Every finding on record at The Lev at San Antonio

Based on observation, interview and record review, the facility failed to ensure a registered nurse was designated to serve as the director of nursing on a full-time basis for 1 of 1 facility reviewed for nursing services. The facility failed to ensure a registered nurse was designated as the DON beginning June 15, 2026. This failure could lead to decreased quality of care for residents. Findings included: Record review of the facility staff roster, undated/ reviewed 7/22/2026, did not reflect a staff member designed as DON. During an interview and observation on 7/21/26 at 8:30 AM, the ADM stated the facility did not have a DON and the ADON assumed the duties of the DON until a new DON was hired. The Administrator did not state who was acting as a DON given the ADON's licensure was that of an LVN. Observation of the facility revealed that there was one RN present. During interview on 7/23/2026 at 3:00 PM, the ADON said the previous DON had resigned from the position on 6/15/2026, and there had not been an RN covering the position in the interim. She said the regional [NAME] President of Operations was assisting the facility, but that person was not a registered nurse. During interview on 7/24/2026 at 9:24 AM, the ADM said their regional DON position was currently vacant, the RNs at the facility were not interested in leadership positions, and so there was not a person available to serve at the facility as the DON. She said the facility had hired a new DON who would be starting in August 2026. She said the facility did not have a policy regarding the DON position.

Based on interview and record review, the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions in an effort to discontinue these drugs for 2 of 5 residents (Resident #1 and Resident #2) reviewed for psychotropic medications. The facility failed to s show evidence that a GDR had been attempted unless clinically contraindicated for Residents #1's clonazepam [a medication used to treat anxiety] and Resident #2's citalopram [a medication used to treat depression]. These failures could result in unintended effects of medications for residents. Findings included: Record review of Resident #1's admission Record dated 7/22/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included generalized anxiety disorder [negative feelings of worry or stress that hinder daily life]. Record review of Resident #1's annual MDS dated [DATE] reflected a BIMS score of 14, which indicated intact cognition. Section E of the MDS reflected no negative behaviors were exhibited by Resident #1 during the assessment period. Record review of Resident #1's Care Plan Report undated/ printed 7/22/2026, did not reveal care planning related to previous or future GDR attempts. Record review of Resident #1's Order Summary Report dated 7/22/2026 reflected the following order dated 7/15/2026:ClonazaPAM [sic] Tablet 0.5 MGGive 1 tablet by mouth three times a day for convulsants [sic] [causing seizures] Record review of the facility document titled Consultant Pharmacist/ Physician Communication dated 4/16/2026 reflected the following:Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for trial dose reduction. Current order: clonazepam 0.5mg TID Proposed change: clonazepam 0.25mg TID If dose reduction is contraindicated or resident failed a previous reduction, please document below . At the bottom of the document, the box checked other with the statement psych [sic] follows and manages meds was handwritten with an undated, illegible signature. Resident #1 was hospitalized during survey and therefore unavailable for interviews attempted on 7/23/2026 and 7/24/2026. Record review of Resident #2's admission Record dated 7/22/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included major depressive disorder, recurrent, moderate [persistent feelings of sadness or hopelessness that interfere with daily life]. Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 99, which indicated the assessment could not be performed due to cognitive decline. Record review of Resident #2s Care Plan Report undated/ printed 7/22/2026, did not reveal care planning related to previous or future GDR attempts. Record review of Resident #2's Order Summary Report dated 7/22/2026 reflected the following order dated 6/17/2026:Citalopram Hydrobromide Oral Tablet 10mgGive 3 tablet by mouth one time a day related to DEPRESSION, UNSPECIFIED [sic] . Give 3 tablets to equal 30mg Record review of the facility document titled Consultant Pharmacist/ Physician Communication dated 4/16/2026 reflected the following:Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for trial dose reduction. Current order: citalopram 20mg QDProposed change: citalopram 10mg QD If dose reduction is contraindicated or resident failed a previous reduction, please document below . At the bottom of the document, the box checked other with the statement psych [sic] follows and manages meds was handwritten with an undated, illegible signature. Resident #2 was unable to participate in an interview attempted on 7/22/2026 at 1:43 PM due to cognitive and communication deficits. In an interview on 7/23/2026 at 9;20 AM, the RPh said she did not have documentation for the GDR recommendations she made for Resident #1 and #2 beyond the documentation of other- psych follows and manages meds. She said she had requested follow-up documentation from facility, but they had not provided any. She said she had also requested contact information for the psychiatry provider so that she may send GDR recommendations directly, but she had not been given that information. She was unsure which staff member she had requested this information from but thought it may have been the DON. In an interview with NP A on 7/23/2026 at 1:55 PM, he said he was the psychiatry provider for Residents #1 and #2. He was unsure if he had completed documentation regarding the GDR recommendations for Residents #1 and #2. He said he felt neither resident would have benefitted from a dose reduction in April 2026, but he was unsure if it had been documented. He said he reviewed the GDR recommendations with the facility and would document directly on the forms if he agreed/disagreed and any additional clinical rationale, so if he had not documented on the forms for Resident #1 or #2, then he likely had not been notified that they were due for a GDR evaluation. In an interview with the ADON on 7/23/2026 at 3:00 PM, she said the GDR reviews for Resident #1 and #2 in April 2026 were reviewed by the former DON. She said the facility performs quarterly reviews of all residents' medications due for GDRs, and the documentation was submitted to the pharmacist and kept on record. She said the facility's medical director often defers to psychiatry for recommendations regarding GDR, and the facility follows up. She was unable to provide documentation regarding the April 2026 GDR recommendation for Resident #2. Record review of the documentation provided by the ADON reflected a progress note for Resident #1 dated 4/02/2026 by NP A that read as follows: .however she reports having been visited by her PCP and pain is to be addressed. she [sic] reports feeling optimistic about this and declines adjustment to psychotropic regimen at this time. no [sic] additional needs concerns [sic] or complaints communicated presently . The ADON said during the same interview she was unsure if this information regarding Resident #1 had been communicated to the pharmacist. She was unsure if a residents' decision about GDR timing was sufficient rationale to decline a GDR attempt. Record review of the facility policy titled Use of Psychotropic Medication dated 2022 reflected the following: .6. Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs .

Based on observation, interview and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 5 (Resident #4) residents reviewed for resident rights: The facility failed to have Resident #4's call within reach while he was in bed. This failure could affect residents who use their call light or desire to use the call light and place them at risk of not being able to notify staff of their needsThe findings included: Record review of Resident #4's face sheet, dated 7/24/26 reflected a -[AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included: dysarthria (motor speech disorder) following cerebral infarction (stroke) (primary), respiratory failure, memory deficit, metabolic encephalopathy (brain dysfunction), hypertension, heart failure, kidney disease, and dementia. The RP was listed as: self.Record review of Resident #4's quarterly MDS, dated [DATE], reflected a BIMS score of 9, indicative of moderate impairment in cognition. The ADLs for: B/B were listed as always incontinent. Transfer was listed as dependent while Mobility was listed as substantial/maximal. Toileting was dependent; eating was dependent; and personal hygiene was substantial/maximal. ROM was no impairment. Assistive device was a W/C.Record review of Resident #4's CP, undated, revealed the goal of ADLs with assistance ranging from supervision to substantial/maximal. During an observation and interview on 7/24/26 at 9:02 a.m., Resident #4 was in bed finishing his breakfast meal. The resident was alert and oriented to self. Observation revealed the resident's call light was not in reach of the resident and was situated on the floor under the bed. The resident stated that staff would respond to the lights, and he would also scream for help. The resident stated he could not find his call light. The resident stated he needed the call light because he hurts sometimes and used the call light to get his medications. The Resident added he needed the call light because he poops [bowel movement]. The resident stated on average it took 15-20 minutes for staff to respond to the call light. The resident stated he saw a nursing staff an hour ago (around 8:00 a.m.) that morning for breakfast tray delivery. During an interview on 7/24/26 at 9:18 a.m., CNA E stated he saw the Resident #4 around 7:30 a.m. and the call light was in place. CNA E stated the resident needed a call light in reach to ask for assistance. CNA E stated the resident did use his call light for medications administration, ADLs, and when in pain. CNA E stated when staff did not respond to the call light the resident yelled. CNA E stated the call light might have fallen when resident's bed was raised to a 45-degree angle allowing the call light to fall and staff present not checking before they left during the breakfast tray delivery. During an interview on 7/24/26 at 9:25 a.m., LVN F confirmed that the resident's pressure release call light was on the floor. LVN F stated the call light being on the floor denied the resident the right to request help. LVN F stated she did not notice the call light on the floor when she made rounds about 7:00 a.m., that morning (7/24/26). LVN F stated the call light might have fallen on the floor when staff sat up the resident for breakfast meal and did not realize the call light might have fallen. LVN F stated her expectation when nursing staff provided a meal to the resident was that they check on the placement of the call light before leaving the room. LVN F stated residents were kept safe through monitoring and rounds, and the checking of call light within reach. During an interview on 7/24/26 at 9:40 a.m., the ADON stated she had no explanation why the call light was on the floor involving Resident #4. The ADON stated her expectation was that a call light was in reach of residents because the call light allowed the resident to call for assistance. The ADON stated what should have happened through rounding or after leaving the resident's room (Resident #4) was that the staff should have checked on the placement of the call light. During an interview on 7/24/26 at 10:00 a.m., CNA G stated she recalled that on 3/21/26 [date is correct] she responded to a call light from Resident #4 where his roommate, Resident #5, threw a trash can at him. CNA G stated Resident #4 could use the call light to ask for assistance as evidenced by him using the call light on 3/21/26 for an alleged act of abuse. CNA G stated the call light needed to be in reach of Resident #4 because he was confused at times. During an interview on 7/24/26 at 11:14 a.m., the Administrator stated regarding Resident #4's call light observed on the floor, the staff were trained to round on the call lights, and she had no explanation for the call light being on the floor. The Administrator stated that the call light needed be within reach of a resident because that is how they communicate to get assistance.Record review of facility's Call Lights: Accessibility and Timely Response policy, dated 20222, read Staff will ensure the call light is within reach of resident and secured as needed.

