-person assistance. CNA reportedly attempted care initially alone, but eventually called for a second staff member to assist. During assessment, patient was noted with an existing bruise to the left upper arm that appeared to have reopened, resulting in a small amount of blood observed on the bedsheet. It remains unclear when the original injury occurred. Patient continued to express that the CNA was rough during care. Writer obtained statements from the involved CNA and requested the primary nurse to initiate an incident report for documentation and follow-up. Patient was repositioned and made comfortable in bed. The DON was notified of the incident and ongoing concerns. Will continue to monitor patient closely and follow up as needed.In a telephone interview on 6/24/2025 at 11:22 AM, LVN A stated she became aware of the incident by CR#1 on Saturday 6/21/2025 around 4:15PM-4:30PM while she was doing her rounds. She stated when she got to CR#1's room he was in bed which was unusual for him since he went to bed after dinner. LVN A went into the room, and she stated CR#1 looked as if he was crying. LVN A stated FM A informed her additional things that were going on like CR#1 had been treated mean and CR#1 stated CNA A hurt him. LVN A stated CR#1 told her CNA A told him if he didn't go to bed, she would let him sit in poop and would refuse to change him or feed him for the rest of the shift. LVN A stated CNA A attempted to transferred him from the wheelchair to the bed, which was an improper transfer as CR#1 was a 2 person assist. LVN A stated CR#1 told her CNA A tossed him in bed. After speaking with CR#1, LVN A stated she immediately notified RN A and told her to come to CR#1's room because he had a complaint and told her who the two CNA's (CNA A and CNA B) involved were. LVN A stated RN A arrived at CR#1's room, where he repeated what happened to him. RN A told LVN A to locate the WCN; however, she had gone home for the day, so LVN A stated she washed the wound and put a bandage on it until CR#1 could be seen Sunday 6/22/25 by WCN A. LVN A stated she telephoned the DON who told her she would call her back. LVN A stated the DON called back and only wanted to speak with RN A. LVN A stated during a telephone conversation between the DON and RN A she interrupted and told the DON and RN A that CNA A's actions were abuse and the abuse coordinator, ED needed to be called along with a report to the staff. She stated the DON said those words (Abuse) would result in severe consequences to her and never use that word in her facility again. LVN A stated the DON told her she didn't need to do anything as the situation would be handled. RN A told LVN A the situation was being taken care of and instructed her to leave for today (6/21/25) as her shift was ending; and return tomorrow (6/22/25) to complete documentation. LVN stated when she arrived for her shift the next day, 6/22/25, she viewed the nursing schedule and observed CNA A was scheduled to work and on 700 hall, which meant she would care for CR#1. LVN stated she called the DON and told her CNA A was scheduled to provide care to CR#1 when she abused him yesterday. LVN A stated she told the DON she was not going to work with CNA A and she was going to document in the nursing notes and file a police report. LVN A stated she requested the administrator's telephone number to report it and neither the DON nor RN A would provide it to her. She stated she obtained the ED's number from another staff member. LVN A stated FM A and FM B came to the facility to visit CR#1 and she was told by RN A she was not allowed to engage in the conversation with the family nor come into CR#1's room. LVN A stated on 6/22/25 she telephoned the ED and was informed she was suspended for not documenting timely, calling on 6/21/25 within 2 hours of being aware of the abuse and due to an immediate investigation. LVN A stated she tried to document in the nursing notes anyway, but her sign in and password were deactivated, which prompted her to call the police and make a report. In a telephone interview on 6/24/2025 at 1:54 PM, RN A stated on the afternoon of 6/21/2025, LVN A called her and said CR#1 had a complaint. She stated she arrived at CR#1's room and observed his left forearm with blood on it. RN A stated CR#1 told her his left arm was injured during a transfer with another nursing staff. CR#1 told her he told CNA A he was a 2-person assist because she attempted to transfer him alone. CNA A called another aide (CNA B) to the room, and both CNAs transferred him to the bed. She stated CR#1 had an old bruise on his arm and she believed it re-opened during the transfer and the bruise began to bleed, which explains the blood on his bed sheet. She stated it was a healing bruise that opened. RN A stated she required a statement from both CNA's due to the wound. RN A stated she told LVN A to call WCN A to look at CR#1's wound. RN A stated CR#1 never told her CNA A was rough with him and admitted during her interview with him she didn't ask. RN A stated LVN A told her CNA A did not handle CR#1 correctly, but admitted she never asked LVN A to clarify rough. RN A stated on 6/22/25, LVN A told her CNA A should not work the 700 hall with CR#1 because she didn't treat CR#1 right yesterday (6/21/2025) because she was rough. RN A stated CR#1 told her he told CNA A to get someone to assist. RN A stated she was informed the resident was transferred safely by the CNA's but could not recall how the resident should be transferred. RN A stated she met with CR#1's family on Sunday 6/22/25 with both CNA's, A and B. RN A stated CR#1 told his family, through speaking Spanish, that one CNA B was nice and CNA A wasn't nice. She stated she did not report the incident or what CR#1 stated to his family or to the abuse coordinator, administrator, even though she knew who the abuse coordinator was. RN A stated she reported it to the DON instead.In a telephone interview on 6/24/2025 at 6:00pm with WCN A, she stated she was called to CR#1's room to look at his arm on Sunday 6/22/25 because the wound occurred on (Saturday), 6/21/2025. She stated CR#1's wound was covered on Sunday when she observed it. The WCN stated CR#1 told her staff gave him a skin tear and did not mention a name. When asked if she had attempted to probe the resident for more information, she stated, I was there to do my job, so I didn't ask any further question. WCN A stated she was aware she was a mandatory reporter and did not report the incident to the abuse coordinator.In an interview on 6/24/2025 at 6:15 PM, the DON stated on Saturday evening 6/21/25, she received a call from LVN A regarding CNA A and had an issue with her. The DON stated she called the supervisor to find out what occurred. She stated CNA A reported she asked LVN A to assist her in transferring a resident to bed because he was a two person assist. The DON stated LVN A refused, and CNA A got CNA B to assist. The DON stated she called RN A to find out what was going on and RN A stated the resident had an old wound that was opened during the transfer. The DON initially stated she never received a call from LVN A on Sunday, 6/22/25; then stated LVN A telephoned her on Sunday, 6/22/2025 afternoon between 3:00PM - 3:30PM and told her she would not work with CNA A because she was rough to a resident when she attempted to transfer CR#1 to the bed alone on yesterday (6/21/2025) and demanded CNA A be sent home. The DON stated she told LVN A she did not make those type of demands. Shortly after the call with LVN A, the DON stated she received a call from the ED and was informed LVN A was alleging abuse. She stated on Sunday (6/22/2025) LVN A reported abuse to the ED (abuse coordinator). The ED suspended LVN A and CNA A. The DON stated she spoke with CR#1 yesterday (6/23/2025) and he told her his weekend was good. The DON stated she asked CR#1 if anything happened this weekend he needed to talk about, and CR#1 told her no. The DON stated she did not asked CR#1 if CNA A was rough with him because he told her his weekend was good. The DON stated she did not speak with the FM's and did not file any report with the state. The DON stated she could not think of a negative outcome regarding this incident; however, she said after LVN A mentioned abuse it was a reportable incident.In an interview on 6/24/2025 at 6:52 PM, the ED stated on Saturday, 6/21/25, she received a phone call from CNA A, who stated CR#1 said he received a skin tear during a transfer with CNA A. She stated she spoke with RN A who stated the resident had an old bruise, which opened during a transfer to the bed by CNA's. She stated the RN told her WCN A was notified to look at the wound. The ED stated on Sunday, 6/22/25, around 2:30PM - 2:45PM, she received a call from LVN A claiming CNA A abused CR#1 yesterday (6/21/2025) afternoon. The ED stated she received information CR#1's FMs were visiting him. She stated she told the receptionist to go to CR#1's room and keep her on facetime so she could speak with the FM's. She stated she was informed by the FMs a CNA was rough with CR#1 yesterday (6/21/2025) and injured his arm while trying to put him in bed by herself. The ED stated during this time she directed RN A to bring in both CNAs (A & B) to identify which ones completed the transfer. She stated CR#1 identified CNA A as being rough with him and CNA B as being nice. The ED stated at this time the LVN and CNA A were suspended immediately and asked to leave the building. The ED stated LVN A told her she called and filed a police report and called in a report to the state survey agency. She stated FM B stated he called the police. The ED stated she reported the incident when she found out about it on Sunday, 6/22/2025. She stated the provider letter stated reports of abuse were to be reported within 2 hours. The negative outcome was other residents could be subjected to abuse because the alleged perpetrator could be providing care to other residents as well. She stated this was why she immediately suspended LVN A because she had an obligation to report. The ED stated as soon as she became aware of the incident she called in a report to the state (Intake#1018590). Based on the initial interviews with staff involved she placed each on suspension, then terminated them. She stated it had only been 2 days since the incident and the provider investigation report has not been submitted to state. In a telephone interview on 7/1/2025 at 1:08 PM, SPO stated he received a call on 6/22/2025 regarding an abuse on an elderly resident. He stated he responded to the facility around 4:00 PM to take a report. Upon arrival, he met the family in the entrance area and walked to the resident room with them. He spoke with LVN A who stated a resident was abused by CNA A and she was working and had access to resident(s). He stated LVN A stated CNA A injured the resident's left arm. He stated he spoke with the resident who stated CNA A was rough with him by putting him in bed roughly. He stated he was unable to locate the CNA for an interview. He stated he spoke with CR#1's family who stated they didn't want to press charges; however, they wanted to wait to see what the facility's response would be. stated FMs A and B said if the facility did not address the issue, then they would press charges. He stated he took photos of the resident's left arm and entered them into evidence. Record Review of the facility's Abuse Protocol policy, dated April 2019, revealed the following: 8. Any person observing an incident of Patient Abuse or suspecting Patient Abuse must immediately report such incidents to the Charge Nurse. The following information should be reported to the Charge Nurse: a. The name of the Patient involved; b. The date and time that the incident occurred; c. Where the incident took place; d. The name(s) of the person(s) committing the incident, if known; e. The name(s) of any witnesses to the incident; f. The type of abuse that was committed (i.e., verbal, physical, sexual, etc.); and g. Other information that may be requested by the Charge Nurse. 9. The Charge Nurse will immediately examine the Patient and notify the Abuse Prevention Coordinator upon receiving reports of mental, physical or sexual abuse. 10. The Abuse Prevention Coordinator will: a. Immediately (within 2 hours) report to The Department of Aging and Disability Services (DADS) and other appropriate authorities incidents of Patient Abuse as required under applicable regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to The Department of Aging and Disability Services (DADS) and other appropriate authorities as required under applicable regulations and regulatory guidance. b. Immediately (within 24 hours) suspend the employee for an abuse allegation until an investigation is completed. c. Conduct and document on a Patient Abuse Investigation (see Form 3-5) a thorough investigation of each incident of Patient Abuse, neglect, exploitation or mistreatment to include: observations, interviews and reviews of all Patient's involved interviews of all witnesses, including Patients, staff and family members notifying physicians notifying families and responsible parties of the involved Patient's recording all relevant physical findings. d. Complete an appropriate assessment of all Patient's involved e. Take all steps necessary to protect the Facility's Patients from further incidents of Patient Abuse, neglect, exploitation or mistreatment while the investigation is in progress. f. Provide a copy of each Patient Abuse Investigation to the Director of Operations, Regional Director of Operations, and the Regional Director of Clinical Services. g. Be responsible for carrying out any interventions or follow-up steps subsequent to the investigation of any abuse or alleged abuse, neglect, exploitation or mistreatment. (Investigation) This was determined to be an Immediate Jeopardy (IJ) was identified on 06/26/2025. The ED was notified and provided with the IJ template on 6/26/2025 at 12:10pm.The following Plan of Removal submitted by the facility was accepted on 6/27/2025 at 2:53pm. 06/27/25Plan of RemovalF610Facility Name and ID #: Impact StatementOn 06/27/2025 the facility was cited for immediate jeopardy related to incident on 06/21/2025. LVN A reported to RN and DON regarding resident abuse by CNA A placing residents at risk of continuous abuse due to the facility not following their abuse policy. The facility was not able to immediately investigate and take action placing the resident in further harm. The facility failed to immediately investigate, suspend suspected staff, and protect CR #1 after the report of abuse by CNA A. Immediate Action:Please accept this as our Plan of Removal for the Immediate Jeopardy related to F610 Failure to Investigate. The Executive Director notified the Medical Director of Immediate Jeopardy on 6/27/25 at 1:00pm. Facility held an Emergency QAPI Meeting. Director of Nursing, LVN A, RN A, and CNA A were terminated on 6/25/2025 for failure to immediately report abuse to the Abuse Coordinator. 1:1 education on Policy and Procedure Abuse and Neglect, including immediate reporting to Abuse Coordinator, immediately investigate allegations of abuse and neglect, and timely reporting per HHSC guidelines was immediately provided Executive Director, ADON, Unit Manager by Senior Executive Director.Completion Date: 06/27/2025 AssessmentAn emergency QAPI meeting was held on 06/27/2025 which was inclusive of a review of our policies/protocols Abuse and Neglect, they were found to be sufficient.Staff in- services, to include all facility employees, were started on Abuse and Neglect, including immediate notification to the Abuse Coordinator. Staff will not be allowed to start on the floor or give care until this training has been completed.All new facility staff will receive the in-services as part of the onboarding orientation process prior to working in the facility.All facility staff members completed a posttest after their education was completed to ensure staff were able to identify abuse and neglect, and proper reporting procedures.If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met.A staff roster was utilized to ensure 100% of staff were in-serviced and tested.In-services were deemed to be effective by the in-services post test scores and verbalization of understanding by all facility staff.Who will be responsible: Executive DirectorThe in-services with all staff will be completed by 06/25/2025. All staff were in-serviced 06/25/2025.Facility leadership completed safe surveys on all current facility patients to ensure they were free from abuse and neglect, no negative findings.Completion Date 06/25/2025 Facility Monitoring Residents will continue to receive safe surveys daily for 7 days, including weekends by facility leadership Manager on Duty, and twice weekly for the next 4 weeks to ensure residents remain free from abuse and neglect. Facility leadership will continue with daily and PRN rounds to ascertain any signs and symptoms of abuse and neglect. Any negative findings will be immediately reported to the Abuse Coordinator. Beginning 06/25/2025 no staff will be allowed to work until the required in servicing has been completed. Who will be responsible: Facility Leadership Who will do monitoring: Executive Director Completed on date: 06/27/2025 Policy and Procedures Policy and procedures were reviewed by Senior Executive Director, Regional Director of Clinical Services, Executive Director. These policies include Abuse and Neglect. No policies needed any revisions. Interviews on 6/26/2025 & 6/27/2025 from 2:45 PM - 5:20 PM, with multiple staff across multiple shifts. Interview conducted with the ED, ADON, RN B, RN C, RN D, RN E and RN F; LVN B, LVN C, and LVN E; CNA C, CNA D, CNA E, CNA F, CNA G and CNA H. All staff stated they were in-serviced and reviewed the facility's policy on abuse and neglect, and exploitation. According to the in-services completed, staff were given a posttest on identifying abuse and neglect, behaviors of residents who may exhibit signs of abuse, identifying any marks or bruises and neglect. The staff were expected to get a score of 90%. Record Review revealed all staff received a 90% or above on the post test. Each stated they have an obligation to reporting abuse immediately. Each were able to identify 3 types of abuse and neglect and the name of the abuse coordinator. Each staff member was able to tell where the abuse coordinator's information throughout the facility. The ED, ADON and LVN D were in-serviced 1:1 by the SED on Policy and Procedure Abuse and Neglect, including immediate reporting to Abuse Coordinator per HHSC guidelines. The ED was informed the Immediate Jeopardy was removed on 6/27/2025 at 6:00 PM The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of Pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interviews and record review, the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 9 residents (CR#1) reviewed for abuse and neglect. 