Based on interview and record review, the facility failed to ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of five residents (Resident #1 and Resident #2) reviewed for pharmacy services. The facility failed to ensure the indication for Resident #1's medication, clonazepam, was ordered for the accurate, intended diagnosis. The facility failed to ensure the indication for Resident #2's medication, finasteride, was ordered for the accurate, intended diagnosis. These failures could lead to improper monitoring of the therapeutic effects of residents' medications. Findings included: 1.Record review of Resident #1's admission Record dated 7/22/2026 reflected a [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included generalized anxiety disorder [negative feelings of worry or stress that hinder daily life]. Record review of Resident #1's annual MDS dated [DATE] reflected a BIMS score of 14, which indicated intact cognition. Section E of the MDS reflected no negative behaviors were exhibited by Resident #1 during the assessment period. Record review of Resident #1's Order Summary Report dated 7/22/2026 reflected the following order dated 7/15/2026:ClonazaPAM [sic] Tablet 0.5 MGGive 1 tablet by mouth three times a day for convulsants [sic] [causing seizures] Record review of Resident #1's July 2026 MAR, dated 7/22/2026 reflected Resident #1 had received the clonazepam in July 2026, as ordered. Record review Resident #1's progress notes revealed documentation from NP A dated 6/18/2026 which indicated Resident #1 was prescribed clonazepam 0.5 mg three times a day for anxiety. In an interview on 7/23/2026 at 9:20 AM, the RPh said her records reflected Resident #1 was prescribed clonazepam for anxiety. She said she was unable to view the facility's records related to Resident #1's prescriptions due to technical issues, but she did not have any records indicating Resident #1 had a history of seizures. She said she reviewed the medication regimens for all residents at the facility on a monthly basis, she and had not seen a clonazepam order for Resident #1 with a documented indication of convulsants. In an interview with NP A on 7/23/2026 at 1:55 PM, he said Resident #1 was prescribed clonazepam for anxiety, and she had been taking the medication since before he was responsible for her care. In an interview with the ADON on 7/23/2026 at 3:00 PM, she said Resident #1 was prescribed clonazepam for anxiety, and she was unsure why the order was entered with an indication for convulsants. She said the orders entered by nursing staff were reviewed during the facility's morning meeting to ensure the accuracy of the orders, and she was unsure how this order had not been noticed and corrected. She said having incorrect indications for medications could lead to improper monitoring of the effects of the medications. 2. Record review of Resident #2's admission Record dated 7/22/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included need for assistance with personal care. Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 99, which indicated the assessment could not be performed due to cognitive decline. Record review of Resident #2's Order Summary Report dated 7/22/2026 reflected the following order dated 3/26/2026:Finasteride 5 MG TabletGive 1 tablet my mouth one time a day for GENITOURINARY AGENTS [sic] females of childbearing age should not touch or handle crushed or broken tablets Record review of Resident #2's July 2026 MAR dated 7/22/2026 reflected he had been received the finasteride as ordered. In an interview with the RPh on 7/23/2026 at 9:20 AM, she said she reviewed the medication regimens for all residents at the facility on a monthly basis. She said she was unable to view the facility's records related to Resident #2's prescriptions during the interview due to technical issues, but genitourinary agents was not a proper indication for a medication because the term described the medication class and not the reason Resident #2 required the medication. In an interview with the ADON on 7/23/2026 at 3:00 PM, she said Resident #2 was prescribed finasteride due to urinary issues relating to an enlarged prostate (physical obstruction making urination difficult). She said the orders entered by nursing staff are reviewed during the facility's morning meeting to ensure the accuracy of the orders, and she was unsure how this order had not been noticed and corrected. She said having incorrect indications for medications could lead to improper monitoring of the effects of the medications. Record review of the facility policy titled Use of Psychotropic Medication dated 2022 reflected the following: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #6) reviewed for infection prevention. The facility failed to ensure staff utilized proper infection control practices, including PPE, when providing care for Resident #6. This failure could lead to the spread of infection and illness. Findings included: Record review of Resident #6's admission Record dated 7/22/2026 reflected a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included dependance on renal dialysis (when the body requires artificial filtering of the blood). Record review of Resident #6's quarterly MDS dated [DATE] reflected a BIMS score of 13, which indicated intact cognition. Section O0100 J1. of the MDS reflected Resident #6 required dialysis treatments, and section O0100 O1 (IV access) was not assessed. Record review of Resident #6's Order Summary Report dated 7/22/2026 reflected the following order dated 6/15/2026:Resident is on Enhanced Barrier Precautions r/t dialysis port: Use gown and gloves for high-contact resident care. May use face shield as needed if there is risk for splash or spray. every shift [NAME] gloves and gown before high contact resident care. Remove gown and gloves and handwash/sanitize hands, before exiting the room or before providing care to another resident in the room. In an observation and interview on 7/22/2026 at 1:40 PM, CNA B was observed providing incontinent care to Resident #6. CNA B was not wearing a gown while performing the procedure. Resident #6's exterior door did not have signage that indicated Resident #6 required EBP. CNA B initially said Resident #6 did not require EBP, as evidenced by the lack of signage. She then said Resident #6 had a dialysis catheter on his chest and did require EBP, and he should have a sign on his door indicating the precautions. She said she should have worn a gown as well as gloves when providing the care, and the failure to do so could lead to the spread of infection. She said she had received training regarding infection prevention but had forgotten to use proper PPE because the sign had somehow been misplaced. In an interview on 7/22/2026 at 1:45 PM, LVN C said Resident #6 required EBP. She was unsure where the sign indicating the EBP was, and she said it had been there previously. In an interview with the ADON on 7/23/2026 at 3:00 PM, she said she served as the facility's Infection Preventionist, and the facility expectation was resident's requiring EBP would have proper signage. She said staff are expected to follow guidelines for PPE and had all received training. Record review of the facility policy titled Enhanced Barrier Precautions dated 2022, reflected the following: .c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves .4. High-contact resident care activities include: .d. Providing hygiene .f. Changing briefs or assisting with toileting .

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals for 1 of 4 medication carts (MA Cart 500 Hall) reviewed for storage of drugs. The facility failed to ensure the cart for 500 Hall was locked and secured. This deficient practice could place residents at risk of medication misuse and diversion.The findings were: Observation on 3/16/2026 at 1:54 pm of the MA Med Cart for 500 Hall revealed it was unlocked. During an interview with MA A on 3/16/2026 at 1:56 p.m., MA A confirmed med cart for 500 hall was unlocked. She stated it was unlocked because she was putting stuff away and was getting ready for shift change to another hall. She stated the cart should not be unlocked because it would be unsafe for residents to have access to the medications. During an interview with ADON on 3/19/2026 at 10:04 am - she stated the medication cart should have been locked to prevent someone from having unauthorized access and for resident safety. Record review of the facility policy titled Medication Storage, revealed, All drugs and biologicals will be stored in locked compartments. Only authorized personnel will have access to the keys to locked compartments.