1. The facility failed to prevent CNA A from having access to CR#1 and other residents after an allegation of abuse was made. 2. The facility failed to ensure CR#1 was free from physical/mental abuse and neglect when CR#1 reported he was abused and threatened by CNA A. CR#1 sustained an injury on the left arm on 6/21/25. An Immediate Jeopardy (IJ) situation was identified on 06/25/2025. While the IJ was removed on 6/26/2025., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of being subjected to continued abuse. Findings include: Record review of CR#1's undated face sheet reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and re-admitted on [DATE]. CR#1 had diagnoses which included toxic encephalopathy (a neurological disorder that occurs with brain is exposed to toxic substances, such as heavy metals or neurotoxic solvents over a period of time) and had a cystostomy catheter (tube inserted through the abdomen into the bladder).Record review of CR#1's Orders revealed, Wound Treatment-Xeroform (dressing) everyday shift cleanse wound to left hand with Normal Saline or skin cleanser. Pat dry. Apply Xeroform to wound. Cover with dry dressing. Start Date-06/22/2025. Record review of CR#1's care plan, dated 6/17/2025, revealed the following:Focus: [CR#1] has an ADL self-care performance deficit r/t. Date initiated 5/2/2025Goal: [CR#1] will maintain currently level of function in through the review date.Interventions: [CR#1] Transfer: Resident is totally dependent of staff for transferring. Date initiated: 5/27/2025 Record review of WCD notes, dated 6/24/2025, revealed a skin tear wound of the left forearm. Wound size 2.2x1x0.3. Primary dressing Xeroform gauze apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Record review of CR#1's admission MDS dated [DATE], revealed CR#1 has a BIMS Score of 12, which indicated moderate cognitive impairment. CR#1 used a wheelchair as a mobility device; required 2 or more helpers to complete to assist with transferring from wheelchair or bed. Record review of Phone Order, by WCD, dated 6/22/25 at 12:42 AM, titled, Wound Orders - [wound] for Wound Treatment). It was an order for Xeroform (wound dressing) Record review of nursing notes, revealed there were no notes documented on 6/21/2025 regarding CR#1's injuries. Record review of text message received from LVN A from her telephone revealed, she telephoned 911 in reference to CR#1's abuse incident on 6/22/25 at 4:21PM. Record review of nursing notes, by WCN A, dated 6/22/25 at 6:38 PM, revealed Received report resident has skin tear to left hand. Assessment done verbally denied pain and discomfort. Physician informed, order in place. Wound care done at this time, tolerated well. Offloads reposition and safety noted. RP updated remain stable. Will continue plan of care. Record review of nursing notes, by RN A, dated 6/22/25 at 6:58 PM, for effective date 6/21/25 at 3:30 PM revealed the following note: Received report from the outgoing nurse that patient voiced concern regarding a CNA's approach during care. Patient reported that the assigned CNA was not gentle and continued to insist that he perform tasks independently, despite the patient stating he felt too weak and required two-person assistance. CNA reportedly attempted care initially alone, but eventually called for a second staff member to assist. During assessment, patient was noted with an existing bruise to the left upper arm that appeared to have reopened, resulting in a small amount of blood observed on the bedsheet. It remains unclear when the original injury occurred. Patient continued to express that the CNA was rough during care. Writer obtained statements from the involved CNA and requested the primary nurse to initiate an incident report for documentation and follow-up. Patient was repositioned and made comfortable in bed. The DON was notified of the incident and ongoing concerns. Will continue to monitor patient closely and follow up as needed. Record review of documentation supplied by ED that revealed, handwritten dated and time of employees termination on top of the Texas Board of Nursing records for each employee involved in the incident. The Director of Nursing (6/25/2025 at 7:29pm), LVN A (6/25/2025 at 8:29pm), RN A (6/25/2025 at 7:31pm), and CNA A (6/25/2025 at 7:36pm), were all terminated on 06/25/2025 for failure to immediately report abuse to the Abuse Coordinator. During an observation and interview on 6/24/25 at 9:15 AM, CR#1 was seated in his wheelchair at the entrance of his room and was observed with a bandage on his left forearm that had a small amount of blood on it. It had a written date of 6/24/2025. CR#1 was alert, orientated to person, place and event. CR#1 stated the injury occurred when CNA A tried putting him in bed by herself by pulling his arms to lift him out of the wheelchair. CR#1 stated he told CNA A he did not want to go to bed, but she insisted anyway and continued to pull on his arms. CR#1 stated CNA A told him she could put him in bed by herself and he told her it would take two people, but he was not ready to go to bed. He stated CNA A told him if she didn't put him in bed then he would be there all night even if he pooped on himself, and she would not bring him any food. He stated CNA A insisted on putting him in bed by herself and he told her he was unable to assist her due to how he was feeling. CR#1 stated during her pulling on his arms by herself, CNA A injured his left arm. CR#1 continued to tell CNA A not to pick him up by herself because it took two people. He stated she did not listen, but when she realized she couldn't she went and got CNA B. CR#1 stated he told LVN what occurred when she came to his room. He stated CNA A was rough with him. In a telephone interview on 6/24/2025 at 11:22 AM, LVN A stated she became aware of the incident by CR#1 on Saturday 6/21/2025 around 4:15PM-4:30PM while she was doing her rounds. She stated when she got to CR#1's room he was in bed which was unusual for him since he went to bed after dinner. LVN A went into the room, and she stated CR#1 looked as if he was crying. LVN A stated FM A informed her additional things that were going on like CR#1 had been treated mean and CR#1 stated CNA A hurt him. LVN A stated CR#1 told her CNA A told him if he didn't go to bed, she would let him sit in poop and would refuse to change him or feed him for the rest of the shift. LVN A stated CNA A attempted to transferred him from the wheelchair to the bed, which was an improper transfer as CR#1 was a 2 person assist. LVN A stated CR#1 told her CNA A tossed him in bed. After speaking with CR#1, LVN A stated she immediately notified RN A and told her to come to CR#1's room because he had a complaint and told her who the two CNA's (CNA A and CNA B) involved were. LVN A stated RN A arrived at CR#1's room, where he repeated what happened to him. RN A told LVN A to locate the WCN; however, she had gone home for the day, so LVN A stated she washed the wound and put a bandage on it until CR#1 could be seen Sunday 6/22/25 by WCN A. LVN A stated she telephoned the DON who told her she would call her back. LVN A stated the DON called back and only wanted to speak with RN A. LVN A stated during a telephone conversation between the DON and RN A she interrupted and told the DON and RN A that CNA A's actions were abuse and the abuse coordinator, ED needed to be called along with a report to the staff. She stated the DON said those words (Abuse) would result in severe consequences to her and never use that word in her facility again. LVN A stated the DON told her she didn't need to do anything as the situation would be handled. RN A told LVN A the situation was being taken care of and instructed her to leave for today (6/21/25) as her shift was ending; and return tomorrow (6/22/25) to complete documentation. LVN stated when she arrived for her shift the next day, 6/22/25, she viewed the nursing schedule and observed CNA A was scheduled to work and on 700 hall, which meant she would care for CR#1. LVN stated she called the DON and told her CNA A was scheduled to provide care to CR#1 when she abused him yesterday. LVN A stated she told the DON she was not going to work with CNA A and she was going to document in the nursing notes and file a police report. LVN A stated she requested the administrator's telephone number to report it and neither the DON nor RN A would provide it to her. She stated she obtained the ED's number from another staff member. LVN A stated FM A and FM B came to the facility to visit CR#1 and she was told by RN A she was not allowed to engage in the conversation with the family nor come into CR#1's room. LVN A stated on 6/22/25 she telephoned the ED and was informed she was suspended for not documenting timely, calling on 6/21/25 within 2 hours of being aware of the abuse and due to an immediate investigation. LVN A stated she tried to document in the nursing notes anyway, but her sign in and password were deactivated, which prompted her to call the police and make a report. In an interview on 6/24/2025 at 1:20 PM, the DOR stated CR#1 was evaluated on 6/18/2025 by the therapy department (PT, OT, and Speech) and CR#1 was totally dependent in the area of standing and transferring to the bed from the wheelchair or the wheelchair to the bed. She stated CR#1 should be transferred by 2 people using a gait belt or Hoyer lift. The DOR stated at no time should the resident be transferred by one person. She stated to transfer from the wheelchair, there should be two staff persons, one in the front and the other in the back of the resident. If the transfer was not done properly, with two people. it could cause injury to all involved. In a telephone interview on 6/24/2025 at 1:54 PM, RN A stated on the afternoon of 6/21/2025, LVN A called her and said CR#1 had a complaint. She stated she arrived at CR#1's room and observed his left forearm with blood on it. RN A stated CR#1 told her his left arm was injured during a transfer with another nursing staff. CR#1 told her he told CNA A he was a 2-person assist because she attempted to transfer him alone. CNA A called another aide (CNA B) to the room, and both CNAs transferred him to the bed. She stated CR#1 had an old bruise on his arm and she believed it re-opened during the transfer and the bruise began to bleed, which explains the blood on his bed sheet. She stated it was a healing bruise that opened. RN A stated she required a statement from both CNA's due to the wound. RN A stated she told LVN A to call WCN A to look at CR#1's wound. RN A stated CR#1 never told her CNA A was rough with him and admitted during her interview with him she didn't ask. RN A stated LVN A told her CNA A did not handle CR#1 correctly, but admitted she never asked LVN A to clarify rough. RN A stated on 6/22/25, LVN A told her CNA A should not work the 700 hall with CR#1 because she didn't treat CR#1 right yesterday (6/21/2025) because she was rough. RN A stated CR#1 told her he told CNA A to get someone to assist. RN A stated she was informed the resident was transferred safely by the CNA's but could not recall how the resident should be transferred. RN A stated she met with CR#1's family on Sunday 6/22/25 with both CNA's, A and B. RN A stated CR#1 told his family, through speaking Spanish, that one CNA B was nice and CNA A wasn't nice. She stated she did not report the incident or what CR#1 stated to his family or to the abuse coordinator, administrator, even though she knew who the abuse coordinator was. RN A stated she reported it to the DON instead. In a telephone interview on 6/24/2025 at 2:00 PM, CNA A stated she worked on Saturday, 6/21/25. She stated CR#1 motioned her around 2:30 PM, while she was making her rounds, to come and put him in bed. CNA A stated CNA B assisted her with CR#1's transfer from his wheelchair to the bed. CNA A stated she was on the resident's right side and CNA B was on the left side. She stated after the transfer she walked on the left side and CNA B was on the right side and they both pulled CR#1 up toward the head of the bed. CNA A was asked why she switched sides, and she stated the left side was the remote control for the bed and call light. CNA A stated at 8:38 PM on 6/21/25, she received a text message from RN A who stated she needed a report on what happened in CR#1's room. CNA A stated she completed her written statement and handed it in to RN A who returned the report back to her and requested she changed her report and say she observed CR#1 had already had the bruise. CNA A refused and told RN A CR#1 did not have a bruise or sore on his left arm, and she would not be re-writing her statement. CNA A said LVN A told her and RN A CR#1's arm looked like abuse so they wanted to call the DON, but CNA A stated she told them she would call the abuse coordinator, ED. CNA A stated she called the ED on 6/21/2025, Saturday evening, and told her she was being accused of an improper transfer. She stated she did not mention LVN A accused her of abuse during this conversation. She stated she was suspended Sunday evening on 6/22/25. In a telephone interview on 6/24/25 at 3:32 PM, FM A and FM B stated CR#1 called them and told them CNA A was rough with him and informed them CNA A put him in bed early and he didn't want to go to bed that early. They indicated when CR#1 agreed to go to bed, CNA A attempted to put him in bed herself; however, he continuously told her he was unable to assist and she needed another person. They indicated CR#1 informed them CNA A threatened CR#1 that if he didn't go to bed early, she would leave him in the wheelchair and would not feed or change him. CR#1 told FM A and FM B, CNA A went to get CNA B to assist her in putting the resident in bed. The FMs stated CR#1 told LVN A what occurred with CNA A, and she immediately called RN A. FM A and FM B stated they were informed by LVN A she was prevented from calling in the complaint on the day of the incident (6/21/25) and was suspended on Sunday (6/22/25), which was when the police were called, and a report filed. They stated to be sure which CNA was involved, RN A brought both CNAs (A and B) in CR#1's room on 6/22/2025 to be identified. CR#1 told RN A and both FM's, CNA A was mean, and CNA B was nice. FM A and FM B stated the police came to the facility between 4PM - 5PM and spoke with CR#1 who told them what happened. FM A and FM B were asked by the police if they wanted to press criminal charges, but they declined because they wanted the facility to handle it. FM A and FM B stated before the two CNA's and RN A came into CR#1's room, CR#1 told FM A and FM B, CNA A came in his room about an hour early, before they arrived to the facility, and asked him if he told her supervisor she injured his arm. CR#1 told the FM he was afraid of CNA A and told her he didn't say anything to anyone. FM A and FM B stated this was clearly intimidation and felt the resident's safety was compromised by allowing CNA A to continue to work with and have access to CR#1. In a telephone interview on 6/24/2025 at 4:24 PM, CNA B stated on Saturday, 6/21/2025, she assisted CNA A with transferring CR#1 from his wheelchair to the bed. She stated CNA A grabbed CR#1 by his left hand and she held his right hand. CNA B stated after assisting with the transfer, she noticed an odd look on CR#1's face and asked him if he was okay and he nodded yes, then CNA A told her she could handle it from there, which was when she exited the room. CNA B stated during the transfer of CR#1 to the bed from the wheelchair, it was done appropriately, and no one was rough. CNA B stated she had to write an incident report but did not include her observation. She stated during the transfer she did not observe any wound on CR#1, but when she was called to return to his room by LVN A, she observed a wound on his left arm but didn't know how he got it. CNA B stated LVN A reported the incident to RN A, which was why she had to write the incident report. CNA B stated she never worked with CNA A prior to this date and couldn't say what her behavior was with the residents. She stated CNA A was primarily assigned to 700 hallway, which was the hallway CR#1 was staying. She stated she was familiar with CR#1 because she worked with him on 600 hallway prior to his last hospitalization. She stated he typically went to bed after dinner. CNA B stated on 6/22/25 she was called to CR #1's room by RN A and when she arrived his family was also in the room. She stated CR#1 was asked about the CNA who injured him, and CR#1 told his family and RN A that CNA B was nice to him, and CNA A was the bad person and mean. CNA B stated she did not know who the abuse coordinator for the facility was because the last ED was no longer there; however, if she suspected abuse she would tell her immediate supervisor. CNA B stated abuse of any resident could be physical, verbal or mental. In an interview on 6/24/2025 at 6:15 PM, the DON stated on Saturday evening 6/21/25, she received a call from LVN A regarding CNA A and had an issue with her. The DON stated she called the supervisor to find out what occurred. She stated CNA A reported she asked LVN A to assist her in transferring a resident to bed because he was a two person assist. The DON stated LVN A refused, and CNA A got CNA B to assist. The DON stated she called RN A to find out what was going on and RN A stated the resident had an old wound that was opened during the transfer. The DON initially stated she never received a call from LVN A on Sunday, 6/22/25; then stated LVN A telephoned her on Sunday, 6/22/2025 afternoon between 3:00PM - 3:30PM and told her she would not work with CNA A because she was rough to a resident when she attempted to transfer CR#1 to the bed alone on yesterday (6/21/2025) and demanded CNA A be sent home. The DON stated she told LVN A she did not make those type of demands. Shortly after the call with LVN A, the DON stated she received a call from the ED and was informed LVN A was alleging abuse. She stated on Sunday (6/22/2025) LVN A reported abuse to the ED (abuse coordinator). The ED suspended LVN A and CNA A. The DON stated she spoke with CR#1 yesterday (6/23/2025) and he told her his weekend was good. The DON stated she asked CR#1 if anything happened this weekend he needed to talk about, and CR#1 told her no. The DON stated she did not asked CR#1 if CNA A was rough with him because he told her his weekend was good. The DON stated she did not speak with the FM's and did not file any report with the state. The DON stated she could not think of a negative outcome regarding this incident; however, she said after LVN A mentioned abuse it was a reportable incident. In an interview on 6/24/2025 at 6:52 PM, the ED stated on Saturday, 6/21/25, she received a phone call from CNA A, who stated CR#1 said he received a skin tear during a transfer with CNA A. She stated she spoke with RN A who stated the resident had an old bruise, which opened during a transfer to the bed by CNA's. She stated the RN told her WCN A was notified to look at the wound. The ED stated on Sunday, 6/22/25, around 2:30PM - 2:45PM, she received a call from LVN A claiming CNA A abused CR#1 yesterday (6/21/2025) afternoon. The ED stated she received information CR#1's FMs were visiting him. She stated she told the receptionist to go to CR#1's room and keep her on facetime so she could speak with the FM's. She stated she was informed by the FMs a CNA was rough with CR#1 yesterday (6/21/2025) and injured his arm while trying to put him in bed by herself. The ED stated during this time she directed RN A to bring in both CNAs (A & B) to identify which ones completed the transfer. She stated CR#1 identified CNA A as being rough with him and CNA B as being nice. The ED stated at this time the LVN and CNA A were suspended immediately and asked to leave the building. The ED stated LVN A told her she called and filed a police report and called in a report to the state survey agency. She stated FM B stated he called the police. The ED stated she reported the incident when she found out about it on Sunday, 6/22/2025. She stated the provider letter stated reports of abuse were to be reported within 2 hours. The negative outcome was other residents could be subjected to abuse because the alleged perpetrator could be providing care to other residents as well. She stated this was why she immediately suspended LVN A because she had an obligation to report. The ED stated as soon as she became aware of the incident she called in a report to the state (Intake#1018590). Based on the initial interviews with staff involved she placed each on suspension, then terminated them. She stated it had only been 2 days since the incident and the provider investigation report has not been submitted to state. In a telephone interview on 7/1/2025 at 1:08 PM, SPO stated he received a call on 6/22/2025 regarding an abuse on an elderly resident. He stated he responded to the facility around 4:00 PM to take a report. Upon arrival, he met the family in the entrance area and walked to the resident room with them. He spoke with LVN A who stated a resident was abused by CNA A and she was working and had access to resident(s). He stated LVN A stated CNA A injured the resident's left arm. He stated he spoke with the resident who stated CNA A was rough with him by putting him in bed roughly. He stated he was unable to locate the CNA for an interview. He stated he spoke with CR#1's family who stated they didn't want to press charges; however, they wanted to wait to see what the facility's response would be. stated FMs A and B said if the facility did not address the issue, then they would press charges. He stated he took photos of the resident's left arm and entered them into evidence. Record review of the Facility's Abuse Protocol policy, dated April 2019, revealed the following:7. The following definitions are provided to assist our Facility's staff members in recognizing incidents of Patient Abuse:a. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all Patient/Resident, irrespective of any physical or mentalcondition, cause physical harm, pain, or mental anguish. Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.b. Taking or using photographs or recordings in any manner that would demean or humiliate a Patient. This includes using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep or distribute photographs and recordings on social media.c. Misappropriation of Patient property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a Patient's belongings or money without the Patient's consent.d. Verbal abuse is defined as any use of oral, written or gestured language that includes disparaging and derogatory terms to Patient or their families, or within their hearing distance, to describe Patient, regardless of their age, ability tocomprehend, or disability.e. Sexual abuse is defined as, but is not limited to, sexual harassment, sexual coercion, or sexual assault, or any nonconsensual sexual contact of any type with the Patient.f. Physical abuse is defined as hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment.g. Involuntary seclusion is defined as separation of a Patient from other Patient's or from his or her room against the Patient will, or the will of the Patient's legal guardian or representative. (Note: temporary monitored separation from other Patient's will not be considered involuntary seclusion and may be permitted when used as a therapeutic intervention to reduce agitation as determined by the Medical Director, and/or the Director of Nursing, and such action is consistent with the Patient's Care Plan).h. Mental abuse is defined as, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. (Identifying)i. Adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof.j. Exploitation means taking advantage of a Patient for personal gain through the use of manipulation, intimidation, threats, or coercion.k. Mistreatment means inappropriate treatment or exploitation of a Patient.l. Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a Patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.m. Person-centered-care means to focus on the Patient as the locus of control and support the Patient in making their own choices and having control over the daily lives. 8. Any person observing an incident of Patient Abuse or suspecting Patient Abuse must immediately report such incidents to the Charge Nurse. The following information should be reported to the Charge Nurse:a. The name of the Patient involved;b. The date and time that the incident occurred;c. Where the incident took place;d. The name(s) of the person(s) committing the incident, if known;e. The name(s) of any witnesses to the incident;f. The type of abuse that was committed (i.e., verbal, physical,sexual, etc.); andg. Other information that may be requested by the Charge Nurse. 9. The Charge Nurse will immediately examine the Patient and notify the Abuse Prevention Coordinator upon receiving reports of mental, physical or sexual abuse. Findings of the examination will be recorded in the Patient's medical record. (Protection)This was determined to be an Immediate Jeopardy (IJ) was identified on 06/25/2025. The ED was notified and provided with the IJ template on 06/25/2025 at 5:27 p.m.The following Plan of Removal submitted by the facility was accepted on 6/26/2025at 8:18am:06/25/2025Plan of RemovalF600Facility Name and IDImpact Statement On 06/25/2025 the facility was cited for immediate jeopardy related to an incident on 06/21/2025. CR#1 reported to LVN A that CNA A was rough with him and injured his arm causing harm. CR#1 reported CNA A threatened him if he did not get to bed, she would leave him in the wheelchair until next shift and would not give him anything to eat. Staff failed to notify the abuse coordinator immediately leaving residents at risk for further abuse/neglect. Immediate Action: Please accept this as our Plan of Removal for the Immediate Jeopardy related to F600 Neglect Resident, CR #1, was assessed by licensed nurse and wound care nurse on 06/22/2025, treatment order in place for skin tear, CR #1 verbally denied pain no signs or symptoms noted. Social Worker completed psychosocial mental well-being evaluation on Resident, CR #1, on 06/24/2025, no negative findings. The Executive Director notified the Medical Director of Immediate Jeopardy on 06/25/2025 at 6:10 PM. The Facility held an Emergency QAPI Meeting. Director of Nursing, LVN A, RN A, and CNA A were terminated on 06/25/2025 for failure to immediately report abuse to the Abuse Coordinator. 1:1 education on Policy and Procedure Abuse and Neglect, including immediate reporting to Abuse Coordinator and timely reporting per HHSC guidelines were immediately provided to the Executive Director, ADON, Unit Manager by Senior Executive Director and Regional Director of Clinical Services. Completed on Date: 06/25/2025 Assessment - The Executive Director notified the facility Medical Director of the Immediate Jeopardy on 06/25/2025 5:31pm. -An emergency QAPI meeting was held on 06/25/2025 which was inclusive of a review of our policies/protocols Abuse and Neglect, they were found to be sufficient. Staff in- services, to include all facility employees, were started on Abuse and Neglect, including immediate notification to the Abuse Coordinator. Staff will not be allowed to start on the floor or give care until this training has been completed. All new facility staff will receive the in-services as part of the onboarding orientation process prior to working in the facility. All facility staff members completed a posttest after their education was completed to ensure staff were able to identify abuse and neglect, and proper reporting procedures.If the employee did not pass the test with at least 90% correctly answered the staff member was re-educated and re-tested until at least 90% pass rate was met. A staff roster was utilized to ensure 100% of staff were in-serviced and tested. In-services were deemed to be effective by the in-services post test scores and verbalization of understanding by all facility staff. Who will be responsible: Executive DirectorThe in-services with all staff will be completed by 06/25/2025. All staff were in-serviced 06/25/2025. Facility leadership completed safe surveys on all current facility patients to ensure they were free from abuse and neglect, no negative findings. Completed on Date 06/25/2025 Facility MonitoringResidents will continue to receive safe surveys daily for 7 days, including weekends by facility leadership Manager on Duty, and twice weekly for the next 4 weeks to ensure residents remain free from abuse and neglect. Facility leadership will continue with daily and PRN rounds to ascertain any signs and symptoms of abuse and neglect. Any negative findings will be immediately reported to the Abuse Coordinator. Beginning 06/25/2025 no staff will be allowed to work until the required in servicing has been completed. Who will be responsible: Facility Leadership Who will do monitoring: Executive Director Completed on date: 06/25/2025 Policy and Procedures Policy and procedures were reviewed by Senior Executive Director, Regional Director of Clinical Services, Executive Director. These policies include Abuse and Neglect. No policies needed any revisions.Interviews on 6/26/2025 from 2:45 PM - 8:45 PM, with multiple staff across multiple shifts. Interview conducted with the ED, ADON, RN B, RN C, RN D, RN E and RN F; LVN B, LVN C, and LVN E; CNA C, CNA D, CNA E, CNA F, CNA G and CNA H. All staff stated they were in-serviced and reviewed the facility's policy on abuse and neglect, and exploitation. According to the in-services completed, staff were given a posttest on identifying abuse and neglect, behaviors of residents who may exhibit signs of abuse, identifying any marks or bruises and neglect. The staff were expected to get a score of 90. All staff received a 90 or above on the post test. Each stated they have an obligation to reporting abuse immediately. Each were able to identify 3 types of abuse and neglect and the name of the abuse coordinator. Each staff member was able to tell where the abuse coordinator's information throughout the facility. The ED was informed the Immediate Jeopardy was removed on 6/26/2025 at 9:10 PM The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate administration of all drugs to meet the needs of each resident for 2 of 6 residents (Resident #1 and CR#2) reviewed for pharmacy services. The facility failed to ensure that Resident #1 received his prescribed blood pressure medication metoprolol, as ordered by his physician. The facility failed to ensure that CR#4 received his prescribed blood pressure medications metoprolol and Midodrine as ordered by his physician. This failure could place residents at risk of medication overdose, medication under-dose, and ineffective therapeutic outcomes by not documenting when medications were held. Findings included: Record review of Resident #1's face sheet dated 04/11/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included hypertension (high blood pressure), lack of coordination (a condition that affects the ability to control and execute movements), muscle weakness (decreased strength in the muscles), dysphagia (difficulty swallowing), aphasia (ability to communicate), pneumonia (infection that inflames air sacs in both lungs), anxiety disorder (feeling of fear, dread and uneasiness) and seizures (uncontrolled jerking and blank stares). Record review of Resident #1's Annual MDS dated [DATE] revealed a BIMS score of 06 indicating he was severely impaired for cognition. For ADL's he was coded as dependent on staff for ADL care which included eating, and toilet use, shower/bathe, lower body dressing, and taking off footwear. For personal hygiene and upper body dressing he was substantial/maximal assist. For bowel and bladder, he was coded as always incontinent of bowel and bladder. Observation of Resident #1 on 4/11/2025 at 10:30am revealed the resident was in bed. He was alert and was mumbling words asking for the nurse. He was clean and groomed with no offensive odor. No visible marks or bruises observed. Record review of Resident #1's recapitulated physician's order for April 2025 revealed an order dated 12/01/2024 for the following active medication: Metoprolol 25mg tartrate tablet, give 0.5mg tablet two time a day. Hold if Systolic blood pressure was less than 110 and Diastolic blood pressure was less than 60 and pulse was less than 60. Record review of Resident #1's medication administration record for April 2025 revealed Metoprolol was not documented as held on 04/02/2025 when Resident #1's blood pressure was 105/65. Record review of Resident #1's nurse's progress notes dated April 2025 revealed no documentation as to why the medication metoprolol was not held. In an interview on 4/11/2025 at 3:15 pm with RN A she said that if Resident #1's blood pressure 105/65 she should have held the medication and document why it was held. She said not documenting correctly would be difficult to determine if the medication was held. She said if the medication was not given it should be indicated on the MAR with a number and in the nurse's notes. She said it medication was not held when there was an order for it to be held the blood pressure could get lower or higher causing the resident to get sick. She said moving forward she will ensure she documents correctly on the MARs on in the nurses' notes. Record review of CR #4's face sheet dated 04/11/2025 revealed CR#4 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4's diagnoses included essential hypertension (high blood pressure), depression (a mental health condition with low mood and loss of interest in pleasurable activities), hyperlipidemia (high level of fat in the blood), peripheral vascular disease (narrowing blood vessel that reduce blood flow to the limbs), anxiety disorder (feeling of fear, dread and uneasiness), bipolar disorder (a mental disorder that causes extreme mood swings), muscle weakness (decrease strength in the muscles) and heart failure(a condition where the heart not pumping blood as it should). Record review of CR#4's Quarterly MDS dated [DATE] revealed she was a BIMS of 12 indicating he was cognitively aware for decision making. He was coded as not exhibiting any behaviors. For ADL care he was coded as needing supervision for eating, toileting and oral hygiene, upper body dressing and shower/bathe, putting on and taking off footwear and for personal hygiene. For lower body dressing he coded as needing partial/moderate assist. For bowel and bladder, he was coded as frequently incontinent. Record review of CR#4's recapitulated physician's orders for March 2025 revealed the following active medications: Order date 12/01/2024 for Midodrine 5mg, give 1 tablet by orally three times a day for hypotension. Hold . for Systolic Blood Pressure greater than 100. Order date 12/01/2024 for Metoprolol 25mg tartrate tablet, give 0.5mg tablet two time a day. Hold if Systolic blood pressure was less than 110 and Diastolic blood pressure was less than 60 and pulse was less than 60. Record review of CR#4's medication administration record for March 2025 revealed the following: Midodrine 0.5 mg was not held on the following dates 03/03/2025 b/p was 128/60, 03/05/2025 b/p was 122/61, 03/06/2025 b/p 130/90, 03/10/2025 b/p was 125/62. Metoprolol 0.5 was not held on 3/02/2025 b/p was 101/63, 3/10/2025 b/p was 101/67 and 3/21/2025 b/p was 109/65. Record review of Resident #4's nurse's progress notes dated March 2025 revealed no documentation as to why the medications was given when it was to be held. Interview on 04/11/2025 at 1:24 pm. with RN A she said when there was an order, they confirm the order and follow the order. She said medications with parameters also deals with the timing, it can be stop or continue. If there are concerns, they should call the doctor. For example, blood pressure medications and insulin with parameters the doctor would be call for confirmation. She said CR#2's blood pressure was always low. His medication was to help increase his blood pressure. RN A said she did not administer the medication on the following dates: 03/03/2025 blood pressure was 128/60, 03/05/2025 blood pressure was 122/61, 03/06/2025 blood pressure was 130/90 and on 03/10/2025 blood pressure was 125/62, she said it was an error. When she was asked why there were check marks indicating blood pressure medication was administered, she responded she documented in error. She said the order for Midodrine 5 mg was to be held for Systolic blood pressure greater than 100 and she would not give if it was greater than 100 and if Metoprolol.was to be held if systolic was less than 110 she would have held it. She said moving forward she will ensure that she does not make that error again. She said, she should document with a check mark and a number indicating it was not given and the reason why it was not given. A check only would indicate it was given and it would be difficult to know if the medication was given or not given. In an interview on 4/11/2025 at 1:55 pm, with RN B, she said when doctor's orders were not followed, you get written up, if you do it again, then you will be reported. She said not following doctor's orders It might cause harm to the resident such as elevated or decrease blood pressure. Medications with parameters were metoprolol, lisinopril, diabetic medications with sliding scales. She said I don't know how I signed that the MAR as given. I cannot give that medication with parameters. Symptom of Ventricular fibrillation-flushed, chest pain and decreased oxygen saturation could be the result of not holding medications when it was to be held. In an interview on 4/11/2025 at 2:15 pm. with Director of Nursing she said all blood pressure medications should have parameters. She said some blood pressure medications with parameters were carvedilol, amlodipine, losartan and metoprolol. She said the consequences of not following the parameters the doctor order for blood pressure medications could cause harm, making blood pressure to be too high or it can drop too low. She said she knew the CR#4 was a dialysis and cardiac patient. She said her expectations were that the nurses were to follow the parameters ordered for medications and document. She said if medication was not given it should be documentation as to why it was held. She said she was responsible for monitoring the nurses and she will be in-servicing all nursing staff on medication administration. In an interview at 3:09 pm. with LVN D he said medications with parameters, was to determine when to administer and when not to administer medication. He said some medications with parameters were, blood pressure medication, pain medications and diabetes medications. He said if a blood pressure medication has parameters, it should be held as per orders. He said if there was concerns about an order the doctor should be called for clarification. He said some consequences of not following doctor's orders were the blood pressure might drop too low or might be too high. Record review of the facility policy and procedures on Administering Medication dated April 2019 read in part . Policy heading: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medication may do so. 2. The Director of Nursing services supervises and directs all personnel who administer medications and/or have related functions. 4. Medications are administered in accordance with prescriber's orders, including required time frame. 6. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process or the need for additional staff training. 21. If a drug is withheld, refused or given at another time other than the schedule time the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.