Based on observation, interview and record review the facility failed to ensure to maintain all mechanical and electrical equipment in safe operating condition in 1 of 1 kitchen reviewed for equipment. The facility failed to ensure the temperature gauge on the dishwasher was working properly and the sanitation level was reaching between 50 PPM and 100 PPM to properly disinfect the dishware. 2. The DS failed to provide an updated water temperature and sanitation log for the dishwasher for documenting readings to ensure the equipment was working properly. These deficient practices could place residents at risk of not having equipment working in safe conditions. The findings were: A record review of the chemical temperature log for the month of September 2025 revealed there was not a log for the month of September 2025. A record review of the chemical temperature log for the month of August 2025 revealed 93 opportunities to document the water temperature and sanitation level with 21 of the 93 opportunities documented were below 50 PPM for the sanitation level and there were 8 missing opportunities for documentation. They were blank. Observation and interview on 09/07/2025 at 9:19 AM revealed DA A running the dishwasher and taking a reading of the level of sanitation in the dishwasher. Interview with DA A revealed the temperature gauge was not reading higher than 103 degrees. She stated the gauge was not working but mentioned it was working last Thursday (9/4/25), on the last day she worked before her days off. Further observation revealed she tested the sanitation level by dipping test strip and inserted into the reservoir on the outside of the dishwasher. She stated it was barely reaching 25 PPM and noted the color on the test strip did not match the color designating 50PPM. DA A stated she noted the sanitation level was reading low for at least the past three weeks and had brought it up to the DS's attention. She stated last Thursday, 9/4/25, she checked the sanitization level twice and the results were also low that day. She stated it should read at least 50 PPM. for it to kill all the bacteria otherwise it could make the residents sick. DA A further stated she was not documenting the water temperature or the sanitation level because there was not an updated log for September 2025. During an observation and interview on 9/7/2025 at 10:18 AM revealed DA A in the kitchen plating desserts in dishware she had previously washed in the morning. DA A presented the chemical / temperature logs for August 2025 which were kept on a clipboard by the DS's office. DA A stated she tested the water chemical sanitizer level prior to using the dishwasher. DA A stated the chemical level was obtained by using a chemical test strip dipped in the dishwasher water while in operation and comparing the test strip to the color scale on the side of the test strip container / bottle. DA A stated for days in August and September the test strip was below the required 50 PPM level and she had reported the finding to the DS. DA A stated she had measured the dishwasher chemical sanitizer water level this morning and the finding was below 50 PPM somewhere around 25 PPM. DA A stated she did not document the findings because there was no log for September 2025. DA A stated she recalled on 9/4/2025 the dishwasher chemical sanitization water level was below 50 PPM. Interview on 09/07/2025 at 10:21 AM with the DS revealed dietary aides were assigned dishwashing duties to include checking the dishwasher for proper sanitization chemical levels and water temperature three times a day before using the dishwasher to wash and sanitize dishes, utensils, pots pans etc. The DS stated the chemical sanitizer would be checked by using a chemical litmus paper strip and placing the test strip in the chemically infused water while the dishwasher was washing dishes and the test strip would be held against the color palette on the side of the litmus paper strip bottle. The DS stated the color reading should match the color palette to indicate 50 PPM of chemical sanitizer in the water and the minimum water temperature should reach 120 F. The DS stated both the chemical level of 50 PPM and the 120 F temperature were required for the dishwasher to effectively sanitize the dishes. The DS stated she would have the dietary aides do a demonstration to ensure they were doing it correctly. The DS stated 10 minutes ago she was informed by Dietary Aide A that Dietary Aide A had exchanged the chemical sanitizer because the chemical sanitizer was not reaching 50 PPM water saturation. The DS stated the lack of documentation and chemical sanitizer levels below 50 PPM could have a negative potential for germs and un-sanitized dishes and utensils. Interview on 9/7/25 at 3:35 PM with the DS revealed she did not know the sanitation levels for the dishwasher were reading 45 PPM before today, 9/7/25. She stated no one had said anything to her. She stated they received the new dishwasher a couple of months ago. She stated if not in the facility, dietary staff was to call her when there was a problem with any of the equipment. She stated she had in-serviced staff related to operating procedures for the dishwasher, temperature levels which should be between 120 and 140 degrees and in reading the sanitation levels in the water which should read between 50 and 100 PPM. She stated she would call the service company if the water temperatures or sanitation levels were outside of required parameters. She stated she called the service provider some time back because the temperature gauge was not working but never because the sanitation levels were reading low. Interview on 9/8/25 at 10:13 AM with DA A revealed she would run the dishwasher twice before washing the dishes and as stated in a previous interview, she noted the sanitation was under 50 PPM for the last 3 weeks. She stated it was right under 50 PPM so she documented it as being 45 PPM. She stated she let one of the Cooks know that there was not a current log for September 2025 for documenting the water temperature and sanitation level for the dishwasher. She stated the Cooks were in charge when the DS was not available. Interview on 9/825 at 10:43 AM with DA P revealed she would operate the dishwasher and would document the temperature and sanitation level on a piece of paper and leave it on the DS's desk because there was not a log for September 2025. She stated she did not remember the readings. Interview on 9/8/25 at 10:58 AM with DA Q revealed he had worked the dishwasher a couple of weeks ago but did not document the temperature or sanitation level because there was not a log for September 2025. During an interview on 9/8/2025 at 11:00 AM the DON revealed the opportunities when the dishwasher was operated below the effective water chemical sanitization levels could have potentially exposed residents to food borne illness. The DON stated the census on 9/7/2025 was 76 residents with a potential to affect 90% of the residents who received foods / meals from the kitchen. The DON stated no one had reported the kitchen's dishwasher had been operating below the chemical sanitizer level of 50 PPM. The DON stated if she had been aware of the situation she would have called for immediate action to include the correction of the chemical sanitizer to effectively sanitize dishware and an assessment of all potentially affected residents. Interview on 9/8/25 at 3:06 PM with the service provider for the facility dishwasher revealed he serviced the dishwasher on 9/7/25 because the DS reported the temperature gauge was not working and the sanitation level was reading low. He stated upon testing the dishwasher he noted the temperature gauge was not working properly and he replaced it. He also tested the sanitation level which was reading 10 PPM and stated it should reach between 50 and 100 PPM. He stated the sanitation level should reach the required parameters and the water temperature should reach 120 degrees during the wash cycle and 140 degrees during the rinse cycle in order for the dishware to properly sanitize and disinfect the dishware removing any bacteria. The service provider stated the DS manager had not reported any problems with the dishwasher before 9/7/25. Interview on 9/8/25 at 4:47 PM with the ADM revealed she was the DS immediate supervisor and expected the DS to ensure all the equipment was running properly, that the temperature logs for all appliances including the dishwasher were updated and that she ensured dietary staff completed the tasks assigned to them. The ADM stated she expected the DS to let her know of any problems and if not able to resolve the issues she would assist as needed. She stated she learned that on 9/7/25 the sanitation level in the dishwasher was reading 45 PPM and the temperature gauge was not working properly. She stated the DS had not reported any problems prior to 9/7/25. The ADM stated the DS should have noted the temperature logs for all appliances including the dishwasher had not been updated while rounding. In addition, the DS should have known the sanitation levels were low and reading 45 PPM during August 2025 and she should have addressed the problem at that time. The ADM stated that not properly sanitizing the dishware could lead to foodborne illness and the residents could get sick as a result. Review of facility policy, Dishwasher Temperature, undated, read in relevant part It is the policy of this facility that the dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. Policy Explanation and Guidance: 1. All items cleaned in the dishwasher will be washed in water that is sufficient to sanitize any and all items. 2. Manufacturer's instructions shall be followed for machine washing and sanitizing. 4. For low temperature dishwashers (chemical sanitation): a. The wash temperature shall be 120 degrees Fahrenheit. b. The sanitizing solution shall be 50 PPM (parts per million) hypochlorite (chlorine) on dish surface in final rinse. 5. Chemical solutions shall be maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time according to manufacturer's guidelines. Results of concentration checks shall be recorded.

Based on observation, interview and record review the facility failed to store, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 Kitchen reviewed for sanitary conditions.Dietary staff failed to ensure:a. the plastic bag of powdered milk was sealed stored in the stand-up refrigerator,b. the cookies they provided for snacks were not expired andc. the temperature logs were posted on the walk-in refrigerator, freezer and stand-up refrigerator and failed to record daily temperatures for all stated appliances. These deficient practices could place all residents at risk for food borne illnesses. The findings were:Observation on 09/07/2025 at 9:15 AM, during Initial tour, revealed an open plastic bag of powdered milk. Further observation revealed the temperature log on the stand-up refrigerator, freezer and walk-in refrigerator ended on 8/31/25. There were no other logs posted anywhere in the kitchen and there were no current temperatures of any of the appliances. Interview on 9/7/25 at 9:10 AM with [NAME] L revealed the plastic bag of powdered milk should be sealed because mold could grow in it or other food items could fall inside the bag and contaminate the milk. [NAME] L stated it could cause the residents to get sick. She stated they served powered milk to all residents for breakfast. [NAME] L further stated the DS usually posted the temperature logs on the stand-up refrigerator, freezer and walk-in refrigerator. She stated she did not know where the DS kept the logs. [NAME] L stated she would read the temperature gauge on the appliances to make sure they were within range but did not record them anywhere because the logs had not been updated. She stated the refrigerators should not be over 41 degrees and the freezer should be between 0 and 32 degrees. Interview on 9/7/25 at 3:35 PM with the DS revealed she left the temperature logs for the walk-in refrigerator, stand-up refrigerator, and the freezer with the Cooks. They should have posted the logs on the appliances but should have made sure they were in place while making rounds in the kitchen. Interview on 9/8/25 at 11:24 AM with [NAME] M revealed the temperature log on the stand-up refrigerator, freezer and walk-in refrigerator ended on 8/31/25 as well as the food temperature logs. He stated he did not know where the DS kept the logs but had continued to take temperatures. He stated he would take daily food temperatures on write them on the back of the production sheets but eventually they had been thrown away. Interview on 9/8/25 at 1:53 PM with the DS revealed she was responsible for ensuring all the temperature logs for the walk-in refrigerator, stand-up refrigerator, the freezer and for the food were provided and in place. She stated she had taken a lot of time off in the last couple of weeks due to personal reasons and guessed she missed making sure the temperature logs were available and that dietary staff was recording the temperatures on the appliances on for the food. The DS stated it was important temperatures were taken of the appliances and the food to ensure the temperatures were within a safe range for service otherwise it could make the residents sick. The DS also stated that all plastic bags of food in the refrigerator should be sealed to prevent it from being contaminated and if left open and served it could also make the residents sick. Observation and interview on 9/10/25 at 12:41 PM revealed a bin of bagged cookies with the date 8/27/25 placed on the prep table placed outside the pantry. There was not an end date. DA O stated they baked the cookies yesterday, but the date on the bin was not updated. DA O stated it should have been updated to reflect the actual date the cookies were baked. She stated the cookies were good for three days and should not be served beyond the three days because it could make the residents sick. Interview on 9/10/25 at 12:55 PM with the DS revealed dietary staff prepped snacks every morning for the afternoon and evening snack times for the same date and for the following morning snack time at 10 AM. She stated any leftover snacks left over after the following morning were discarded. The DS stated dietary staff probably forgot to change the date on the snack bin. She stated the cookies were not cooked and delivered in bulk form. She presented a box of oatmeal cookies and stated they received the cookies on 8/24/25 which was written on the box. She stated the best by date, was 9/3/25 which was the expiration date. She stated dietary staff should not serve them because it could make the residents sick but stated there was another box of cookies and those were the cookies dietary staff prepped for the residents. She stated the box was thrown away. When asked when it was thrown away, she stated 1 or 2 days ago. Review of a facility policy, Date Marking for Food Safety, undated revealed in relevant part 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 5. The discard day or date may not exceed the manufacturer's use-by date.8. Note: prepared foods that are delivered to the nursing units shall be discarded within two-hour, if not consumed. These items shall not be refrigerated as the time/temperature controls cannot be verified. Review of a facility policy, Food Safety Requirements, undated revealed in relevant part Policy Explanation and Compliance Guidelines:1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following:b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.