Based on record review and interviews, the facility failed to provide and document sufficient preparation and orientation of residents to ensure safe and orderly transfer or discharge from the facility for 1 of 1 resident (Resident #3) reviewed for transfer and discharge rights. -The facility failed to notify the representative (Office of the State Long-Term Care Ombudsman) of the transfer or discharge with the reasons for the move in writing in a language and manner they understand. This failure placed residents at risk of not receiving an advocate who can inform them of their options, rights, and the added protection from being inappropriately transferred or discharged . Findings include: Record review of Resident#3's face sheet dated 03/22/25, revealed she was admitted to the facility on [DATE] with diagnoses of myasthenia gravis without (acute) exacerbation (a chronic condition causing muscle weakness), acquired absence of left leg below the knee, muscle weakness, presence of automatic (implantable) cardiac defibrillator (implanted device that detects and corrects life-threatening heart rhythms), morbid (severe) obesity due to excess calories, acute on chronic systolic (congestive) heart failure, type 2 diabetes mellitus with hyperglycemia (blood sugar levels are too high due to diabetes), chronic kidney disease stage 3B, heart disease, right bundle-branch block (electric signals in the heart are delayed or blocked), hyperlipidemia (high levels of fats in the blood), muscle wasting and atrophy, aftercare following explanation of knee joint prosthesis, chest pain, and acute pulmonary edema ( is a medical condition where fluid suddenly builds up in the lungs making it difficult to breathe). Record review of Resident #3's Brief Interview for Mental Status (BIMS) Evaluation dated 01/20/25, revealed the resident's BIMS score was 15, which indicated her cognitive response was intact. Record review of Resident #3's Progress notes dated 01/30/25, revealed the Social Worker Issued Notice of Medicare Non-Coverage on 01/30/25 at 2:00 pm. Resident #3 said she does not want to do long-term care due to them taking most of her money to live there. Resident #3 said that her FM informed her that she could not return home if she was unable to walk and manage her own care. Record review of Resident #3's Progress notes dated 01/30/25, revealed the Social Worker spoke with Resident #3's regarding her discharge. The Resident's FM said that Resident #3 could not come to his home, and he wanted her to be assisted with a Medicaid application for Long-Term Care. The Social Worker informed Resident #3's FM that Resident #3 did not want Long-Term care. Resident #13's said he will speak with Resident #3. Record review of Resident #3's Expedited Appeal Documentation Request dated 01/30/25, revealed submitted medical records, Notice of Medicare Non-Coverage, Detailed Explanation of Non-Coverage, copy of the beneficiary's medical record from the last seven days, face sheet, wound care orders and flow sheets, skilled nursing notes, ST evaluation and progress notes, OT evaluation and progress notes, PT evaluation and progress notes, physician progress notes, physician orders, and history and physical. Record review of Resident #3's Notice of Medicare Non-Coverage, revealed the effective date coverage of residents skilled nursing facility services would end 02/01/25 signed by Resident #3 on 01/30/25. Record review of Resident #3's progress note dated 02/03/25, revealed the Social Worker scheduled a community liaison to speak with Resident #3 last week. The Social Worker said Resident#3 was provided boarding home options but the resident declined. Record review of Resident #3's Letter of written notice dated, 02/18/25 revealed that the resident received her 30-day written notice attached with another copy of the Notice of Medicare Non-Coverage. Record review of Resident #3's progress note dated 03/04/25, revealed the Social Worker informed the resident she had been denied Long-term care due to being over resourced. Record review of Resident #3's progress note dated 03/05/25, revealed the Social Worker informed the resident she had been denied Long-term care due to being over resource amount. Record review of Resident #3's Psychiatric Subsequent assessment dated [DATE], revealed assessment/plan Generalized anxiety disorder is being treated with Alprazolam 0.5 orally Disintegrating (breaking down into smaller parts or fragments) tablet 0.25mg (milligram) BID (twice a day) PRN (as needed) and Hydroxyzine 1 tablet 25mg (milligram) will continue to use Alprazolam and Hydroxyzine to target sxs (symptoms) of anxiety .will continue with supportive care. Record review of an Invoice #005 dated and issued, 03/18/25 to assist Resident #3's housing fee in the amount of $700.00. The comprehensive care plan and the advance directives provided. Record review of Resident #3's progress note dated 03/18/25, revealed the Social Worker spoke with the resident regarding a discharge update. Resident#3 was discharging to a PCH . Resident #3 said she has already ordered her hospital bed and wheelchair is at her bedside. Record review of Resident #3's progress note dated 03/18/25, revealed the Social Worker called the resident and scheduled a follow-up appointment dated 04/15/25. Record review revealed Resident #3's discharge date d 03/18/25, revealed she went to an assisted living/board and care/group home . During an interview on 3/22/2025 at 10:08 am with the DON, she said once the resident admits in the facility, there were weekly updates the facility sends to the insurance. The DON said when the resident was at their maximum the resident could go to the next level of care. The DON said the insurance issues a NONMC (notice of non-medical coverage). The DON said the resident had a right to appeal. The DON said if the resident won the appeal they could remain in the facility. The DON said the resident could continue with their services until another NONMC was received. The DON said if the resident did not appeal the insurance the resident was given 48 hours. The DON said if the resident did not win the appeal it would transfer to private pay. The DON said when the resident did not pay private pay then a 30-day discharge was given to the resident. The DON said the resident was given the NONMC, and the Social Worker could assist if the resident requested assistance (how to appeal the NONMC). The DON said the risk to an unsafe transfer/discharge was the resident returning to the hospital. The DON said the risk was also the resident not getting proper care and which could harm the resident . During an interview on 3/22/2025 at 12:38 pm with LVN A, she said she had been working with Resident #3 every weekend since she has been admitted into the facility. LVN A said Resident#3 was a pleasant person to her. LVN A said she knew Resident#3 had an amputee on her right leg. LVN A said Resident #3 was very outspoken and she would tell you what she needed. LVN A said Resident #3 never took showers, she has always taken bed baths on Saturdays. LVN A said Resident#3 never complained. LVN A said Resident #3 provided her with the address by showing her a flyer and wanted LVN A to visit. LVN A said the resident said she was going to leave the facility and go to her new place. LVN A said she took a picture of the flyer with her cellphone to assure Resident #3 she would visit her at her new place. LVN A said Resident #3 did not seem sad. LVN A said Resident#3 was packing on the day she was talking to her. During a telephone interview on 3/22/2025 at 1:14 pm with Resident #3, she said she was waiting to receive all her boxes from the home. Resident#3 said she wanted to get back on low subsidy. Resident#3 said she moved again into a brand-new house in {another city name}. During a telephone interview on 3/22/2025 at 3:01 pm the Business Manager said the process for Transfer/Discharge was: She received a fax of the NONMC, she issued it to the patient/resident if they were their own RP, she issued the NONMC to the RP/family, she showed the resident the last service date on the NONMC, she showed the resident the discharge date , she informed the resident of the appeal they could start, she said she informed the residents they had until 12 noon the following date to make the appeal, she checked with the residents the same day to see if they were going to appeal again, she said once the appeal request came through via fax, she said medical records got their records together for the appeal process, she said she waited for the decision by fax, she said she called the patient about the decisions, she said the discharge paperwork was handled by the Social Worker, she said the Social Worker followed up with the resident, she said they prepared the resident for everything (medication, items needed for care etc.), she said she checked out with the nurse, she said she made sure the resident had more than enough medication on hand, she said she made sure the discharge information was correct. She said she forgot the facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. She said she had no idea the ombudsman was to be notified and sent a copy of the information. She said the risk to the resident was the resident receiving an unsafe transfer and an unsafe discharge . During an interview on 3/22/2025 at 3:59 pm with the Executive Director (ED), he said he had been working at the facility since 10/28/24. The ED said pertaining to the Transfer/Discharge he would make sure the ombudsman was notified and have the information sent via email. The ED said once the Business Manager and the Social Worker returned to work, as well as the person that handled medical records, he would make sure staff were trained and in-serviced on the proper process of Transfer/Discharge pertaining to the policy and the CMS revised Regulations. The ED said he would talk about the transfer/discharge daily. The ED said he would perform audits to ensure compliance. The ED said the risk to the resident not having a safe transfer/ discharge was having an unsafe discharge, he said the resident could return to the hospital due to an adverse effect. Record review of the policy, Transfer or Discharge Notice dated 12/2016 revealed the following:1. A resident, and /or her representative (sponsor) will be given a thirty (30)-day advance notice of an impending transfer or discharge from the facility .4. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate administration of all drugs to meet the needs of each resident for 2 of 11 residents (CR#3, Resident #4) reviewed for pharmacy services. The facility failed to ensure that CR#3 and Resident #4 received their prescribed medications, as ordered by their physician. This failure could place residents at risk of medication overdose, medication under-dose, and ineffective therapeutic outcomes by not documenting when medications were given or not given. Findings included: Record review of CR #3's face sheet dated 02/04/2025 revealed CR#3 was a [AGE] year olf female who was admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. CR # 3's diagnoses included hyperthyroidism(overproduction of thyroid hormone), dementia (condition characterized by progressive or persistent loss of intellectual functioning), depression (a mental health condition with low mood and loss of interest in pleasurable activities), pain, insomnia ( difficulty falling asleep), hypotension ( a condition where the blood pressure was lower than normal), lack of coordination (a condition that affects the ability to control and execute movements), vitamin deficiency (deficiency of essential vitamins), protein calorie malnutrition(lack of sufficient energy and protein in the body), neurogenic bowel(loss of bowel function caused by nerve problem) osteomyelitis (inflammation of the bone), injury of C5level of cervical spinal cord (damage to the 5th cervical vertebra in the neck resulting in paralysis), quadriplegia (loss of motor and sensory function in all four limbs), muscle weakness (decreased strength in the muscles), dysphagia (difficulty swallowing) and neuromuscular dysfunction of bladder (bladder impaired due to damage nerve or muscles). Record review of CR# 3's Quarterly MDS dated [DATE] revealed she had a BIMS score of 14 indicating she was cognitively aware; she was coded as not exhibiting any behaviors. She was dependent on staff for ADL care which included eating, and toilet use, shower, dressing upper and lower body, putting on and taking off footwear, and personal hygiene. For bowel and bladder, she was coded as having a foley catheter and was always incontinent of bowel. In a confidential interview on 02/04/2025 at 11:00am it was revealed that CR#3 did not get her thyroid medications. The complaintant also stated that on the weekend of 01/25/2025 CR#3 had to beg for her thyroid medications. Record review of CR#3's physician's orders for January 2025 revealed the following active medication orders: Levothyroxine tablet 75mcg, give 1 tablet by orally one time a day related to hypothyroidism. Active 1/19/2025 Midodrine tablet 10mg, give 1 tablet orally three times a day related hypotension. Active 01/18/2025 Melatonin tablet 3 MG, give 1 tablet orally one time a day related to Insomnia. Active 10/1/2024 Sertraline 50mg, give 1 tablet orally one time a day related to depression. Active 01/18/2025 Ascorbic Acid 500mg, give one tablet by mouth one time a day for vitamins. Active 1/18/2025. Cipro oral tablet 500mg, give 1 tablet by mouth one time a day related to infection. Active 1/18/2025. Gabapentin 300mg, give 3 capsule orally every 8 hours for pain. Active 01/18/2025 Doxycycline 100mg, give 1 tablet by mouth one time a day for wound infection. Active 01/18/2025 Record review of CR#3's medication administration record for January 2025 revealed the following medications were not documented as given on the following days: Levothyroxine tablet 75mcg was not documented as given on 01/22/2025, 01/23/2025, 01/25/2025 and 01/27/2025 at 5:00am. Midodrine tablet 10mg was not documented as given at 8:00am and 12:00 noon on 1/20/25, 1/22/25-1/24/25 and 1/29/20275. Melatonin tablet 3 mg for insomnia was not documented as given on 1/25/2025 at 8:00pm. Sertraline 50mg, for depression was not documented as given from 1/20/25-1/24/25 and 1/29/2025 at bedtime. Ascorbic Acid 500mg for wound healing was not documented as given on 1/20/25, 1/21/25-1/24/2025 and 1/29/25 at 8:00am. Cipro oral tablet 500mg for infection was not documented as given on 1/20/25, 1/22/25-1/24/25 and 1/28/25 at 8:00am. Gabapentin 300mg for pain was not documented as given at 1:00am on 1/22/2025, 1/23/2025 and 1/25/2025 at 9:00am on 1/20/25, 1/22/2025-1/24/2025 and 1/29/2025 and at on 1/25/2025 at 5:00pm. Doxycycline 100mg, for wound infection was not documented as given at 9:00am on 1/20/2025, 1/22/25-1/24/2025 and 01/29/2025. Record review of CR#3's nurse's progress notes dated January 18 to January 30th, 2025 revealed no documentation as to why the medications were given or not given. Further record review revealed no documentation that CR#3 refused her medications. Resident #4 Record review of Resident #4's face sheet dated 02/04/2025 revealed Resident #4 was a [AGE] year old female who was admitted to the facility on [DATE]. Resident #4's diagnoses included essential hypertension (high blood pressure), diabetes (high blood sugar), depression (a mental health condition with low mood and loss of interest in pleasurable activities), hyperlipidemia(high level of fat in the blood),peripheral vascular disease (narrowing blood vessel that reduce blood flow to the limbs), GERD (acid reflux) Insomnia (difficulty sleeping), and Alzheimer disease (a progressive disease that affects memory and other mental functions). Record review of Resident #4's Annual MDS dated [DATE] revealed she was moderately impaired for cognitive skills for decision making. She was coded as not exhibiting any behaviors. She need supervision for eating and oral hygiene. She was dependent on staff for toileting and lower body dressing and needed substantial/maximal assistance for ADL care which included shower, upper body dressing, putting on and taking off footwear, and personal hygiene. For bowel and bladder, she was coded as frequently incontinent. Observation of Resident #4 on 2/19/2025 at 10:30am revealed the resident was up in her wheelchair, she was alert and speak mostly Spanish, she was clean and groomed with no offensive odor. No visible marks or bruises observed. Record review of Resident #4's physician's orders for January 2025 revealed the following active medication orders: Furosemide tab 20mg, give 1 tablet by mouth two times a day related to edema. Active 12/01/2024. Atorvastatin tab 10mg, give 1 tablet orally at bedtime related to hyperlipidemia. Active 12/28/2024. Melatonin tablet 5 MG, give 1 tablet orally by mouth at bedtime related to Insomnia. Active 12/12/2024. Omeprazole cap 40mg, give 1 tablet by mouth at morning related to GERD. Active 12/29/2024. Ascorbic Acid 500mg, give one tablet by mouth two times a day for vitamins. Active 12/01/2024. Gabapentin 300mg, give 1 capsule orally three times a day for neuropathy. Active 12/01/2024 Record review of Resident #4's medication administration record for January 2025 revealed the following medications were not documented as given on the following days: Furosemide tab 20mg, give 1 tablet by mouth two times a day for edema were not documented as given on 1/20/2025-1/24/2025 and 1/28/2025 at 9:00pm. and was not documented as given between 1/20/2025 and 1/23/2025 at 3:00pm and 9:00pm. Atorvastatin tab 10mg, give 1 tablet orally at bedtime for hyperlipidemia was as given between 1/20/2025 and 1/24/2025 and 1/28/25 at 8:00pm. Melatonin tablet 5 MG, give 1 tablet orally by mouth at bedtime for insomnia was not documented as given between 1/20/2025 and 1/24/2025 at 9:00pm. Omeprazole cap 40mg, give 1 tablet by mouth at morning GERD was not documented as given on 1/3/2025, 1/5/2025, 1/8/2025, 1/12/2025, 1/14/2025, 1/20/2025, 1/21/2025, 1/23/2025, 1/26/2025, 1/28/2025-1/31/2025 at 5:00am. Ascorbic Acid 500mg, give one tablet by mouth two times a day for vitamins was not documented as given between 1/20/2025 and 1/23/2025 and on 1/28/2025 at 9:00pm Gabapentin 300mg, give 1 capsule orally three times a day for neuropathy was not documented as given between 1/20/2025 and 1/23/2025 at 3:00pm and 9:00pm and on 1/28/2025 at 9:00pm. Record review of Resident #4's nurse's progress notes dated January 2025 revealed no documentation as to why the medications were not given or if the resident had refused the medication. In an interview on 2/19/2025 at 12:55pm with Unit Manager C she said if medications were administered, or the resident refused it should be documented. She said there should be no holes on the MARS. She said medications given should be documented and if it was not given it should be documented and the reason why it was not given. In an interview on 2/19/2025 at 1:10 pm with RN A she said if medications were given it should be documented and if it was not given it should also be documented and the reason why it was not given. She said if there were no documentation on the MARs it would be difficult to determine if the was given or not given. She said there should be no blanks on the MARS. In an interview on 2/19/2025 at 1:15pm with the DON she said there should be no blanks on MARs. She said the expectation of the nurses were to sign the MARs whether the medications were given or not given. She said if there were blanks on the MARs it would be difficult to determine if the meds were given or not given and would result in the resident been overmedicated or not getting their medication. She said she was going to in-service the nurses. In an interview on 2/19/2025 at 2:40 p.m. LVN E said he worked some of the days when the medications were not documented as given or not given. He said if medications were not given it should be documented and the reason why it was not given. He said he usually works the 6:00am to 2:00pm shift and he usually give Resident #3 her medications he said he might have forgotten to document that the medication was given. He said was sure Resident #3 was given her medication. He said if there were no documentation to indicate if medications were given or not given it could be seen as neglect. He said if the resident did not get their medications they would take longer to get well. He said if the resident refused to take his/or her medications the physician, responsible party, DON or ADON should be notified. He said he will have to pay more attention, ensuring that when medications were given they were documented, and if medications were not given they should be documented and the reasons why they were not given. She said the thyroid medication was not given on his shift it was to be done on the night shift. Record review of the undated facility policy and procedures on PHYSICIAN'S ORDERS read in part . POLICY: It is the policy of this Facility that physician orders are maintained per state and federal regulations. RESPONSIBILITY: Medical Records Technician PROCEDURE: NOTE: Orders must be signed electronically within a timely manner. 3. Physician orders include: a. All medications b. Treatments e. Special medical procedures required for the safety and well being of the Patient f. Limitation of activities g. Others as necessary and appropriate 6. Medications, diets, therapy, or any treatment may not be administered to the Patient without a written order from the attending physician.

Based on observations, interviews, and record review the facility failed to provide the necessary care and services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 resident (Resident #1) of 11 residents reviewed for ADLs. The facility failed to ensure Resident #1's fingernails were cleaned and trimmed on 2/21/2025. These failures could place residents at risk for loss of dignity due to not receiving care and assistance with daily living activities. Findings included: Record review of the undated face sheet for Resident #1 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), hyperlipidemia (high level of fat in the blood), muscle weakness (decreased strength in the muscles), renal insufficiency (inability for the kidney to remove waste), dementia (memory loss), anxiety (worry or fear about everyday situation). Record review of Resident #1's Quarterly MDS dated [DATE] revealed her BIMS was code at 13 indicating she was cognitively aware for decision making. She had no behavior issues. For functional abilities she needs supervision for eating and hygiene, for toileting and lower dressing she was substantial/maximal assist, and for shower/bath, upper body dressing, personal hygiene and taking off and putting on footwear she was partial or moderately assisted. For bowel and bladder, she was frequently incontinent. Record review of Resident #1's care plan effective date 02/21/2025 revealed: Problem: Rejection of care: Resident #1 rejects or resists care ADL assistance, showers, nails, getting out of bed. Goals: Negative outcomes related to resistance to care will be minimized over the next 90 days. Intervention: Identify times/approaches, approaches/staff that result in least resistance. Communicate to all caregivers. Notify physician. Seek different forms of the drug. Talk to Resident #1 and family about reasons for refusal of care and potential risks. When care is refused, remind resident of potential risk. Coax but do not force compliance. Observation on 2/21/2025 at 2:25pm revealed Resident#1 was in bed. She was alert and oriented with some confusion. She was dry with no offensive odor. Resident was observed with long nails to right hand and long dirty nails to the left hand. An interview was attempted with Resident #1 regarding her finger nails, but the resident did not respond. In an interview on 02/21/2025 at 2:25pm with Staffing Coordinator CNA A she said she was going to ensure that Resident #1's nails were cleaned. She said the resident was not diabetic and she was going to ask the nurse if she could trim the resident's nails. Record review of Resident #1's the shower sheet revealed her shower days were Monday, Wednesday and Friday. Record review of the ADL shower sheet dated 02/21/2025 revealed she had a bed bath on 02/21/2025 in the morning and refused nail care. Further record review of the shower sheet revealed the section for Charge Nurse's assessment and intervention were blank. In an interview on 02/21/2025 at 2:30pm with CNA B she said she provided care for Resident #1 that morning. She said she cleaned her down, but she did not clean the resident's nail because the resident would not allow her to clean her nails. She said she did not report to the nurse that the resident had refused nail care. Further interview with CNA B revealed that if a resident refused care, she should report it to the nurse. No reasons were given by the CNA why she did not report the resident refusing nail care to the nurse. In an interview with the DON on 2/21/2025 at 2:55pm she said nail care was the responsibility of all CNAs and Nurses. She said staff were in-service recently on showers, incontinent care, and ADL care. She said when ADL care was done and there are any changes in a resident condition, or the resident refuse care the nurse should be notified. She said her expectation of the CNA was to report residents refusal of shower or nail care to the nurse and the nurse should try to clean and trim the nails. She said Resident #1 was not diabetic so the nurse could trim her nails. She said the last time the Podiatrist was in the building was in November 2024. Record review of the facility policy and procedures dated March 3/2018 on Activities of Daily Living (ADL's) read in part . Policy Statement: Resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Resident who are unable to carry out ADL independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. Policy interpretation 2. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident/family in accordance with the plan of care including appropriate support and assistance with: Hygiene (bathing, dressing, grooming and oral care).

Based on interviews, and record review, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly for 1 of 10 residents (CR#1) reviewed for changes of condition . -The facility did not notify CR#1's physician of his changes in condition on [DATE], after which EMS was called, and transported the resident to the hospital where he passed away two days later, on [DATE]. On [DATE] an Immediate Jeopardy (IJ) situation was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility continuing to monitor the implementation and the effectiveness of their Plan or Removal. These failures could place residents at risk of not receiving needed care and services to meet their physical, mental, and psychosocial needs. Findings included: In an interview with the Private Nurse on [DATE] at 8:42 AM, she said she was very concerned about the resident's condition on [DATE]. She said the resident had terminal cancer; however, the resident was alert and very vocal. She said EMS immediately recognized the resident was in distress and needed emergency medical evaluation and treatment. She said the resident was admitted to the hospital on [DATE], and passed away two days later on [DATE]. In an interview with the Transporter on [DATE] at 9:03 AM, she said she was not sure of the exact time but was sure the incident with CR#1 occurred in the afternoon on [DATE]. She said as she was preparing to get the resident up for his appointment, his cell phone rang, and it was his private nurse on FaceTime. She said they both recognized something was not right with the resident. She said the resident was not able to speak and was very weak. She said the resident was always alert, and full of life. She said she thought the resident was having a stroke. She said she did not know what to do, so she called for help for the resident. She said RN A, RN B, and the Treatment Nurse came into the room and began providing care to the resident. Record review of CR#1's progress notes by RN B on [DATE] at 3:16 PM did not reveal that the physician was notified of the resident's change in condition, or any orders provided by the physician. However, the progress note revealed the following: RN B noted, CNA came and notified resident is feeling weak. Resident was on bed. Writer checked resident. Vitals BP: ,d+[DATE] P: 58 Res:18 Temp: 97.5 O2: 94% PRN oxygen. Blood sugar was 218. Nurse administered fluid. Resident eyes open and was responding by name, stated his name. DON came and assessed the patient. Notified NP. Caregiver call EMS. EMS took the patient to the hospital due to caregiver request. In an interview with RN A on [DATE] at 9:40 AM, She said she told RN B to notify the doctor to get order for bloodwork and notify the family. She said protocol if the resident was not stable, was to notify the doctor, family, management, and the DON. She said the DON was already aware because she was there. She said later, she asked RN B if she called the doctor, and RN B said yes. In an interview with RN B on [DATE] at 10:12 AM, she said she notified the wrong NP of the resident's change in condition, via text message, on [DATE]. She said she texted the NP and said the resident was weak and she requested an order for PRN oxygen. She said the NP replied to her text message stating they were not the NP assigned to the resident. She said she did not make any other attempts to contact the resident's NP or MD. She said she did not know why she did not make any other attempts to contact the appropriate physician. She said there was a lot going on that day, and the incident with the resident happened toward the end of her shift. She said failure to notify a physician of a resident's change in condition could put a resident at risk of death. Record review of text message dated [DATE] at 3:14 PM, from RN B to NP B revealed, CR#1 was seen weak. Checked the vitals. Patient was stable. Administered fluids. Can I get an order for oxygen? Record review of text message, dated [DATE] at 3:14 PM, from NP B to RN B revealed, I don't have that pt. In an interview with the DON on [DATE] at 1:20 PM, she said she asked RN B if she contacted the resident's physician and RN B told her yes. She said she reviewed CR#1's electronic health record and RN B noted she contacted the physician. She said she did not know RN B contacted the wrong physician via text message. She said RN B should have contacted the proper physician via telephone, provided a summary of what happened, what care was provided, and waited to receive any orders from the physician. She said the facility protocol did not require the nurses to document who they spoke with, or the mode of communication used when they contacted physicians because each resident had one main physician, and they needed to contact them via phone call. She said it was only appropriate to send a text message when they were not able to get in touch with the physician. She said if RN B called the physician and was not able to reach the physician, RN B was supposed to notify the DON immediately. She said the nurse was also responsible for documenting the notification and any orders given in the resident's electronic health record. She said she did not believe the resident was placed at risk because the resident was not in distress due to experiencing low O2 saturation. She said the resident had recent episodes of syncope (loss of consciousness for a short period of time) and a lower-than-normal O2 saturation level was the resident's baseline. She said RN B should have called the doctor to make notification and documented in the resident's electronic health record. Record review of CR#1's Treatment Administration Records, dated [DATE]-[DATE], did not reveal an incidcation of regular or PRN oxygen use by the resident. However, the treatment administration record revealed the following: Take vitals signs by shift starting [DATE]. .Blood Pressure: [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] .Pulse Oximeter [DATE] 97.00 [DATE] 100.00 [DATE] 98.00 [DATE] 98.00 [DATE] 98.00 [DATE] 98.00 [DATE] 96.00 [DATE] 97.00 [DATE] 97.00 [DATE] 97.00 [DATE] 98.00 [DATE] 97.00 [DATE] 100.00 [DATE] 97.00 [DATE] 98.00 [DATE] 97.00 [DATE] 98.00 [DATE] 98.00 . Record review of CR#1's Treatment Administration Records, dated [DATE]-[DATE], did not reveal an incidcation of regular or PRN oxygen use by the resident. However, the treatment administration record revealed the following: Take vitals signs by shift starting [DATE]. .Blood Pressure: [DATE] ,d+[DATE] [DATE] ,d+[DATE] .Pulse Oximeter [DATE] 99 [DATE] 98 . Further review of CR#1's treatment administration record did not reveal additional information related to the incident on [DATE]. Record review of CR#1's physician orders, dated [DATE], did not reveal an order from the physician on [DATE] for oxygen. The physician orders also did not reveal a standing order or PRN order for oxygen for CR#1. Further review of the physician orders revealed the resident was full code status, nursing was to perform weekly head-to-toe assessments, and take vital signs each shift. Further review of the progress notes by LVN A on [DATE] at 4:04 PM did not reveal that the physician was notified of the resident's change in condition, or any orders provided by the physician. However, the progress note revealed the following: LVN A noted, Arrived on shift and received report that patient was lethargic and had a low O2 saturation. DON as well as ,d+[DATE] nurse (LVN A) put patient on O2 to stabilize O2. Levels raised to 98 while in room. Patient assessed every 15 minutes. Shortly after caregiver arrived and called EMS to send patient out to hospital. DON and ADON notified. Vitals: HR:68 RR:19 O2:98 BP:,d+[DATE] Further review of the progress notes revealed, no physician was notified of the resident's change in condition on [DATE]. Further review of CR#1's progress notes, clinical records, vital signs and physician's orders did not reveal additional information related to the incident on [DATE]. In an interview with LVN A on [DATE] at 2:42 PM, he said he did not notify the resident's physician about the resident's initial change in condition because he was not aware of what care was provided to the resident before his arrival at 2:00 PM. He said he was sure RN B notified the physician while she was wrapping up charting the incident. He said at about 2:45 PM he and the DON went into the resident's room to check on him. He said he checked the resident's vitals and the resident's O2 saturation level was at 88 or 89. He said a normal O2 saturation level was between 93 and 96. He said he cranked the resident's oxygen up to about 15 liters to stabilize the resident's O2 saturation. He said the resident's oxygen level returned to about 93. He said he did not consider notifying the resident's physician about the drop in the resident's O2 saturation level. He said there was a lot going on that day, he felt like the staff came together and did the best they could for the resident. In an interview with the DON on [DATE] at 3:00 PM, she said she did go into the resident's room with LVN A. She said she was aware LVN A performed an assessment on the resident. She said she did not see, nor was she made aware that the resident's O2 saturation level dropped to 88 or 89. She said they had to switch the resident's oxygen tank out, but the resident never went without oxygen after he experienced the first change in condition. She said she thought LVN A was mistaken because she did not recall the resident's oxygen level dropping that low. She said if LVN A observed the resident's O2 saturation level at 88 or 89, he should have notified her and the physician of an additional change in condition. She said she did not believe the resident was at risk or in any distress because the resident seemed to be doing better since the initial incident. She said failure to notify the physician when a resident experienced a change in condition put residents at risk for re-hospitalization or a decline in health. In an interview with the Administrator on [DATE] at 3:23 PM, she said she was not aware CR#1's physician was not notified of the resident's changes in condition on [DATE]. She said it was her expectation of the nurses to contact physicians to notify them when a resident experienced a change in condition. She said the nurses could contact physicians via text message or phone call. She said the nurses were supposed to notify the physician of what they observed, how they found the resident, the assessment they did, and provide vital signs. She said she did not ask detailed questions regarding CR#1's changes in condition on [DATE] because she trusted her team handled the situation appropriately, based on the feedback provided from the DON, and the staff involved. She said the nurses were trained to use their best judgment, based on their training. She said failure to notify a physician when a resident experienced a change in condition put residents at risk for re-hospitalization or a decline in health. In an interview with the DON on [DATE] at 2:00 PM, she said every day during the morning meeting, the IDT team (the Administrator, the DON, the MDS Coordinators, the Director of Therapy, the Director of Social Services, and the Dietary Manager) reviewed the 24-hour report to make sure all changes in condition were handled appropriately. She said if any issues with accuracy or proper documentation were reviewed, they addressed, and discussed issues during the meeting. She said the nursing team did not handle making notifications to CR#1's physician appropriately. She said the nurses had recently been re-in-serviced to attempt to call the resident's physician via phone at least three times. She said if the nurse was unable to reach the physician on the third call, they were to call the medical director. She said the nurses were also in-serviced to document a summary of what they observed when the resident experienced the change in condition, vital signs, and assessment of the resident prior to contacting the physician. She said the nurses were to document the change in condition in the resident's progress notes or on an SBAR in the electronic health record. She said once the nurse made notification, they also needed to document the physician was contacted, and any orders given by the physician. She said the facility updated all the physician's contact information, so no staff contacted the wrong physician. In an interview with the Administrator on [DATE] at 2:40 PM, she said at the time the IDT team reviewed the 24-hour report after CR#1's changes in condition on [DATE], the IDT team did not see anything wrong with the documentation of notifications to the resident's physician. She said sometimes, people got complacent in their positions. She said the DON possibly needed to review the facility's policies and procedures more often. She said there was always room for the facility's staff to make improvements. She said the nursing team had been re-educated on making notifications to physicians and the facility updated all physician's contact information to ensure accuracy. She said if the facility staff had followed policies and procedures, the outcome of the situation may have been different. Record review of CR#1's face sheet dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses of chronic kidney disease (gradual loss of kidney function which can cause dangerous levels of fluid, electrolytes, and wastes to build up in the body), malignant neoplasm of the bladder (bladder cancer), malignant neoplasm of the colon (colon cancer), congestive heart failure (long-term condition that occurs when the heart cannot pump a normal blood supply to the body, and blood and fluid collect in the lungs and legs over time), and dehydration (absence of a sufficient amount of water in the body). Record review of CR#1's admission MDS dated [DATE], revealed the resident's BIMS score was 13, which indicated his cognition was intact. CR#1 used a wheelchair, and required set-up or clean-up assistance with eating, oral hygiene, and upper body dressing. He required supervision for personal hygiene and moderate assistance for toileting, lower body dressing, rolling to the left or right, sitting to lying position, sit to stand position, and chair/bed-to chair transfers. Record review of CR#1's baseline care plan, dated [DATE], did not reveal problems, goals, or interventions related to the resident's regular or PRN use of oxygen. Further review of the care plan revealed he was at risk for infections. Interventions included nursing staff assessing him for any symptoms of confusion, changes in mental status, delirium or confusion, following the policy for reportable conditions, and consulting with physician, PA, CNP, therapy, and dietitian. Record Review of Emergency Services records, dated [DATE], did not reveal oxygen provided to the resident, by the facility, on [DATE] prior to EMS' arrival. However, review of the records revealed the following: Call Recieved: 2:58 PM Dispatched: 2:59 PM En Route: 3:00 PM On Scene: 3:03 PM At Patient: 3:06 PM Depart Scene: 3:21 PM Level of Service: Advanced Life Support Transportation Mode Description: Lights and Sirens Clinical Impression Primary Impression: Altered Mental Status Onset Time: 3:00 PM [DATE] Duration: 2 Hours Signs & Symptoms: Hypotension (the pressure of blood