Based on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 7 medication carts reviewed for storage of drugs and biologicals. - The facility failed to ensure the treatment cart was locked and secured.- The facility failed to ensure the medication cart for the 400 hall was locked and secured. These failures could place residents at risk of medication misuse or drug diversion. The findings included: During an observation on 9/7/2025 at 9:03 AM revealed the facility's nurse treatment cart unlocked, unattended and unsupervised. The treatment cart had miconazole antifungal powder, an enzyme paste collagenase (an enzyme ointment which breaks down dead tissue), hypochlorous acid (HOCl), a solution designed for wound care, cleanser for debriding and irrigating wounds, ulcers, burns, and non-intact skin, and other wound care medications. During an interview on 9/07/2025 at 9:06 AM LVN K stated the treatment cart was unlocked, and LVN H had the keys. LVN K stated the cart had wound care medications, and the cart should be locked. LVN K stated the unlocked cart could have a negative outcome for residents by medications being taken out of the cart. During an interview on 9/07/2025 at 9:08 AM LVN H stated she was the nurse assigned the treatment cart. LVN H stated the cart was left unlocked. LVN H stated the keys were by the nurse’s station. LVN H stated the cart contained medications and the possible negative outcome could be loss of medication control. A record review of the facility’s undated policy titled “Medication Storage” revealed, “it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medication rooms according to the manufacturers recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy explanation and compliance guidelines; general guidelines; all drugs and biologicals will be stored in locked compartments (i.e., medication carts, drawers, refrigerators, medication rooms) under proper temperature controls. ….” Observation and interview on 09/09/2025 at 4:43 PM, LVN G was observed in a room with a resident administering medications. His medication cart was observed sitting outside of the resident's room unlocked and unattended. LVN G stated his medication cart should have been locked if he walked away from it. Interview on 09/11/2025 at 4:37 PM, the DON stated her expectation is for staff to lock their medication carts prior to walking away from the cart with no screen showing any patient information and no medications sitting on top of the cart. The DON stated there is a risk to residents if a medication cart is left unlocked as other residents could potentially get into the medication cart or anything on top of the cart.

Based on observations, interviews, and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident for 1 of 8 residents (Resident # 47) reviewed for pharmacy services. LVN H did not document an SBAR to Resident #47's physician in which Resident #47 had dislodged her intravenous access and had not received her 1 dose of the prescribed antibiotic. LVN H administered Resident #47's physician ordered antibiotic without documenting the physician's order. This failure could place residents at risk for harm due to not receiving pharmacy services as ordered. The findings included: A record review of Resident #47's admission record dated 9/10/2025 revealed an admission date of 1/4/2022 with diagnoses which included schizophrenia (a chronic mental health condition characterized by a persistent disruption in thoughts, perceptions, and behaviors), dementia (a general term for a group of conditions that cause a gradual decline in cognitive abilities, such as memory, thinking, reasoning, and language), and heart failure. A record review of Resident #47's quarterly MDS assessment dated [DATE] revealed Resident #47 was a [AGE] year-old female admitted for LTC and assessed with a BIMS score of 06 out of a possible 15 which indicated severe cognitive impairment. A record review of Resident #47's care plan dated 9/10/2025 revealed, (Resident #47) is at risk for adverse reactions related to polypharmacy . if resident has more than one prescribing medical doctor ensure that each physician has the full list of meds available including over the counter and as needed medications while ordering. A record review of Resident #47's physicians orders dated 9/8/2025 revealed the Physician prescribed for Resident #47 to receive ceftriaxone (a powerful, broad-spectrum antibiotic that works by killing bacteria) 2 grams once a day intravenously at midnight for 5 days for pneumonia starting on 9/9/2025. A record review of Resident #47's nursing progress notes dated 9/9/2025 at 1:52 AM revealed LVN I documented, Patient pulled out IV tubing. pending (intravenous access contractor) to replace iv. A record review of Resident #47's Nursing Progress notes dated 9/9/2025 at 7:57 AM revealed LVN H documented, IV Ceftriaxone 2mg/100ml started and running well. IV placed to right forearm- posterior. A record review of Resident #47's physicians orders and medication administration record for September 2025 revealed no order for a 1-time administration of ceftriaxone 2 grams intravenously at 7:57 AM on 9/10/2025. During an interview on 9/9/2025 at 7:41 PM LVN I stated Resident #47 was diagnosed with pneumonia and was prescribed Ceftriaxone intravenously daily at midnight with the first dose scheduled for 9/9/2025 at midnight. LVN I stated she was the nurse on duty at that time but had not given the medication because Resident #47 had pulled out her IV access earlier in the day and could not administer the medication. LVN I stated she worked 9/8/2025 from 2:00 PM to 9/9/2025 at 6:00 AM. LVN I stated she organized the intravenous contractor to arrive early 9/9/2025 to re-establish the intravenous access for Resident #47. LVN I stated she gave report to LVN H at 6:00 AM 9/9/2025. During an interview on 9/10/2025 at 1:39 PM LVN H stated she had received report from LVN I on 9/9/2025 at 6:00 AM which included Resident #47 had removed her IV access and had not received her first dose of her antibiotic. LVN H stated the intravenous access contractor had arrived shortly after 6:00 AM on 9/9/2025 and re-established her intravenous access. LVN H stated she had SBAR'ed (a report of situation, background, and recommendation) the physician and received a 1-time order to administer Resident #47 antibiotic now and continue with the scheduled antibiotic daily at midnight. LVN H stated she had not documented the report to the physician and had not entered the order into the physician's order summary nor the medication administration record. LVN H stated she administered the antibiotic on 9/9/2025 at 7:57AM and had not documented the administration on Resident #47's medication administration record. During an interview on 9/11/2025 at 4:30 PM the DON stated the expectation for nurses who reported a change of condition to a physician was for the nurse to accurately and timely document the report to include any new orders. The DON stated the documentation could be but not limited to the physicians' orders, the medication administration record, and the progress notes. The DON stated she received a report that LVN H had not documented the physicians new order for a 1-time medication administration of Resident #47's antibiotic nor had LVN H documented the change of condition SBAR for Resident #47's loss of intravenous access and missed first dose of her antibiotic. The DON stated LVN H also had not documented Resident #47's antibiotic administration on 9/9/2025 at 7:57 AM in Resident #47's medication administration record. The DON stated the potential negative outcome could be lack of documentation for Resident #47's medication administration. During an interview on 9/11/2025 at 5:00 PM the administrator stated she agreed with the DON's findings regarding LVN H and Resident #47's intravenous antibiotic administration. A record review of the facility's undated policy titled Medication Administration revealed, 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, any manner to prevent contamination or infection. policy explanation and compliance guidelines; . review MAR to identify medication to be administered.

Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 28 medication administration opportunities with 2 errors resulting in a 7.14% medication error rate, for 1 of 8 residents (Resident #57) reviewed for medication administration errors. Medication Aide J administered to Resident #57 his prescribed:Metoclopramide (a prescription medication used to treat and prevent nausea and vomiting, and to manage certain gastrointestinal issues.)Gabapentin (a prescription medication used to treat nerve pain and epilepsy.)Late by 51 minutes. These failures could place residents at risk for not receiving the therapeutic effects of their medications. The findings included: A record review of Resident #57's admission record dated 9/10/2025 revealed an admission date of 6/26/2025 with diagnoses which included diabetes mellitus with diabetic neuropathy (nerve damage related to high blood sugar levels) and gastro-esophageal reflux (a condition where stomach contents flow back up into the esophagus, causing irritation and inflammation.) A record review of Resident #57'a quarterly MDS assessment dated [DATE] revealed Resident #57 was a [AGE] year-old male admitted for LTC and assessed with a BIMS score of 12 out of a possible 15 which indicated intact cognition. A record review of Resident #57's care plan dated 9/10/2025 revealed, (Resident #57) has diabetes mellitus . diabetes medication as ordered by doctor . (Resident #57) had GERD related to hyperacidity . give medications as ordered . A record review of Resident #57's physicians orders dated 9/10/2025 revealed the physician prescribed for Resident #57 to receive:- Metoclopramide oral tablet 5mg give 1 tablet by mouth three times a day at 9:00 AM, 3:00 PM, and at 9:00 PM, related to GERD.- Gabapentin oral capsule 100mg give 2 capsules by mouth two times a day at 7:00 AM and at 3:00 PM related to diabetic neuropathy. During an observation and interview on 9/9/2025 at 4:51 PM revealed Medication Aide J prepared and administered to Resident #57 his metoclopramide 5mg and his gabapentin 100mg 2 capsules 51 minutes past the prescribed 3:00 PM to 4:00 PM time frame. Medication Aide J stated she had administered Resident #57's medications 51 minutes past the prescribed 3:00 PM to 4:00 PM time frame because when she attempted to administer the medications around 3:00 PM Resident #57 was receiving a bath and she made the decision to re-attempt later in the afternoon. Medication Aide J stated she had not alerted the charge Nurse to the potential late medication administration. During an interview on 9/11/2025 at 4:30 PM the DON stated the expectation was for medication aides and nurses to administer residents' medications at the time the prescriber intended with a time frame of 1 hour prior and 1 hour past the prescribed time. The DON stated a medication ordered for administration at 3:00 PM and administered at 4:51 PM would be 51 minutes past the acceptable time frame. The DON stated the potential negative outcome could be residents would not receive the intended therapeutic effects of their prescribed medications. A record review of the facility's undated policy titled Medication Errors revealed, this is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. definitions; medication error means the observed or identified preparation or administration of medications 4 biologicals which is not in accordance with prescribers' order . medication error rate is determined by calculating the percentage of errors observed during a medication observation. The numerator is the total number of errors that is observed, both significant and non-significant. The denominator consists of the total number of observations or opportunities of error it includes all the doses observed being administered plus the doses ordered but not administered. The equation for calculating the visionary is as follows: medication error rate = number of errors observed divided by the opportunities for errors. the facility shall insure medications will be administered as follows: according to physicians' orders. 5% or as well as their events.