circulating around the body is lower than normal or lower than expected), Altered Mental Status (changes in consciousness and symptoms that can affect many organ systems), Tachycardia (a heart rate over 100 beats a minute), Tachypnea (abnormally rapid breathing) Barriers of Care: Psychologically Impaired Initial Patient Acuity: Emergent Assessment Time [DATE] 3:09 PM Mental Status: Confused; Unresponsive Skin: Cold; Dry Breath Sounds Clear and Equal Sepsis Screening performed: [DATE] at 3:15 PM qSOFA Criteria Met: Yes SIRS Criteria Met: Yes Sepsis infection suspected or documented: Yes ETCO2 less than 25 mmHg: Yes Systolic Blood Pressure less than 100 mmHg: Yes Respiratory Rate greater than 22 breaths/min: Yes Glasgow Coma Scale less than 15: Yes Temperatire less than 36 celsius or greater than 30 celsius: No Heart Rate greater than 90 bpm: Yes Respiratory Rate greater than 20 breaths/min: Yes Vital Signs Time: 3:08 PM; BP ,d+[DATE]; Pulse 107; RR: 25; SPO2: 100 room air; ETCO2: 21.0 mmHg 3:14 PM; Pulse 72: RR: 38; SPO2 98 room air; ETCO2: 22.0 mmHg 3:15 PM BP: ,d+[DATE]; Pulse: 56; ETCO2: 18.0 mmHg; Temp: 98.1 3:20 PM BP: ,d+[DATE]; Pulse: 93; RR: 25; SPO2: 98 room air 3:24 PM BP: ,d+[DATE]; Pulse: 114; RR: 23; SPO2: 98 room air; ETCO2: 21.0 mmHg 3:28 PM BP: ,d+[DATE]; Pulse: 118; RR: 23; SPO2: 95 room air; 20.0 mmHg 3:32 PM BP: ,d+[DATE]; Pulse: 77; SPO2: 95 room air; ETCO2: 18.0 mmHg 3:37 PM BP: ,d+[DATE]; Pulse: 110; RR: 22; SPO2: 99 room air; ETCO2: 18.0 mmHg Treatments 3:08 PM 12-lead Electrocardiogram; Patient Response: Unchanged 3:09 PM Oxygen Nasal Cannula 2 liters per minute; Patient response: Improved 3:15 PM IV Therapy Saline Lock; Patient Response: Improved 3:24 PM IV Therapy Normal Saline (.9% NaCl); Total Fluid 300 mL; Patient Reponse: Improved 3:24 PM Norepinephrine 10 mcg; Intravenous; Patient Response: Improved 3:25 PM Norepinephrine 10 mcg; Intravenous; Patient Response: Improved EMS dispatched to a medical call .responded with emergency traffic .arrived at the NH without delays. Upon arrival found an [AGE] year-old male lying supine on his hospital-like bed. The patient ' s caregiver was on the scene and explained that she found the patient with an altered mental status and called 911. the patient had been at the NH for a fall he suffered 3 weeks ago, according to the caregiver. The patient was responsive to verbal commands but was confused. It was noted that the patient had low blood pressure, was breathing rapidly, and had a rapid pulse rate. The patient did not present with a fever. EMS promptly placed the patient on the EMS stretcher in the Trendelenburg position and ushered him to the back of the ambulance. The patient was placed on a cardiac monitor, and his blood pressure was monitored. EMS noted the patient had difficult veins and a history of cancer and chemotherapy. EMS initiated emergency traffic to the hospital and sent a sepsis alert to the receiving ER. EMS managed to obtain IV access, initiated a fluid challenge, and administered push-dose norepinephrine. The patient ' s mental status did not improve. It was noted that after the norepinephrine administration, the patient's BP improved. EMS arrived at the ER without delays and registered the patient .While waiting, it was noted that the patient ' s BP was decreasing again, so EMS administered another dose of push-dose norepinephirine. The patient ' s BP improved within a couple of minutes After a few minutes, the patient was given a room and moved to the hospital bed using the bed sheet method. The receiving nurse and doctor were given a verbal report, and patient care was transferred . Several unsuccessful attempts were made to interview the MD via telephone on [DATE] and [DATE]. Record review of the policy, revised [DATE], titled, Physician Notification revealed the following: These types of conditions which arise frequently are listed. This list is not inclusive. Altered mental status, bleeding, chest pain, diarrhea, edema, emesis, falls, family concerns, gastronomy tubes, medication error, pressure sore, seizures, shortness of breath, skin rash, vital signs, laboratory values It is the responsibility of the nursing staff to observe the change, make an assessment, and notify the physician as indicated based on the assessment The physician; physician assistant; nurse practitioner; or clinical nurse specialist is to be promptly notified .The nurse will: Recognize the condition change; monitor the patient and continue to assess the condition and changes; notify the physician, patient and patient representative of any change in condition. Record review of the policy, revised [DATE], titled, Charting and Documentation revealed the following: Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. d. Changes in the resident's condition 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 4. Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy . f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 8:26 PM. The Administrator was notified. The Administrator was provided the IJ template on [DATE] at 8:26 PM. The following POR submitted by the facility and was accepted on [DATE] at 5:12 PM: Plan of Removal Impact Statement On [DATE] a complaint survey was initiated at the facility . On [DATE], the facility was provided notification that the survey agency had determined that the conditions at the center constitute an immediate jeopardy to resident health. The facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, and the comprehensive care plan for CR#1 on around noon on [DATE] when he was weak, lethargic, unable to speak, and had a lower-than-average O2 saturation level. Around 2:45 PM, his O2 saturation level dropped to 88 or 89. Between 1 to 2 hours after the resident's initial change in condition, EMS was contacted by CR#1's private hired nurse and the resident was transported to the hospital where he expired on [DATE]. Immediate Action: Please accept this as our Plan of Removal for the Immediate Jeopardy related to F580 Notification. CR#1 expired on [DATE] in the hospital. Residents that can be affected are those who reside in the community. 1:1 education was immediately provided to both RN B and LVN A by the Director of Nursing and the Regional Director of Clinical Services. The topics covered were the following: 1. Policy & Procedure on Notification - Physician Notification 2. Policy & Procedure on Quality of Care - Change of Condition 3. Updated Physician Contact Numbers and Nurse Practitioners Completion Date: [DATE] Systematic Approach: Assessment -The Executive Director notified the facility Medical Director of the Immediate Jeopardy on [DATE] at 8:15 p.m. -An emergency QAPI meeting was held on [DATE], which was inclusive of a review of our policies/protocols for Change in Condition and Physician Notification, they were found to be sufficient. -The Administrator, the DON, and the ADON were in-serviced by the RDCS (Regional Director of Clinical Services) on Change in Condition and Physician Notification on [DATE]. Staff in-services, to include all licensed clinical staff, were started on Change in Condition and Physician Notification. This in-servicing will continue until all licensed clinical staff have been trained. Staff will not be allowed to start on the floor or give care until this training has been completed. -All new licensed clinical staff will receive the in-services as part of the onboarding orientation process prior to being assigned and providing care to residents. All licensed clinical staff will be in-serviced on change in condition and physician notification. No licensed clinical staff will be allowed to work in the facility until the above required in-services are completed. The in-services with all staff will be completed by [DATE]. All staff were in-serviced [DATE]. -All current residents were assessed to determine if there has been any change in status and/ or condition. The assessments were noted in the individual residents' EMR's. The physician will be made aware of any noted changes from the resident's normal baseline. This will be completed by the licensed/registered nurses and nursing leadership. Completion Date: [DATE] After completion of the resident audits, no other residents were found to be at imminent risk of having a change in condition and at their normal baseline completed [DATE]. Facility reviewed current residents for change in condition in last 30 days and proper reporting, no noncompliance noted completion date [DATE]. Who will be responsible: Nurse Managers and the DON Who Will monitor: Executive Director and Regional Director of Clinical Services (RDCS). Monitoring -Residents will continue to be reviewed and discussed in the daily IDT Meeting by reviewing the 24-hour Report for any changes in condition. Timely follow up and MD notification will occur. Charge nurses and nursing leadership will continue with daily and prn rounds and assessments to ascertain any changes in condition and to follow up the with MD promptly. -Residents will be assessed on admission for baseline and reviewed daily and prn for any changes in status and follow up the physician timely. -Starting [DATE] Director of nursing and/or Nurse Managers will review the 24-hour report for any incident of residents being outside during unfavorable weather conditions, each day for 4 weeks week, then weekly for 4 weeks. The Executive Director will review the documentation each week for compliance. -Beginning [DATE] no staff will be allowed to work until the required in-servicing has been completed. Policy and Procedures Policy and procedures were reviewed by Senior [NAME] President of Operations, Director of Regulatory and Compliance, Senior Executive Director, Regional Director of Clinical Services, Executive Director, and Director of Nursing. These policies include Change in Condition and Physician Notification. No policies needed any revisions. Monitoring of the plan of removal included: The surveyor confirmed the facility implemented their plan of removal sufficiently from [DATE] - [DATE] to remove the IJ by: Reviewed curriculum and competency assessments for RN B and LVN A; topics included Physician Notification Policy & Procedure, Quality of Care - Change of Condition Policy & Procedure, and acknowledgment of updated physician and nurse practitioner contact numbers. Reviewed QAPI meeting notes from [DATE], which included a review of policies and protocols for change in condition and physician notification. The results of the meeting determined both polices to be sufficient. Reviewed curriculum and competency assessments on change in condition, physician notification, SBAR, completed by the Administrator, the DON, the ADON, and all licensed clinical staff between [DATE] and [DATE]. Reviewed the facility's 30-day audit of resident electronic health records for changes in condition and appropriate notification to physicians. Reviewed updated nursing assessments for changes in resident's condition. No unknown changes identified by nursing staff. Reviewed daily schedules of clinical staff on [DATE], [DATE], [DATE], [DATE], and [DATE] to ensure scheduled staff completed necessary in-services and competency assessments prior to shift start. Interviews were conducted with staff from all shifts from [DATE]-[DATE], which included the Administrator, the DON, 10 RN's, and 15 LVN's , across 6:00 AM-2:00 PM, 2:,d+[DATE]:00 PM and 10:00 PM-6:00 AM shifts, regarding all in-services and they were able to explain the policies and procedures related to recognizing, assessing, documenting, notifying physicians of, and providing on-going monitoring after changes in condition. Interviews were conducted with the Administrator and the DON to ensure they understood the importance of maintaining and implementing an effective system for nursing staff to recognize, assess, document, notify physicians of, and provide on-going monitoring after changes in condition. The Administrator was informed the Immediate Jeopardy (IJ) was removed on [DATE] at 4:26 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal arm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interviews and record review, the facility failed to ensure the resident's right to be free from neglect for 1 of 10 residents (CR#1) reviewed for neglect. The facility did not appropriately assess, document assessments, notify the physician, follow physician orders, provide ongoing monitoring, or provide emergency medical treatment in a timely manner, after CR#1 experienced changes in condition on [DATE], after which EMS was called, and transported the resident to the hospital where he passed away two days later, on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place resident at risk of a delay in medical treatment, worsening of condition, infection, and pain. Findings included: In an interview with the Private Nurse on [DATE] at 8:42 AM, she said she was very concerned about the resident's condition on [DATE]. She said the resident had terminal cancer; however, the resident was alert and very vocal. She said the resident was admitted to the hospital on [DATE], and passed away two days later on [DATE]. In an interview with the Transporter on [DATE] at 9:03 AM, she said the resident was not able to speak and was very weak. She said the resident was always alert, and full of life. She said she thought the resident was having a stroke. Record review of CR#1's progress notes by RN B on [DATE] at 3:16 PM did not reveal that the times the events included in the progress note occurred on [DATE]. However, the progress note revealed the following: RN B noted, CNA came and notified resident is feeling weak. Resident was on bed. Writer checked resident. Vitals BP: ,d+[DATE] P: 58 Res:18 Temp: 97.5 O2: 94% PRN oxygen. Blood sugar was 218. Nurse administered fluid. Resident eyes open and was responding by name, stated his name. DON came and assessed the patient. Notified NP. Caregiver call EMS. EMS took the patient to the hospital due to caregiver request. Record Review of CR#1's electronic health record revealed no SBAR was documented when RN B noted a change in the resident's condition on [DATE]. In an interview with RN A on [DATE] at 9:40 AM, she said on [DATE] after lunchtime or close to lunchtime, RN B called for help from the door of CR#1's room. She said she went into the room and RN B said the resident looked weak. She said the resident was lying in the bed, his skin color was normal, and he did not look like he was in any distress. She said RN B checked his blood sugar and it was normal. She said the Treatment Nurse checked his oxygen level and it was below 92, so they decided to put him on PRN oxygen. She said the whole time, she was doing a sternum rub on the resident. She said she performed the sternum rub by massaging his chest. She said she was also calling the resident's name. She said the resident opened his eyes and he began to talk to her. She said she did not know how long she massaged his chest before he opened his eyes. She said he responded to the sternum rub almost immediately. She said she asked him if he knew where he was, and if he knew who he was. She said the resident said yes and he told her his name. She said they also gave the resident water to drink once he began to speak. She said a CNA came and told her that her patient needed her, so she left. She said the Treatment Nurse and RN B were left behind with the resident. She said RN B was the nurse assigned to the resident at the time. She said she did not have a clear picture of what happened after she left the resident's room because she had a lot of other responsibilities to tend to. She said she did not know for sure but thought emergency services was contacted for the resident. She said RN B and LVN A were both handling the resident's care when EMS arrived. She said failure to ensure residents received emergency medical treatment could potentially cause death. In an interview with RN B on [DATE] at 10:12 AM, she said she was not typically assigned to work on the resident's hall, and was not familiar with him. She said [DATE] was her first time working with him. She said she thought it was around 2:00 PM when she heard a CNA shout from CR#1's room for a nurse. She said when she made it into the resident's room, the Transporter, and a CNA were holding his shoulders while the resident was sort of lying off the side of his bed. She said she could not remember who the CNA was. She said she could not remember the resident's exact positioning, but she knew they had to help him put his feet back into the bed for him to lay down. She said the only thing she noticed was the resident was not talking. She said she called for help and RN A and the Treatment Nurse came in the room to assist. She said the resident's O2 saturation level was low so, she went to get an oxygen mask to administer PRN oxygen. She said she could not remember the resident's exact O2 saturation level, but she knew it was below normal levels. She said she got a blood pressure cuff, gloves, and by the time she came back, the resident's eyes were open. She said the resident did not look pale. She said she did not see, nor was she aware RN A did a sternum rub or massaged the resident's chest. She said she thought the Treatment Nurse also checked his blood pressure because she recalled RN C having a blood pressure cuff too. She said she and RN A were talking to the resident. She said she asked him if he knew who he was and if he was okay. She said after the resident began talking, they gave him some water to drink. She said she could not contact emergency services for a resident because someone said to call 911. She said she had to have doctor's orders to send a resident to the hospital. She said if emergency services needed to be contacted for the resident, the DON was also present in the resident's room, and would have made the call, if it was necessary. She said the resident was speaking, said his name, and he seemed fine. She said he did not appear to be in distress to her. She said she assessed the resident and the only thing in her assessment that was concerning was his O2 saturation level. She said she checked his temperature, blood sugar, blood pressure, respiration, and his O2 saturation. She said she followed his PRN orders and administered oxygen to the resident. She said she did not know how long they were in the resident's room. She said she did not know how much time passed between each round she did, but she returned to the resident's room to monitor him twice before the end of her shift. She said she only checked the resident's vitals during her initial assessment, after being called into the room by the CNA. She said she did not check his vitals or O2 saturation level either time she rounded on the resident. She said she did a visual assessment both times she returned to his room, and he seemed fine. She said LVN A arrived at 2:00 PM, she handed over the shift, gave him report, and stayed at the facility late to finish charting. She said the facility did not have a specific form she was supposed to complete in resident's electronic health record when they had a change of condition, or when she performed an assessment. She said a resident who was in distress and in need of emergency services was at risk of death. She said she did not believe the resident was in distress on [DATE]. She said the resident never fully passed out, and facility staff immediately began checking on the resident to make sure he was okay. She said she followed doctor's orders by administering oxygen and continuing to monitor the resident. In an interview with RN C on [DATE] at 11:59 AM, she said when she got to the resident's room, the Transporter, a CNA, and RN B were already in the room with CR#1. She said herself and RN A went into the room at the same time. She said the resident was lying in his bed on his back. She said the resident was lethargic, his skin was not clammy, he was not sweaty, and his skin had color. She said the nurses were providing care to the resident as a team effort. She said there was a lot of back and forth between the nurses and what they were doing for the resident. She said she could not recall every single detail. She said the resident was not speaking and responded slowly to painful stimuli. She said the painful stimuli she was referring to, was a sternum rub. She said she observed a nurse massage the resident's chest. She said she could not recall which nurse massaged the resident's chest, but remembered the nurse did not have to rub the resident hard or long before he responded to the massage. She said he responded almost immediately to the massage. She said she checked his oxygen saturation, which was below 90, so they had to start him on oxygen. She said RN B checked his blood pressure and his blood sugar. She said low oxygen saturation and high or low blood pressure, or low oxygen saturation level and high or low blood sugar would be an indication a resident was in distress. She said the resident's oxygen saturation was not so critically low that it indicated he was in distress. She said the rest of the resident's vitals were within normal range. She said she did not think the resident was in distress at the time she was present in the resident's room. She said while she was present in the resident's room, no one considered contacting emergency services for the resident. She said before she left the room, the resident was stable, and speaking to the nurses. She said RN B notified the resident's doctor and documented their assessment. She said she felt like the staff did what they could for the resident that day. She said she was not sure who called EMS for the resident. She said she knew the resident expired at the hospital. She said maybe if emergency services had been contacted earlier, the outcome could have been different. In an interview with the DON on [DATE] at 1:20 PM, she said by the time she became aware there was a situation happening with CR#1, RN A, RN B, and the treatment nurse had already wrapped up providing care to the resident. She said she could not recall all the details. She said she went to the resident's room to check on him and he was okay. She said she did not perform an assessment on the resident, herself. She said she was aware the nurses observed the resident to be weak, lethargic, and unable to speak. She said she asked RN B what was done for the resident. She said RN B told her the resident was assessed, had his vitals checked, started him on oxygen, and the nurses gave the resident water. She said she was not aware RN A, and RN C observed the resident with closed eyes and slow to respond to painful stimuli. She said she was not aware any nurse performed a sternum rub or massaged the resident's chest. She said the nurse who performed the sternum rub must not have been familiar with the resident. She said the resident had recent episodes of syncope (loss of consciousness for a short period of time) and a lower-than-normal O2 saturation level was the resident's baseline. She said if the nurse had known, she likely would not have done the sternum rub, or chest massage because it was not necessary. She said she was not aware CR#1's physician was not notified of the resident's change in condition. She said she asked RN B if she contacted the resident's physician and RN B told her yes. She said based on the feedback from the nurses regarding the resident's assessment, vital signs, and baseline of low O2 saturation level, the resident was not in distress, and emergency services did not need to be contacted even though his physician was not notified of his change in condition. She said she was sure the nurses used their best judgement while providing care to the resident. She said the resident was not in distress due to experiencing low O2 saturation. Record review of CR#1's Treatment Administration Records, dated [DATE]-[DATE], did not reveal an incidcation of regular or PRN oxygen use by the resident. However, the treatment administration record revealed the following: Take vitals signs by shift starting [DATE]. .Blood Pressure: [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] [DATE] ,d+[DATE] .Pulse Oximeter [DATE] 97.00 [DATE] 100.00 [DATE] 98.00 [DATE] 98.00 [DATE] 98.00 [DATE] 98.00 [DATE] 96.00 [DATE] 97.00 [DATE] 97.00 [DATE] 97.00 [DATE] 98.00 [DATE] 97.00 [DATE] 100.00 [DATE] 97.00 [DATE] 98.00 [DATE] 97.00 [DATE] 98.00 [DATE] 98.00 . Record review of CR#1's Treatment Administration Records, dated [DATE]-[DATE], did not reveal an incidcation of regular or PRN oxygen use by the resident. However, the treatment administration record revealed the following: Take vitals signs by shift starting [DATE]. .Blood Pressure: [DATE] ,d+[DATE] [DATE] ,d+[DATE] .Pulse Oximeter [DATE] 99 [DATE] 98 . Further review of CR#1's treatment administration record did not reveal additional information related to the incident on [DATE]. Record review of CR#1's physician orders, dated [DATE], did not reveal an order from the physician on [DATE] for oxygen. The physician orders also did not reveal a standing order or PRN order for oxygen for CR#1. Further review of the physician orders revealed the resident was full code status, nursing was to perform weekly head-to-toe assessments, and take vital signs each shift. Further review of the progress notes by LVN A on [DATE] at 4:04 PM did not reveal that the times the events included in the progress note occurred on [DATE]. However, the progress note revealed the following: LVN A noted, Arrived on shift and received report that patient was lethargic and had a low O2 saturation. DON as well as ,d+[DATE] nurse (LVN A) put patient on O2 to stabilize O2. Levels raised to 98 while in room. Patient assessed every 15 minutes. Shortly after caregiver arrived and called EMS to send patient out to hospital. DON and ADON notified. Vitals: HR:68 RR:19 O2:98 BP:,d+[DATE] Further review of the progress notes revealed, no physician was notified of the resident's change in condition on [DATE]. Further review of CR#1's progress notes, clinical records, vital signs and physician's orders did not reveal additional information related to the incident on [DATE]. Record review of CR#1's physician orders, dated [DATE], did not reveal an order from the physician on [DATE] for oxygen. The physician orders also did not reveal a standing order or PRN order for oxygen for CR#1. Further review of the physician orders revealed the resident was full code status, nursing was to perform weekly head-to-toe assessments, and take vital signs each shift. In an interview with LVN A on [DATE] at 2:42 PM, he said when he arrived at work on [DATE], he said every time he worked with the resident, he was always alert. He said he was surprised to hear the resident had been unresponsive. He said he received report from RN B. He said she told him the resident was stable, and never indicated that LVN A needed to do anything for the resident based on the situation that occurred prior to his arrival. He said he began rounding on his residents like normal. He said at about 2:45 PM he and the DON went into the resident's room to check on him. He said he checked the resident's vitals and his O2 saturation level was at 88 or 89. He said a normal O2 saturation level was between 93 and 96. He said he cranked the oxygen up to about 15 liters to stabilize the resident's O2 saturation. He said the resident's oxygen level returned to about 93. He said the DON accompanied him to the resident ' s room and he did what she instructed. He did not think about reviewing the resident ' s chart or contacting the physician. He said he trusted what the DON told him to do. He said the DON left, and he stayed with the resident for 20 to 30 minutes to ensure he remained stable. He said he was mistaken and did not document the assessment he performed when the resident's oxygen level dropped to 88. He said he documented the assessment he performed on CR#1 once his O2 saturation level rose back up to the 90's. He said he performed assessments on the resident every 15 minutes after he observed the resident's drop in O2 saturation. He said he did not know the length of time between each assessment, nor did he know how many assessments he performed on the resident. He said he knew each time he performed an assessment, he checked the resident's vitals, and they were stable. He said he checked all the resident ' s vitals, including his BP several times, and documented them all on a scratch sheet of paper he was using on [DATE]. He said he did not know where the scratch sheet of paper would have been located after [DATE]. He said he did not know why did not enter the vital signs in the resident ' s electronic health record. He said he could have been more thorough in his documentation by including what care he provided to the resident and his vital signs. He said he did not consider notifying the resident's physician about the drop in the resident's O2 saturation level. He also said he did not consider calling 911 for the resident. He said the resident had experienced a change in condition prior to the start of his shift, and the DON was aware of the resident's status. He said he felt like the DON would have made sure to call 911 if the resident was in distress. He said he could not recall what time, or exactly what he was doing when CR#1's caregiver showed up at the facility. He said he there was a lot going on that day, and he felt like the staff came together and did the best they could for the resident. In an interview with the DON on [DATE] at 3:00 PM, she said she did go into the resident's room with LVN A after the resident's first change in condition. She said she was aware LVN A performed an assessment on the resident. She said she did not see, nor was she made aware the resident's O2 saturation level dropped to 88 or 89. She said she was aware the resident's oxygen tank had to be switched out. She said the resident never went without oxygen and did not believe his O2 saturation level dropped as low as 88 or 89, after the resident experienced the first change in condition. She said she thought LVN A was mistaken because she did not recall the resident's oxygen level dropping. She said if LVN A observed the resident's O2 saturation level at 88 or 89, he should have notified her and the physician of an additional change in condition. She said she did not believe the resident was at risk of anything, nor was the resident in any distress when she checked on him with LVN A. She said the resident seemed to be doing better since the initial incident. She said she asked the resident if he was okay, and he said he was tired. She said she left LVN A in the resident's room and left the facility to go to another building. She said she did not know how long she was gone when she received a phone call from LVN A notifying her the caregiver was at the facility and wanted to contact emergency services for the resident. She said it was the caregiver's right to contact emergency services on behalf of the resident. She said the nurses did what was expected of them when they provided care to CR#1 on [DATE]. She said once a resident experienced a change in condition and the doctor had been notified, the nurse was expected to continue monitoring the resident every 15 to 30 minutes. She said during monitoring the nurse was supposed to check vitals, perform a head-to-toe assessment, and document their findings in the resident's electronic health record. She said she was not aware additional monitoring was not done by RN B after the resident experienced the first change in condition. She said RN B should have called the doctor to make notification, documented her initial assessment, and all care provided to the resident, including the fact that they had to do a sternum rub, in the resident's electronic health record. She said RN B should have also continued to monitor and assess and document the assessments after the resident's initial change in condition. She said she saw LVN A perform an assessment on the resident while she was in the resident's room. She said if LVN A did additional assessments, he should have documented what he did for the resident, the findings of his assessment, and the resident's vital signs in the electronic health record every time he monitored the resident. She said she should have made sure RN B and LVN A documented every time they assessed and monitored the resident after the resident was initially weak, lethargic, and unable to speak. She said she did not believe the resident was in distress on [DATE]. She said when Emergency Services arrived at the facility, the resident was not unresponsive, but was alert. She said failure to properly assess a resident and provide emergency medical treatment put residents at risk for re-hospitalization or a decline in health. In an interview with the Administrator on [DATE] at 3:23 PM, she said the nurses were supposed to notify the physician of what they observed, how they found the resident, the assessment they did, and provide vital signs. She said she was not aware the resident did not receive additional monitoring and assessments after his changes in condition on [DATE]. She said the nurses were supposed to document their observations and assessments in the electronic health record. She said she did not ask detailed questions regarding CR#1 on [DATE] because she trusted her team handled the situation appropriately based on the feedback provided from the DON and the staff involved. She said the nurses were trained to use their best judgment, based on their training. She said if the nurses felt the resident was in distress, they knew to contact emergency medical services. She said the nurses were trained to use their best judgment, based on their training. She said if the nurses felt the resident was in distress, they knew to contact emergency medical services. She said failure to perform appropriate assessments and ensure emergency medical treatment in a timely manner put residents at risk for a decline in health. Further review of CR#1's progress notes, clinical records, vital signs and physician's orders did not reveal an indication of regular or PRN oxygen use by the resident. Further review of CR#1's progress notes, clinical records, vital signs and physician's orders did not reveal additional information related to the incident on [DATE]. In an interview with the DON on [DATE] at 2:00 PM, she said the only thing the nursing team did not handle appropriately on [DATE] was making notifications to CR#1's physician. She said her nursing staff may have been neglectful to point with their documentation and notifications, but not in a way she felt had a direct impact on CR#1's overall health or condition. She said the nurses had recently been re-in-serviced to call the resident's physician. She said moving forward, when there is a change in condition, the nurses were re-in-serviced to call the physician at least three times, and if no answer contact the medical director. She said once the nurse made notification, the nurse needed to document the physician contacted, and any orders given in the electronic health record. She said the facility also updated all physician's contact information to ensure facility staff contacted the appropriate physician. In an interview with the Abuse Prevention Coordinator on [DATE] at 2:40 PM, she said she worked to prevent residents from abuse and neglect daily. She stated she randomly inquired with current residents and new admissions to ensure services and care provided by staff maintained the facility's standards. Staff also know to contact her with concerns of abuse or neglect. She said she also made her 24-hour contact information available at each of the nurse's stations and it was highlighted in the facility's welcome packet for residents. She said residents and families knew to contact her about concerns. She said she also went out on the floor and made random rounds with residents. She said if she ever had a question or concern with abuse or neglect identified within the facility, she would call the Senior Executive Director and Regional Director of Clinical Services immediately. She said at the time the IDT team reviewed the 24-hour report after CR#1's changes in condition on [DATE], the IDT team did not see anything wrong with the documentation of notifications to the resident's physician, or nurses' assessments of the resident. She said she did not want to use the word neglect to describe the incident with CR#1. She said sometimes, people got complacent in their positions. She said the DON possibly needed to review the facility's policies and procedures more often. She said there was always room for the facility's staff to make improvements. She said the nursing team had been re-educated on making notifications to physicians and the facility updated all physician's contact information to ensure accuracy. She said if the facility staff had followed policies and procedures, the outcome of the situation may have been different. Several unsuccessful attempts were made to interview the MD via telephone on [DATE] and [DATE]. Record review of CR#1's face sheet dated [DATE], revealed he was admitted to the facility on [DATE] with diagnoses of chronic kidney disease (gradual loss of kidney function which can cause dangerous levels of fluid, electrolytes, and wastes to build up in the body), malignant neoplasm of the bladder (bladder cancer), malignant neoplasm of the colon (colon cancer), congestive heart failure (long-term condition that occurs when the heart cannot pump a normal blood supply to the body, and blood and fluid collect in the lungs and legs over time), and dehydration (absence of a sufficient amount of water in the body). Record review of CR#1's admission MDS dated [DATE], revealed the resident's BIMS score was 13, which indicated his cognition was intact. CR#1 used a wheelchair, and required set-up or clean-up assistance with eating, oral hygiene, and upper body dressing. He required supervision for personal hygiene and moderate assistance for toileting, lower body dressing, rolling to the left or right, sitting to lying position, sit to stand position, and chair/bed-to chair transfers. Record review of CR#1's baseline care plan, dated [DATE], did not reveal problems, goals, or interventions related to the resident's regular or PRN use of oxygen. Further review of the care plan revealed he was at risk for infections. Interventions included nursing staff assessing him for any symptoms of confusion, changes in mental status, delirium or confusion, following the policy for reportable conditions, and consulting with physician, PA, CNP, therapy, and dietitian. Record Review of Emergency Services records, dated [DATE], did not reveal oxygen provided to the resident, by the facility, on [DATE] prior to EMS' arrival. However, review of the records revealed the following: Call Recieved: 2:58 PM Dispatched: 2:59 PM En Route: 3:00 PM On Scene: 3:03 PM At Patient: 3:06 PM Depart Scene: 3:21 PM Level of Service: Advanced Life Support Transportation Mode Description: Lights and Sirens Clinical Impression Primary Impression: Altered Mental Status Onset Time: 3:00 PM [DATE] Duration: 2 Hours Signs & Symptoms: Hypotension (the pressure of blood circulating around the body is lower than normal or lower than expected), Altered Mental Status (changes in consciousness and symptoms that can affect many organ systems), Tachycardia (a heart rate over 100 beats a minute), Tachypnea (abnormally rapid breathing) Barriers of Care: Psychologically Impaired Initial Patient Acuity: Emergent Assessment Time [DATE] 3:09 PM Mental Status: Confused; Unresponsive Skin: Cold; Dry Breath Sounds Clear and Equal Sepsis Screening performed: [DATE] at 3:15 PM qSOFA Criteria Met: Yes SIRS Criteria Met: Yes Sepsis infection suspected or documented: Yes ETCO2 less than 25 mmHg: Yes Systolic Blood Pressure less than 100 mmHg: Yes Respiratory Rate greater than 22 breaths/min: Yes Glasgow Coma Scale less than 15: Yes Temperatire less than 36 celsius or greater than 30 celsius: No Heart Rate greater than 90 bpm: Yes Respiratory Rate greater than 20 