Based on observations, interviews, and record reviews the facility failed to establish an infection prevention and control program with written standards, policies, and procedures for standard and transmission-based precautions to be followed to prevent spread of infections for 1 of 3 residents (Resident #7 and Resident #28) reviewed for disinfecting the glucometer in between Residents. LVN G did not disinfected the glucometer after assessing Resident #28's blood sugar level and then attempting to assess Resident #7's blood sugar level. This failure could place residents at risk for blood borne pathogens and infections. The findings included: Resident #28A record review of Resident #28's admission record dated 9/10/2025 revealed an admission date of 8/8/2025 with diagnoses which included type II diabetes, infectious gastroenteritis (common stomach flu), and sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection.) A record review of Resident #28's Quarterly MDS assessment dated [DATE] revealed Resident #28 was a [AGE] year-old male admitted for LTC. A record review of Resident #28's physicians orders dated 9/10/2025 revealed the physician prescribed for Resident #28 to receive insulin injections before meals per a sliding scale as per his blood sugar levels. Resident #7A record review of Resident #7's admission record dated 9/10/2025 revealed an admission date of 2/18/2025 with diagnoses which included diabetes, pneumonia, and sepsis (a life-threatening illness that develops when an existing infection triggers an extreme immune system response in your body.) A record review of Resident #7's quarterly MDS assessment dated [DATE] revealed Resident #7 was a [AGE] year-old female admitted for LTC. A record review of Resident #7's physicians orders dated 9/10/2025 revealed the physician prescribed for Resident #7 to receive insulin injections before meals per a sliding scale as per his blood sugar levels. During an observation on 9/8/2025 at 4:20 PM revealed LVN G prepared a glucometer (a portable medical device used to measure blood glucose sugar levels) without disinfecting the glucometer and proceeded to Resident #28 and assessed Resident #28's blood sugar level by developing a drop of blood from Resident #28's finger. Further observation revealed LVN G continued to the medication cart to document Resident #28's blood sugar levels. LVN G was observed to preform hand hygiene but had not disinfected the glucometer. Continued observation revealed at 4:29 PM LVN G proceeded to Resident #7 with the same glucometer used to assess Resident #28. LVN G attempted to assess Resident #7 by developing a drop of blood from Resident #7 when the state surveyor intervened and impeded LVN G prior to developing a drop of blood from Resident #7. During an interview on 9/8/2025 at 4:30 PM LVN G recognized he had not disinfected the glucometer in between assessing Resident #28 and Resident #7. LVN G stated he would disinfect the glucometer with an approved chemical wipe for blood borne pathogens. LVN G stated the potential risk for residents could be cross contamination which could include blood borne pathogens. During an interview on 9/11/2025 at 4:30 PM the DON stated the expectation for assessing residents for blood sugar levels was for the nursing staff to disinfect the glucometers prior to and in between residents' use. The disinfectant must be a chemical wipe designated to disinfect for blood borne pathogens. The DON stated the potential negative outcomes for not disinfecting the glucometer in between resident use was cross contamination for infections. A record review of the facility's undated policy titled Glucometer Disinfection revealed, the purpose of this procedure is to provide guidelines for the disinfection of capillary blood glucose sampling devices to prevent transmission of bloodborne diseases to residents and employees. Definitions: disinfection is a process that eliminates many or all pathogenic microorganisms except bacterial spores on inanimate objects . policy explanation and compliance guidelines, the facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi resident use.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to make choices about aspects of his or her life in the facility for 1 of 8 (Resident #4) reviewed for resident rights. Resident #4 was not informed of the care being provided to her regarding a cut on her face received during a surgical procedure. These failures could place residents at risk of not having choices regarding treatment.Record review of Resident #4's admission Record, dated 09/12/2025, reflected that Resident #4 was initially admitted on [DATE] with diagnoses of schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Record review of Resident #4's Diagnosis Report, dated 09/12/2025, reflected that Resident #4 was diagnosed with schizoaffective disorder, depressive type on 04/03/2025, and bipolar disorder on 12/03/2024. Record review of Resident #4's Quarterly MDS Assessment, dated 06/17/2025, reflected that Resident #4 had a BIMS score of 14, indicating intact cognition. Further review reflected that Resident #4 had diagnoses of anxiety disorder, depression, bipolar disorder, and schizophrenia. Record review of Resident #4's Comprehensive Person-Centered Care Plan, dated 09/09/2025, reflected, [Resident #4] uses psychotropic medications r/t schizoaffective disorder depressed type initiated on 05/29/2025, and [Resident #4] has a mood problem r/t mood disorder due to known physiological condition with depressive features, bipolar disorder, anxiety disorder initiated on 02/26/2025. Record review of Resident #4's Skin Assessment, dated 09/07/2025, reflected that the Wound Care Nurse had assessed Resident #4 with a cut on the right side of her cheek with no new orders. Interview on 09/08/2025 at 10:25 AM, Resident #4 stated that somehow, she got a cut on her cheek, about an inch, next to her nose, during a surgery the week prior. Resident #4 stated that a nurse looked at it but has not told her the plan of care. Resident #4 stated that she preferred to have some sort of ointment for the cut since it is on such a prominent area of her face. Resident #4 stated she told the nurse she was concerned about the cut scarring. Interview on 09/10/2025 at 9:35 AM, the Wound Care Nurse stated that she did a skin assessment for Resident #4 at which time, Resident #4 had voiced concern for the cut on her face. The Wound Care Nurse stated she had told Resident #4's physician of the cut on her face and that there were no new orders. The Wound Care Nurse stated she had not talked to Resident #4 about no new orders for the laceration on her face. Interview on 09/11/2025 at 4:37 PM, the DON stated her expectation is to complete a risk management injury of unknown origin form, which would prompt staff to follow-up with notifying the physician/NP, RP, and to detail the treatments and/or monitoring. The DON stated she was told by the Wound Care Nurse that she was not informed of Resident #4's laceration to her face because it's a scab. The DON stated that scarring could be a negative outcome of not informing residents of treatment options when lacerations occur. Record review of facility policy, undated, titled, Resident Rights reflected, The resident has the right to be informed of, and participate in, his or her treatment, including: .d. The right to be informed by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the laternative or option he or she prefers.

Based on observations, interviews, and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which had been furnished as well as that which had not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 8 residents (Resident #77) reviewed for making a grievance. Resident #77 made a grievance to CNA D that she no longer wished for CNA E to provide care for her and CNA D did not initiate a grievance report nor did she report Resident #77's grievance to anyone. This failure could place residents at risk for not having their grievances heard and or resolved. The findings included: A record review of Resident #77's admission record dated 9/10/2025 revealed an admission date of 1/9/2023 with diagnoses which included complete quadriplegia (a severe spinal cord injury that results in the complete loss of motor and sensory function below the neck), major depressive disorder, and bipolar disorder (a mental health condition characterized by significant and persistent shifts in mood, energy, and behavior between periods of highs and extreme lows.) A record review of Resident #77's quarterly MDS assessment dated [DATE] revealed Resident #77 was a [AGE] year-old female admitted for LTC and assessed with a BIMS score of 15 out of a possible 15 which indicated no cognitive impairment. A mood assessment revealed Resident #77 had experienced some episodes of feeling down, depressed, and hopeless and feelings of isolation and loneliness over the review period August 2025. Further review revealed Resident #77 was assessed as requiring assistance with her needs for Activities of Daily Living (ADL), dependent - helper does all of the effort. Resident does none of the effort to complete the activity. A record review of Resident #77's care plan dated 9/10/2025 revealed, (Resident #77) is dependent on staff for meeting emotional, intellectual, physical, and social needs related to quadriplegia. all staff to converse with resident while providing care. (Resident #77) has an ADL self-care performance deficit related to quadriplegia . the resident is totally dependent on one or two staff per personal hygiene all care. During an observation and interview on 9/07/2025 at 11:18 AM Resident #77 revealed Resident #77 in her room and in her bed. Resident #77 stated she was a quadriplegic and could not move herself other than use her head and speak. Resident #77 stated she was dependent on staff for all her needs and felt disrespected and ignored when staff would not communicate with her in English. Resident #77 stated she only spoke English and could not understand Spanish. Resident #77 stated many of the facility's staff only spoke Spanish and the language barrier was a significant detriment to her ability to ask for help or to request specific needs. Resident #77 stated she could not communicate with staff regarding the quality of incontinent care and specified she felt the staff had not thoroughly cleaned her with incontinent care. Resident #77 stated when she would attempt to communicate her wishes Spanish Speaking staff would often assume, incorrectly, what she meant. Resident #77 stated she felt frustrated when the language barrier produced events where staff would stare at her with a grin while not comprehending her wants and needs. Resident #77 stated how frustrating and demoralizing the experience when all she could do is speak and no one could understand her; simple tasks such as enjoying a meal, a drink, being comfortable and clean became unpleasant experiences. Resident #77 stated she had reported this grievance to staff which included CNA D and included her wish to not have CNA E provide care for her anymore. During an interview on 9/8/2025 at 2:40 PM with CNA D stated she had received a grievance from Resident #77 in the afternoon of 9/7/2025 which included she no longer wished for CNA E to provide care for her due to CNA E's inability to speak and or understand English. CNA D stated she had not initiated a grievance report and had not reported the grievance to anyone. During an interview on 9/11/2025 at 3:20 PM LVN F stated she was the nurse for Resident #77 and supervised CNA D. LVN F stated Resident #77 only spoke English and was not aware if Resident #77 could understand Spanish. LVN F stated she believed CNA E could understand some English and expected CNAs to speak to residents in English. LVN F stated she was unaware CNA D had received a grievance from Resident #77 and would expect for staff to report grievances and to initiate a grievance report. During an interview on 9/11/2025 at 5:10 PM the DON stated the expectation was for staff to assist residents to initiate grievance reports whenever the staff receive a grievance. The DON stated CNA D had reported she had not initiated Resident #77 grievance on 9/7/2025 and on 9/8/2025 CNA D assisted Resident #77 to document a grievance report. The DON stated the grievance was reported to the Administrator and was in the review process for adequate resolution. The DON stated the potential negative outcome could be residents would not have their grievances heard and or resolved. During an interview on 9/11/2025 at 6:00 PM the Administrator stated she concurred with the DON and would address the grievance process with an in-service for the staff. A record review of the facility's undated policy titled, Resident and Family Grievances revealed, it is the policy of this facility to support each resident and family members right to voice grievances without discrimination, reprisal, or fear of discrimination or reprisal . a resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their long term care facility stay. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form . forward the grievance form to the grievance official as soon as practicable.

Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program for residents with newly evident or possible serious mental disorder for 1 of 8 Residents (Resident #6) whose records were reviewed related to PASARR screenings. The facility failed to refer Resident #6 for Level I screening after being diagnosed with a mental disorder. This failure could place residents with new mental diagnoses at risk for not receiving services as identified by PASARR. The findings included:Record review of Resident #6's admission Record, dated 09/11/2025, reflected that Resident #6 was initially admitted on [DATE] with diagnoses of Bipolar II Disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), end stage renal disease (condition in which the kidneys lose the ability to remove waste and balance fluids), and type 2 diabetes mellitus. Record review of Resident #6's Diagnosis Report, dated 09/11/2025, reflected that Resident #6 was diagnosed with Bipolar II Disorder on 04/10/2025. Record review of Resident #6's Quarterly MDS Assessment, dated 06/11/2025, reflected that Resident #6 had a BIMS score of 9, indicating moderate cognitive impairment. Further review reflected Resident #6 had a diagnosis of bipolar disorder. Record review of Resident #6's Comprehensive Person-Centered Care Plan, dated 09/10/2025, reflected, [Resident #6] has a mood problem r/t Bipolar disorder initiated on 04/23/2025. Record review of Resident #6's Electronic Health Record reflected that Resident #6 had not had a PASARR since his admission PASARR. PASARR dated 3/31/2025did not reflect resident had a diagnosis of bipolar disorder and depression. Interview on 09/10/2025 at 10:04 AM, the Social Worker stated that she had recently become the person who oversaw PASARR at the facility. The Social Worker stated she was uncertain if a new PASARR should be done if a new diagnosis is added if they have already had a PASARR assessment that has resulted in a negative initial PASARR screening. Interview on 09/11/2025 at 4:37 PM, the DON stated her expectation was for PASARR screenings to be completed if they receive a new diagnosis. The DON stated that all notes from behavioral health are reviewed by MDS for new diagnoses and staff would be informed by MDS about these new diagnoses. The DON stated that there is the risk for residents to not receive appropriate benefits if they do not get a new PASARR screening after receiving a new diagnosis. Record review of facility policy titled, Resident Assessment - Coordination with PASARR Program, undated, reflected, Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.