breaths/min: Yes Vital Signs Time: 3:08 PM; BP ,d+[DATE]; Pulse 107; RR: 25; SPO2: 100 room air; ETCO2: 21.0 mmHg 3:14 PM; Pulse 72: RR: 38; SPO2 98 room air; ETCO2: 22.0 mmHg 3:15 PM BP: ,d+[DATE]; Pulse: 56; ETCO2: 18.0 mmHg; Temp: 98.1 3:20 PM BP: ,d+[DATE]; Pulse: 93; RR: 25; SPO2: 98 room air 3:24 PM BP: ,d+[DATE]; Pulse: 114; RR: 23; SPO2: 98 room air; ETCO2: 21.0 mmHg 3:28 PM BP: ,d+[DATE]; Pulse: 118; RR: 23; SPO2: 95 room air; 20.0 mmHg 3:32 PM BP: ,d+[DATE]; Pulse: 77; SPO2: 95 room air; ETCO2: 18.0 mmHg 3:37 PM BP: ,d+[DATE]; Pulse: 110; RR: 22; SPO2: 99 room air; ETCO2: 18.0 mmHg Treatments 3:08 PM 12-lead Electrocardiogram; Patient Response: Unchanged 3:09 PM Oxygen Nasal Cannula 2 liters per minute; Patient response: Improved 3:15 PM IV Therapy Saline Lock; Patient Response: Improved 3:24 PM IV Therapy Normal Saline (.9% NaCl); Total FLuid 300 mL; Patient Reponse: Improved 3:24 PM Norepinephrine 10 mcg; Intravenous; Patient Response: Improved 3:25 PM Norepinephrine 10 mcg; Intravenous; Patient Response: Improved EMS dispatched to a medical call .responded with emergency traffic .arrived at the NH without delays. Upon arrival found an [AGE] year-old male lying supine on his hospital-like bed. The patient ' s caregiver was on the scene and explained that she found the patient with an altered mental status and called 911. the patient had been at the NH for a fall he suffered 3 weeks ago, according to the caregiver. The patient was responsive to verbal commands but was confused. It was noted that the patient had low blood pressure, was breathing rapidly, and had a rapid pulse rate. The patient did not present with a fever. EMS promptly placed the patient on the EMS stretcher in the Trendelenburg position and ushered him to the back of the ambulance. The patient was placed on a cardiac monitor, and his blood pressure was monitored. EMS noted the patient had difficult veins and a history of cancer and chemotherapy. EMS initiated emergency traffic to the hospital and sent a sepsis alert to the receiving ER. EMS managed to obtain IV access, initiated a fluid challenge, and administered push-dose norepinephrine. The patient ' s mental status did not improve. It was noted that after the norepinephrine administration, the patient's BP improved. EMS arrived at the ER without delays and registered the patient .While waiting, it was noted that the patient ' s BP was decreasing again, so EMS administered another dose of push-dose norepinephirine. The patient ' s BP improved within a couple of minutes After a few minutes, the patient was given a room and moved to the hospital bed using the bed sheet method. The receiving nurse and doctor were given a verbal report, and patient care was transferred . Review of the policy, revised [DATE], titled, Staffing, Sufficient and Competent Nursing revealed the following: Policy Statement: Our facility provides .nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans .Basic nursing skills; m. Identification of changes in condition; 4. Licensed nurses and nursing assistants are trained and must demonstrate competency in identifying .and reporting resident changes of condition consistent with their scope of practice and responsibilities . Review [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure 1 of 7 residents ( Resident # 1) reviewed for care provided, were provided care and services to attain or maintain their highest practicable physical, mental and psychosocial well-being. - Resident #1 sustained a fall on 11/6/15 at 7:00 pm. LVN B did not read Resident #1's full Preliminary x-ray result showing a fracture to the physician on 11/7/15. - A final X-ray report of the fracture was not obtained in a timely manner, resulting in a delay in sending Resident #1 to receive treatment in the hospital. These failures affected 1 resident and placed 6 other residents with a history of falls at risk of not receiving adequate assessments, medical care and services, which could have a negative impact on their health and well-being. Intake: # 3 and 4 Findings include: Resident # 1: Record review of Resident # 1's face sheet revealed a [AGE] year old female with an admission date of [DATE],[DIAGNOSES REDACTED]. Record review Resident #1's quarterly MDS assessment dated [DATE] revealed her cognitive skills for daily decision making were moderately impaired. Resident #1 required extensive assistance for transfer and used a wheelchair, needed extensive assistance of one person with eating. She required extensive assistance for dressing, personal hygiene, bathing. Record review of Resident #1's nurses ' notes revealed Resident #1 had a fall on 11/6/15 at 7:30 p.m. and a bilateral hip x-ray was ordered by the physician. Record review of the preliminary radiology interpretation x-ray report faxed to the facility on [DATE] at 12:45 a.m. The report read: 1- two views of the right hip .Findings: Mildly displaced comminuted intertrochanteric [MEDICAL CONDITION] proximal femur with lateral rotation of the femoral neck and superior sublimation of the more distal femoral fragment . No dislocation. Osteopenia. No other acute fracture identified. Mild to moderate arthritis of the right hip joint .Impression: Comminuted mildly displaced acute right intertrochanteric femur fracture. Consider orthopedic follow up. 2- two views of the left hip: Comparison: None, Findings: Normal alignment. No acute fracture .Osteopenia. Mild to moderate [MEDICAL CONDITION] of the left hip joint. Impression: No acute fracture or dislocation. Record review of the the final X-ray report faxed to the facility on [DATE] at 4:31 a.m. revealed in part: Two views of each hip were submitted .bones are demineralized . Comminuted right intertrochanteric fracture is seen . Preliminary report was provided. In an interview on 11/23/15 at 2:53 p.m. with LVN A (who worked on 11/6/15 from 2:00 p.m. to 10:00 p.m.) she said that CNA A called her to come to Resident #1's room at around 7:30 pm. Resident #1 was sitting on the floor by her bed, with her back by her bed. LVN A said that Resident #1 said she was trying to get her slippers and fell . LVN A said she assessed Resident #1 and assisted her from the floor. Resident #1 did not complain about pain and was able to move all extremities. Resident #1 said she only had eye pain and [MEDICATION NAME] was given. Resident ' s pain scale was 3 at the time. She said she did reassess resident in about 30 minutes and she was sleeping comfortable. LVN A said she called the doctor and the resident's family member to inform them about the fall, but the doctor just told her to continue to monitor. LVN A said that Resident #1's family member later came to the facility and spend the night. Record review of Resident #1's November 2015 Treatments sheet dated 11/6/15 at 7:00 p.m. revealed neurological checks done. On 11/6/15 at 9:00 p.m. Resident #1 was medicated with ([MEDICATION NAME]) [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (1 tablet) by mouth for complaint of pain score of 3. Resident #1 was reassessed on 11/6/15 at 10:00 p.m. and she was sleeping. Interview on 11/23/15 at 2:04 p.m. with LVN B (she worked the 10 pm to 6 am shift) she said she was informed by LVN A during report on 11/6/15 at around 10:00 pm that Resident #1 had fallen. LVN B said she did reassess Resident #1 on 11/6/15 at 11:00 p.m. and no problems were noted. LVN B said she was in Resident #1's room on 11/7/15 at about 1:45 a.m. helping the CNA with incontinent care and while turning Resident #1, the resident complaint of pain in her legs of a score of ten and [MEDICATION NAME] for pain was administered. LVN B consulted the on call doctor who ordered an X-ray to bilateral hips. Further interview at the time with LVN B she said that Preliminary Radiology X-ray result was faxed to the facility and she received it. LVN B said she misread the Preliminary Radiology Interpretation that was faxed to both the doctor and the family. She said the report had two views, but she only read the end of the report. She said she called the doctor who was on call twice to inform him of the report and left a message on the answering service of no fracture. LVN B said after administering the last pain medication, she went to the room to assess the Resident several times and but the family member wanted Resident #1 to be left alone because she was sleeping comfortably. The resident was very quiet and did not complain about any pain during her shift. Record review of Resident #1's November 2015 Treatments record dated 11/7/15 at 2:54 a.m. revealed that Resident #1 was medicated with [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg (1 tablet) by mouth for complaint of pain score of 10. Resident #1 was reassessed at 3:54 a.m. and pain was effective. Interview on 11/23/15 at 3:06 p.m. with RN A who worked the weekend of the incident, revealed she received report on 11/7/15 from LVN B regarding Resident #1 ' s fall . RN A said she went to assess Resident #1 on 11/7/15 at 7:15 a.m. but the resident was sleeping and the family member that was in the room did not want pain medication for the resident. She went back to check on the resident later in the morning and the resident was sitting up in bed eating breakfast and denied any pain. RN A said she went back just before lunch to reassess and the resident denied any pain. She said that at about 12:00 p.m. on 11/7/15 the weekend supervisor said the resident was going to the hospital. In an interview on 11/23/15 at 1:50 p.m. with Resident #1's family member said she called the resident for something else on 11/6/15 in the evening and the resident told her that she had fallen. The family member said that the nurse called her on 11/6/15 at 9:00 p.m. to tell her the resident had fallen and that pain medication was administered at 8:00 p.m. The family member said the facility staff did not call her until 9:00 pm. She also said that when a nurse called her on 11/7/15 after midnight, she was told the x-ray was negative for a fracture. She said it was not until 11/7/15 at around 10:30 am that she was told Resident #1 had a fracture. Record review of the weekend supervisor nurses ' notes revealed at around 10:30 a.m. on 11/7/15 she found two x-ray results for Resident #1 on the fax machine and she went to assess the resident. The resident only reported pain when move in bed. Resident #1 ' s family member was called outside the room and informed of the x-ray result. At 10:45 a.m. the doctor was called and left message on the voice mail. The doctor returned call on 11/7/15 at 11:15 a.m. and ordered Resident #1 to be transferred to a local hospital. The resident left the facility at 1:00 p.m. In an interview with the DON on 12/4/15 at 9:15 a.m. the DON said LVN B was reprimanded for reading the preliminary radiology interpretation wrong. The DON said the weekend supervisor saw the final X-ray with the fracture on 11/7/15 at 10:30 a.m. she said that the Resident was send to the hospital on [DATE] at 1:00 p.m. and had surgery on 11/12/15. The DON said the X-ray company was supposed to call her anytime there is a fracture and that was in the facility signed contract. The DON further stated she call the X-ray liaison to talk about their expectation of calling the DON and Administrator for any positive x-ray report. The DON said in-service was given to all nurses ' to check the fax machine at the beginning of their shift, during the shift and at the end of the shift. In an interview with Resident #1 on 12-4-15 at 9:50 am she said that she fell in the facility and broke her leg. She said that she fell trying to sit on her bed to put her slippers on. She said that she yelled for help and staff came to help her. In an interview with the Administrator on 12/4/15 at 10:00 a.m. she said she had a meeting with the x-ray company liaison on 11/10/15 to add her name for the people to be called on any positive x-ray report fracture. In an interview with the x-ray company liaison on 12/4/15 at 10:30 a.m. she confirmed that the DON was not called to report Resident #1 had a fracture and the results were faxed to the facility. Record review of a signed contract with the X-ray Company dated 1/5/2015 revealed that the X-ray Company was to call the DON at any time there is a positive X-ray for fracture. The facility provided a Resident Census stating that there were 7 residents with history of falls.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with comprehensive assessments and plan of care for 2 of 15 residents reviewed for assessments. (Resident #1, #10) Resident #1's pain medication was not given before pressure ulcer treatment as ordered by the physician. Resident #10 was not provided pain medication per physician's orders. These failures affected 2 residents and placed 71 residents at risk with of not receiving care and services, delay in treatment, complications, and hospitalization . Findings include: Resident #1 Record review of Resident #1's Face Sheet revealed she was a [AGE] year female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review Resident #1's Quality Assessment, Minimum Data Set (MDS) quarterly dated 10/1/14 revealed her cognitive skills for daily decision making was blank. Resident #1 required total assistance for transfer and used a wheelchair, needed extensive assistance of one person with eating. She required total assistance for dressing, personal hygiene, bathing. She was coded as having a stage III or IV pressure ulcers or Eschar measuring 3.2 cm (L) x 01.4 cm (W) x 00.5 cm (D) . Resident #1 was always incontinent of bowel and incontinent of bladder. Review of the facility care plan for pain dated 10/1/14 revealed medicate resident #1 for pain prior to treatments and therapy if indicated, administer [MEDICATION NAME] as ordered, implement pain management flowsheet,observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions ( facial grimacing, bracing, restlessness, rubbing, other). Frequency of monitoring as needed. Notify physician if interventions are not consistently effective. Record review of a physician's order dated 3/28/14 revealed [MEDICATION NAME] ( Tylenol) 325 mg 2 tablets by mouth for pain every 4 hours as needed for ( pain score 1-3) not to exceed 4 grams (= 4,000 mg) of [MEDICATION NAME] in 24 hours period. Observation on 12/15/14 at 4:25 p.m. revealed LVN J administered [MEDICATION NAME] 325 mg 2 tablets to Resident #1. Resident #1 was able to follow direction and responded well to questions asked. Observation on 12/15/14 at 4:34 p.m. revealed LVN (Treatment nurse) performing wound care on Resident #1 with CNA Y assisting. The Resident had a Stage IV sacral pressure ulcer that measured: 3 cm (length) x 1 cm (width) x 1.2 cm (depth). The Treatment nurse did not ask Resident #1 if she was in pain before the procedure or assessed Resident #1 for pain. The Treatment Nurse placed 4 x 4 gauze the sacral wound, used Q-tip pushing the gauze inside the wound and cleaned three times with each time Resident #1 was screaming "it hurts, oh, ouch, ouch, it hurts". Resident #1 pointed to sacral area and continued to say " it hurts". The treatment Nurse kept performing the treatment and said " medication will kick in, just allow sometime". Record review of the physician's order dated 11/18/2014 revealed to administer [MEDICATION NAME] 20mg/ml solution .Give 0.25 ml (=5mg) PO/SL every 4 hours as needed for SOB/severe pain. Further review of the MAR indicated [REDACTED]. Post- Administration pain assessment was not done. There was no documentation on the pain management flowsheet. Record review of Nurses PRN ( as needed ) notes revealed no documentation regarding Resident #1 being medicated for pain on 12/13/14 and 12/14/14. During an interview with the DON on 12/16/14 at 4:00 p.m. she said she monitored LVN (treatment nurse ) daily and medicated the residents with pressure ulcers before treatment. Interview with the treatment Nurse on 12/17/14 at 10:05 a.m. regarding wound care assessment for pain before treatment was performed, she said Resident #1 was given pain medication before her wound treatment today. The treatment Nurse said she should have stop the treatment and come back later when Resident #1 was saying "it hurts, ouch, ouch". Resident #10 Record review of Resident #10 ' s face sheet revealed a [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. During an interview on 12/15/14 at 9:52 a.m., Resident #10 stated that for the last two days (Saturday and Sunday) the only pain medications given to her was two 325 milligram (mg) Tylenol. Resident #10 reported that a male nurse gave it to her and told her no other medication was in stock at the time. Resident #10 reported she requested it several times and her family member also asked staff about pain medication. Resident #10 indicated that her pain was between 6 and 7 on the pain scale and that she would rather have the [MEDICATION NAME] that was prescribed. Observation on 12/15/14 at 9:55 a.m. RN D was observed pulling medication from the E-Kit (emergency kit) [MEDICATION NAME] 10/325 mg and administered it to Resident #10. Record review of care plan on 12/12/14 indicates care plan for arthritis and is at risk for decrease in ADL's (activities of daily living) and increased joint pain. Care plan states that resident currently takes [MEDICATION NAME] for pain to right knee. Another problem care plan indicates pain related to: surgical procedure. Goal is that resident pain will be maintained between 1-3 times a daily bases on scale 1-10. Interventions state 5. Administer pain medication as ordered and assess for adverse reaction of pain medications. 8. States notify Medical Doctor/responsible party of ineffective pain management Record review of admission orders [REDACTED]. Further review of the MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. Record review of pain assessment dated [DATE] on nursing admission indicates pain 6 on 1-10 pain scale and onset of pain started 12/9/14 from total knee replacement. Pain assessment indicates that resident was on prn [MEDICATION NAME] Q 12 hour and [MEDICATION NAME] every 4 hours prn. Further review of the nurses ' notes revealed no documentation that the resident had requested medication stronger than Tylenol on 12/12 or 12/13. Record review of the physician orders dated 12 /14/14 at 4:15 p.m., revealed pain medication was changed to [MEDICATION NAME] 10/325 1 tablet po Q 8 hour 's times for 48 hours, then discontinue. In an interview on 12/16/14 at 5:50 pm the DON reported that if medications are not available staff is to go to the E kit (emergency kit). If medications were not in E kit then nurse should call pharmacy and if that does not work notify the Medical Doctor. She said that narcotics requires a triplicate and can be removed from E- Kit if not immediately available. Interview on 12/17/14 at 10:02 a. m RN D said that for medications ordered and not delivered by the pharmacy they would be taken out of the E-Kit or a large box like the E- Kit in the medication room. The nurse revealed that the E-Kit is for controlled substances and the other box is for routine meds. Further interview and observation with RN D at 10:34 a.m. revealed the E Kit had the following medications on hand [MEDICATION NAME] 15 mg tab, [MEDICATION NAME] 10/325, APAP with [MEDICATION NAME] # 3 300mg/30mg, and [MEDICATION NAME] 50 mg. Records indicate no medication was pulled from E kit on 12/12/14 or 12/13/14. Review of the facility policy and procedure " Lippincott procedures- Pain Assessment revised: October 04, 2013 page 2 of 6... Ask the patient whether he is experiencing any pain. If he answer yes, then ask about the pain's character, quality, onset, location and whether it radiates, duration, and frequency. Determine what exacerbates the pain and what relieves it. Determine whether the patient has a current pain regimen and, if he does, how it relates to his level of pain. Findings from these assessments provide information about the patient's current pain level of pain and provide a baseline for future assessments. The facility form CMS 642 revealed a census of 73.