Based on observations, interviews, and record reviews, the facility failed to ensure each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility and each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for 2 of 16 residents (Resident #77 and Resident #32) reviewed for a dignified existence. CNA D, who was bilingual and CNA E, who only spoke Spanish, provided incontinent care for Resident #77 while only speaking Spanish although Resident #77 could not understand Spanish and felt disrespected and demoralized.LVN B and LVN H failed to take action when Resident #32 reported a change in condition which resulted in Resident #32 questioning whether she mattered. These deficient practices could place residents at risk for feeling unworthy and for an undignified existence.The findings included: 1. A record review of Resident #77’s admission record dated [DATE] revealed an admission date of [DATE] with diagnoses which included complete quadriplegia (a severe spinal cord injury that results in the complete loss of motor and sensory function below the neck), major depressive disorder, and bipolar disorder (a mental health condition characterized by significant and persistent shifts in mood, energy, and behavior between periods of highs and extreme lows.) A record review of Resident #77’s quarterly MDS assessment dated [DATE] revealed Resident #77 was a [AGE] year-old female admitted for LTC and assessed with a BIMS score of 15 out of a possible 15 which indicated no cognitive impairment. A mood assessment revealed Resident #77 had experienced some episodes of feeling down, depressed, and hopeless and feelings of isolation and loneliness over the review period [DATE]. Further review revealed Resident #77 was assessed as requiring assistance with her needs for “Activities of Daily Living” (ADL), “dependent – helper does all of the effort. Resident does none of the effort to complete the activity.” A record review of Resident #77’s care plan dated [DATE] revealed, “(Resident #77) is dependent on staff for meeting emotional, intellectual, physical, and social needs related to quadriplegia. … all staff to converse with resident while providing care. … (Resident #77) has an ADL self-care performance deficit related to quadriplegia … the resident is totally dependent on one or two staff per personal hygiene all care.” During an observation and interview on [DATE] at 11:18 AM revealed Resident #77 in her room and in her bed. Resident #77 stated she was a quadriplegic and could not move herself other than use her head and speak. Resident #77 stated she was dependent on staff for all her needs and felt disrespected and ignored when staff would not communicate with her in English. Resident #77 stated she only spoke English and could not understand Spanish. Resident #77 stated many of the facility’s staff only spoke Spanish and the language barrier was a significant detriment to her ability to ask for help or to request specific needs. Resident #77 stated she could not communicate with staff regarding the quality of incontinent care and specified she felt the staff had not thoroughly cleaned her with incontinent care. Resident #77 stated when she would attempt to communicate her wishes Spanish Speaking staff would often assume, incorrectly, what she meant. Resident #77 stated she felt frustrated when the language barrier produced events where staff would stare at her with a grin while not comprehending her wants and needs. Resident #77 stated how frustrating and demoralizing the experience when all she could do is speak and no one could understand her; simple tasks such as enjoying a meal, a drink, being comfortable and clean became unpleasant experiences. During an observation and interview on [DATE] at 2:21 PM revealed Resident #77 in bed requesting incontinent care. CNA D and CNA E entered Resident #77 room and began organizing Resident #77’s room for incontinent care which included sanitization of the bedside table, preparing supplies, and providing privacy. CNA D greeted Resident #77 in English and CNA E greeted Resident #77 in Spanish. Observation of the incontinent care revealed CNA D and CNA E conversed with each other in Spanish and had not translated their conversation to Resident #77. Resident #77 throughout the care experience had addressed the CNAs regarding details of the care they were providing and CNA E responded to Resident #77 in Spanish. Resident #77 stated the experience was frustrating but not uncommon. During an interview on [DATE] at 2:40 PM with CNA D and CNA E, CNA E stated she could understand some English but could not speak English and CNA D stated she was bilingual and recognized CNA E could not understand details in English. CNAs D and E agreed they had provided care for Resident #77 and conversed with each other in Spanish and had not translated any of the conversation to Resident #77. During an interview on [DATE] at 3:20 PM LVN F stated she was the nurse for Resident #77 and supervised CNA D and E at times. LVN F stated Resident #77 only spoke English and was not aware if Resident #77 could understand Spanish. LVN F stated she believed CNA E could understand some English and expected CNAs to speak to residents in English. LVN F stated she was unaware CNA D and E provided care to Resident #77 while speaking Spanish and not translating the communication with Resident #77. During an interview on [DATE] at 5:10 PM the DON stated the expectation was for staff to provided dignified care to residents while communicating in a language the residents could understand and for staff to understand residents wants and needs which were expressed in English. The DON stated a language barrier could contribute to Residents’ frustration and demoralization. During an interview on [DATE] at 6:00 PM the Administrator stated she concurred with the DON and would address the language barrier between the staff and residents and would bring the problem to the QAPI committee. A record review of the facility’s undated policy titled, “Resident Rights” revealed, “when residents' knowledge of English or the predominant language of the facility is inadequate for comprehension, a means to communicate the information concerning rights and responsibilities in a language familiar to the resident will be made available and implemented ….” 2. Review of Resident #32's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses including Cardiomyopathy, unspecified (a disease of the heart muscle. It causes the heart to have a harder time pumping blood to the rest of the body, which can lead to symptoms of heart failure) and Type 2 Diabetes Mellitus (condition that occurs when the body develops insulin resistance and no longer responds effectively to insulin) with diabetic polyneuropathy (occurs when there is damage to multiple nerves in the peripheral nervous system in different parts of the body at the same time. Peripheral nerves are the nerves outside the brain and spinal cord). Review of Resident #32's quarterly MDS assessment, dated [DATE], revealed her BIMS score was 10 of 15 reflective of moderate cognitive impairment, she had history of Diabetes Mellitus and Cardiomyopathy. Review of Resident #32's Care Plan, revised [DATE], revealed she had Diabetes Mellitus, interventions included Diabetes medication as ordered by doctor. Monitor/document for side effects andeffectiveness. Further review revealed Resident #32 was at risk for acute pain and has chronic pain r/t Diabetic Polyneuropathy and interventions included Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Review of Resident #32's progress notes from [DATE] to [DATE] revealed there were no nurse's progress noted entered related to Resident #32 reporting numbness to her left arm, left leg and having chest pain Interview on [DATE] at 1:05 PM with Resident #32 revealed her left arm and left leg felt completely numb a couple of times in the last couple of weeks. She stated she also felt a sharp pain on her chest (she put her left hand over her heart). She stated she reported her symptoms to a day nurse and a night nurse. Resident #32 stated she did not remember their names. She stated one night she rubbed and massaged her arm until it felt better. She stated she had not heard anything back from the nursing staff. Resident #32 stated a female doctor came by but only ordered labs. Resident #32 commented, I know I'm old and I'm going to die maybe that's why the nurse's haven't done anything. I don't know what's going on. Resident #32 stated she felt sad because she was worried about her health. Interview on [DATE] at 4:37 PM with the DON revealed that nursing staff had not reported Resident #32's change of condition, her reported concerns regarding her having numbness to her left arm, left leg or having chest pain. She stated she imagined Resident #32 felt like she was not important and did not feel good about the fact that nursing staff had not taken any action. The DON stated It was important that nursing staff completed a change of condition form, document a progress note, assess the resident, report it to the MD/NP and follow any new orders so the resident received the care and services as needed. The DON stated failure to do so could jeopardize the resident's health and in Resident #32's case she expected nursing staff to send her out via 911. The DON stated Resident #32 could have had a heart attack and died. The DON stated nursing staff should also report any changes to her and or the ADON, so everyone was aware of the changes and there was a continuity of care for Resident #32. Review of the facility’s undated policy titled, “Resident Rights”, undated, revealed in relevant part Respect and dignity. The resident has a right to be treated with respect and dignity.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the residents choices for 2 of 13 residents (Resident #4 and Resident #32) reviewed for quality of care. 1.Resident #4 did not receive wound care to a laceration on her face after voicing concerns over lack of wound care and potential scarring. 2.LVN B and LVN H failed to act upon Resident #32's change of condition when she reported her left arm and left leg were going numb and having chest pain. These failures could place residents at risk for not receiving appropriate care and treatment and/or a decline in their health. The findings included:2. Review of Resident #32's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with diagnoses including Cardiomyopathy, unspecified (a disease of the heart muscle. It causes the heart to have a harder time pumping blood to the rest of the body, which can lead to symptoms of heart failure) and Type 2 Diabetes Mellitus (condition that occurs when the body develops insulin resistance and no longer responds effectively to insulin) with diabetic polyneuropathy (occurs when there is damage to multiple nerves in the peripheral nervous system in different parts of the body at the same time. Peripheral nerves are the nerves outside the brain and spinal cord). Review of Resident #32's quarterly MDS assessment, dated [DATE], revealed her BIMS score was 10 of 15 reflective of moderate cognitive impairment, she had history of Diabetes Mellitus and Cardiomyopathy. Review of Resident #32's Care Plan, revised [DATE], revealed she had Diabetes Mellitus, interventions included Diabetes medication as ordered by doctor. Monitor/document for side effects andeffectiveness. Further review revealed Resident #32 was at risk for acute pain and has chronic pain r/t Diabetic Polyneuropathy and interventions included Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Review of Resident #32's progress notes from [DATE] to [DATE] revealed there were no nurse's progress noted entered related to Resident #32 reporting numbness to her left arm, left leg and having chest pain Interview on [DATE] at 1:05 PM with Resident #32 revealed her left arm and left leg felt completely numb a couple of times in the last couple of weeks. She stated she also felt a sharp pain on her chest (she put her left hand over her heart). She stated she reported her symptoms to a day nurse and a night nurse. Resident #32 stated she did not remember their names. She stated one night she rubbed and massaged her arm until it felt better. She stated she had not heard anything back from the nursing staff. Resident #32 stated a female doctor came by but only ordered labs. Resident #32 commented, I know I'm old and I'm going to die maybe that's why the nurse's haven't done anything. I don't know what's going on. Resident #32 stated she felt sad because she was worried about her health. Interview on [DATE] at 1:51 PM with LVN H revealed she verbalized her understanding of identifying a resident's change of condition and the facility protocol. She stated a change of condition was a resident experiencing anything out of the ordinary like someone throwing up twice a shift; something that had not happened before. She stated, I would notify the MD, RP, assess the resident and complete a change of condition evaluation in the resident's record. LVN H stated an assessment included taking the resident's vitals. She stated she would report them to the MD. LVN H stated about two weeks ago Resident #32 reported her arm was going numb. She stated Resident #32 told her she met with NP C and NP C ordered labs. LVN H stated she called NP C, confirmed the labs with NP C and she entered the new order for the labs into Resident #32's record. LVN H stated she did not pass the information to the oncoming nurse because she believed NP C had addressed Resident #32's concerns but stated she did not discuss Resident #32's reported concern with NP C. She stated Resident #32 also mentioned she told another nurse so again she believed the Resident's concern had been addressed. LVN H stated she did not look in Resident #32's progress notes to ensure her reported concerns had been addressed. She stated when she assessed Resident #32, she did not see anything out of the ordinary and if she wrote a progress note it would be in Resident #32's electronic record. LVN H stated she did not complete a change of condition, did not write a note in the 24-hour report and did not call the RP. LVN H stated depending on the situation she could let the DON know about it and stated she did not report Resident #32's reported concerns it to the DON. LVN H then stated NP C said Resident #32 told her about the numbing of the arm and that's why she ordered labs. LVN H stated NP C ordered a CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) and Magnesium test (the signs of low or high magnesium levels). She stated she did not know the results. Interview on [DATE] at 3:09 PM with NP C revealed she met with Resident #32 on [DATE] during rounds. She stated she met with Resident #32 every time while at the facility because Resident #32 always had something to complain about. She stated Resident #32 did not report numbness to her left arm, left leg and or having chest pains to her. NP C stated nursing staff called her about the labs she ordered for Resident #32 but did not call her to report numbness to Resident #32's left arm, left leg or that she was having chest pains. NP C stated sometimes Resident #32 was not consistent when sharing her concerns but if Resident #32 was experiencing reported symptoms nursing staff should have called her to report Resident's signs and symptoms. NPC stated she would have ordered an EKG ((electrocardiogram) is a quick, non-invasive test that records the electrical activity of your heart to help diagnose various heart conditions) or at the very least would provide nursing staff with an order to administer nitroglycerin (Nitroglycerin is a medication used to treat or prevent chest pain (angina). NP C stated Resident #32 could have had a heart attack or worse, especially if she had a diagnosis of Cardiomyopathy. Interview on [DATE] at 4:03 PM with LVN B revealed she normally worked 2:00 PM to 10:00 PM; the second shift. She stated Resident #32 was able to communicate her needs with staff. LVN B stated she did not remember NP C's last visit, but stated she worked, Saturday, [DATE]. Then, LVN B stated she remembered NP C being at the facility during the early morning hours but did not provide any new orders. LVN B stated, to her, Resident #32 did not look like she was experiencing any changes on [DATE]. She stated Resident #32 mentioned a couple of weeks ago about having numbness to her left arm. She stated she administered 4 units of insulin that same night and Resident #32 complained of pain. She stated she called NP C and NP C scaled the sliding scale insulin back to level 1 on the sliding scale. LVN B stated she thought Resident #32's numbness was related to the pain. She stated Resident #32 said she told another nurse about having numbness, but nursing staff had not said anything to her during report. LVN B stated Resident #32's reported numbness to her left arm was considered to be a change of condition because Resident #32 had never reported numbness before. LVN B stated for a change of condition, she should report it to NP C, write a progress note and report it to the ADON/DON. She stated she would also notify the family. LVN B stated the first thing she would do was assess Resident #32, take vital signs before reporting the findings to NP C and would follow any new orders. LVN B stated she assessed Resident #32 who told her she barely had any feeling to her left arm. LVN B stated she took Resident #32's vitals which were within normal limits but stated she did not document the vitals. LVN B stated it slipped my mind, but again stated, but I completed a full assessment, and her vitals were within normal limits. LVN B stated she should also pass on the information in report so staff would be aware of Resident #32's change of condition and were up to date about Resident #32's concerns. LVN B stated she did not pass the information during report to the on-coming nurse. She stated because she did not tell the on-coming nurse, there was a lag in communication and it was possible there would not be any follow up related to Resident #32's change of condition. LVN B stated Resident #32 could have gotten worse. She stated she woke Resident #32 up once during the night after reporting numbness and Resident #32 said she was feeling better. LVN B stated Resident #32 did not report having chest pain. Interview on [DATE] at 4:37 PM with the DON revealed nursing staff had not reported Resident #32 having numbness to her left arm. She stated she was also not aware that Resident #32 reported numbness to her left leg and had chest pain. The DON stated It was important that nursing staff completed a change of condition form, document a progress note, assess the resident, report it to the MD/NP and follow any new orders so the resident received the care and services as needed. The DON stated failure to do so could jeopardize the resident's health and in Resident #32's case she expected nursing staff to send her out via 911. The DON stated Resident #32 could have had a heart attack and died. The DON stated nursing staff should also report any changes to her and or the ADON, so everyone was aware of the changes and there was a continuity of care for Resident #32. Review of facility policy, Notification of Changes, undated, read in relevant part: Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications. Record review of Resident #4’s admission Record, dated [DATE], reflected that Resident #4 was initially admitted on [DATE] with diagnoses of schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and Parkinson’s disease (disorder of the central nervous system that affects movement, often including tremors). Record review of Resident #4’s Diagnosis Report, dated [DATE], reflected that Resident #4 was diagnosed with schizoaffective disorder, depressive type on [DATE], and bipolar disorder on [DATE]. Record review of Resident #4’s Quarterly MDS Assessment, dated [DATE], reflected that Resident #4 had a BIMS score of 14, indicating intact cognition. Further review reflected that Resident #4 had diagnoses of anxiety disorder, depression, bipolar disorder, and schizophrenia. Record review of Resident #4’s Comprehensive Person-Centered Care Plan, dated [DATE], reflected, “[Resident #4] uses psychotropic medications r/t schizoaffective disorder depressed type” initiated on [DATE], and “[Resident #4] has a mood problem r/t mood disorder due to known physiological condition with depressive features, bipolar disorder, anxiety disorder” initiated on [DATE]. Record review of Resident #4’s Skin Assessment, dated [DATE], reflected that the Wound Care Nurse had assessed Resident #4 with a cut on the right side of her cheek with no new orders. Interview on [DATE] at 10:25 AM, Resident #4 stated that somehow, she got a cut on her cheek, about an inch, next to her nose, during a surgery the week prior. Resident #4 stated that a nurse looked at it but has not told her the plan of care. Resident #4 stated that she preferred to have some sort of ointment for the cut since it is on such a prominent area of her face. Resident #4 stated she told the nurse she was concerned about the cut scarring. Interview on [DATE] at 9:35 AM, the Wound Care Nurse stated that she did a skin assessment for Resident #4 after coming back from surgery on [DATE]. The Wound Care Nurse stated she had while she had told Resident #4’s physician of the laceration on her face, it was not documented anywhere and that there were no new orders. The Wound Care Nurse stated she had not talked to Resident #4 about not receiving new orders for the laceration on her face, but that the Wound Care Nurse remembered Resident #4 being concerned that the laceration would scar. Interview on [DATE] at 4:37 PM, the DON stated her expectation is to complete a risk management injury of unknown origin form, which would prompt staff to follow-up with notifying the physician or NP, RP, and to detail the treatments and/or monitoring. The DON stated she was told by the Wound Care Nurse that she was not informed of Resident #4’s laceration to her face because “it’s a scab”. The DON stated that scarring could be a negative outcome of not informing residents of treatment options when lacerations occur. The DON stated that her expectation for injuries, particularly if a resident is concerned for scarring, is to listen to their concerns and implement any suggestions for care if appropriate, such as an ointment for the facial laceration. Interview on [DATE] at 7:20 PM, NP C stated that she had seen Resident #4 on [DATE] and had ordered wound care on the laceration on Resident #4's face. NP C stated she was not aware why the Wound Care Nurse had not implemented these orders. No records were found in Resident #4's Electronic Health Record to support any wound care orders prior to [DATE] after surveyor intervention.

Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 6 residents (Resident #25) reviewed for care plan revisions. The facility failed to ensure Resident #25's care plan was comprehensive and reflected uncontrollable nausea and vomiting during the resident's menstrual cycles. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included:Record review of Resident #25's face sheet, dated 09/11/2025, reflected that Resident #25 was a [AGE] year-old female resident with an initial admission of 10/08/2021 with diagnoses of hypoglycemia (condition in which the body's blood sugar level goes below the standard range), bipolar disorder, and type 2 diabetes mellitus. Record review of Resident #25's Quarterly MDS Assessment, dated 06/09/2025, reflected that Resident #25 had a BIMS score of 11, indicating moderate cognitive impairment. Record review of Resident #25's Comprehensive Person-Centered Care Plan, dated 09/08/2025, did not reflect any information related to Resident #25's menstrual cycle. Interview on 09/08/2025 at 2:05 PM, LVN B stated that Resident #25 has uncontrollable nausea and vomiting while she was on her menstrual cycle most months. Interview on 09/09/2025 at 9:37 AM, NP C stated that Resident #25 had frequent uncontrollable nausea and vomiting while she was on her menstrual cycle most months, and that there is a standing order for Zofran because of it. Interview on 09/11/2025 at 4:37 PM, the DON stated that Resident #25's uncontrollable nausea and vomiting during her menstrual cycle should be on a care plan. The DON stated that if it is not in the care plan the resident has the risk of other staff not being aware of that symptom and could lead to misdiagnosis. A policy on updating care plans was requested on 09/11/2025 at 4:45 PM and was not provided to the survey team prior to exit.

Based on observations, interviews, and record reviews the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility for 1 of 3 years of recertification surveys (2024) for survey results reviewed. The facility posted the results for annual recertification survey for 2023 and omitted the most recent survey results from 2024. This failure could deny residents, Resident representatives, and the public from examining the most recent survey results. The findings included:The findings included: During an observation and record review on 9/7/2025 at 3:50 PM revealed the facility's survey results binder by the receptionist desk in the facility's public common area. the survey results binder was kept in a wall mounted binder holder. The binder contained results from previous surveys with the latest date of 2/16/2024. A record review of the Texas Unified Licensure Information Portal (TULIP) website accessed 9/7/2025 revealed the last recertification survey for the facility was 8/30/2024. During an interview on 9/11/2025 at 5:00 PM the Administrator stated it was their policy to ensure the most recent survey results were kept in the binder and made public. The Administrator stated the binder with the most recent survey results was kept in a binder on the wall by the receptionist desk in the facility's public lobby. The Administrator stated it was her responsibility to ensure the results of the most recent survey were kept in the binder and stated the most recent survey results were from August 2024. The Administrator stated she was unaware the results were not in the binder. The administrator stated the potential negative outcome could be that Residents, Resident representatives, and the public would be denied examining the most recent survey results. A policy was requested, and the Administrator stated the facility followed HHSC guidelines.

Based on observations, interviews, and record reviews the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 1 facility reviewed for safe and clean environment clean medication-cart wheels. The facility failed to maintain the floors free from seeping adhesive glue used to secure the flooring and causing the wheels of the medication carts to become matted with hair and debris. This failure could place residents at risk for dirty floors and wheeled equipment.The findings included: A record review of Resident #68's admission record dated 9/11/2025 revealed an admission date of 10/18/2023 with diagnoses which included acquired absence of both right and left legs, type II diabetes (a disease which results in the body's cells inability to utilize blood sugars and thus high levels of blood sugars produce negative effects), and chronic obstructive pulmonary disease (a group of long-term lung conditions such as emphysema and chronic bronchitis which cause shortness of breath, coughs that gets worse and could affect daily activities over time.) A record review of Resident #68's quarterly MDS assessment dated [DATE] revealed Resident #68 was a [AGE] year-old male admitted for LTC and assessed with a BIMS score of 14 out of a possible 15 which indicated no impairment of cognition. Further review revealed Resident #68 was assessed with adequate vision, hearing, and could make himself understood and could understand others. Resident #68 was assessed with the need of a wheelchair for ambulation. A record review of the facility's letter from the flooring contractor dated 9/12/2025 revealed, Subject: Flooring Concerns;To whom it may concern, We have had several issues with the flooring at the above location due to the glue sent to us by the manufacture of the floor. (Contractor) has been out to try to rectify the issue and has been in contact with the flooring company and the community throughout this process. - June 19, 2024, (Contractor) was on site to relay the flooring due to having issues with the glue used for the flooring. - September 24, 2024, crew came in with a floor cleaning and buffing machine, closed any gaps from the deep clean, and set glue on areas coming up, left marked with painter's tape. - October 14, 2024, crew sent to continue working on spot checking floors, scraping up painter's tape and assessing areas that were glued once more from last visit. - November 14, 2024, the office manager met with facility crew to look at the issue. - July 10, 2025, met with (facility Maintenance Director) to round on glue replacement, found that previous attempts were not successful, discussed other glue options used internally by the community in the BOM office. - July 19, 2025, crew sent to remove sections of flooring, clean and reinstall with different manufacturer glue. - August 14, 2025, met with (the Administrator) to discuss a plan to make repairs. - September 8, 2025, spoke to (the Administrator) again about what could be done due to the glue not adhering and leaking out the edges of the flooring. Tentative plan to remove all flooring and replace with new glue, pending scheduling arrangements. We have been in contact with the warranty department for the flooring and it has been determined to be an issue with the glue itself. Sincerely, CEO (Contractor). During daily observation from 9/8/2025 through 9/11/2025 revealed the facility's floors were dirty with glue seeping from the tiles / planks. During daily observation from 9/8/2025 through 9/11/2025 revealed the facility's medication-carts wheels were clotted with matted hair and debris. During an observation and interview on 9/11/2025 at 11:34 AM with the facility's Housekeeping Director (HK Director) and Resident #68; the HK Director stated the floors were dirty with the glue which was used by the flooring contractor which has continued weeping up from under the floor and gums up the floor. The HK Director stated she and the maintenance director had attempted to clean and mop the floors but could not contain the flooring glue from weeping / oozing out and acting like gum collecting dirt. The HK stated she would assign staff to assist the maintenance director with attempts to scrape up the glue monthly. The HK director stated the flooring had been weeping glue since the flooring was installed about a year ago. Resident #68 agreed and stated, they need to get a solvent and clean it up or replace the floor with a good sealant. Resident #68 stated the floors were sticky and collected hair and trash which stuck to his wheelchair and would get on his hands as he used his hands to grab the wheels and propel himself. During an interview on 9/11/2025 at 5:00 PM the Administrator stated the flooring contractor had used a faulty ineffective flooring adhesive which had seeped out from underneath the tiles. The Administrator stated she had been coordinating with the flooring contractor since 2024 to remedy the seeping glue and was ready to coordinate a time and space to begin replacing the flooring. The Administrator stated the potential negative effect to residents could place residents at risk for dirty floors and wheeled equipment. A policy was requested, and the Administrator stated the facility followed HHSC guidelines.

Based on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice that would meet the resident's physical needs for 2 of 6 (Residents #22 and #5) residents reviewed for quality of care, in that: 1. The facility failed to ensure Resident #22 had a follow-up appointment with a GI doctor within 4-6 weeks from 05/25/24 for a esophageal stent removal, as recommended. Resident #22 did not have an appointment until 10 weeks later where the stent had migrated into the stomach causing an unanticipated need for removal of the stent from the stomach. 2. The facility failed to ensure Resident #5 had a follow-up appointment with a cardiologist in 4 weeks from January 25th. Resident #5 did not see a cardiologist until her 07/17/24 hospitalization for heart health issues. An Immediate Jeopardy (IJ) situation was identified on 08/29/24. The IJ template was provided to the facility on [DATE] at 02:58 PM. While the IJ was removed on 08/30/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. This failure could place residents at risk for delay in needed treatment and diminished quality of care. The findings included: 1. Record Review of Resident #22's Admission Record, dated 08/28/24, reflected a [AGE] year-old male initially admitted [DATE] with diagnoses to include esophageal obstruction (a blockage or narrowing of the esophagus, the tube that connects the mouth to the stomach), severe protein-calorie malnutrition, surgical aftercare following surgery on the digestive system, dysphagia (difficulty swallowing), gastric ulcer, (open sores on the inner lining of the stomach and the upper part of the small intestine) and gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). Record Review of Resident #22's quarterly MDS assessment, dated 07/23/24, reflected Resident #22 had a BIMS score of 13 out of 15, indicating intact cognition. It further revealed Resident #22 had a feeding tube while a resident. Record Review of Resident #22's care plan, dated 08/28/24, reflected, [Resident #22] requires tube feeding r/t Weight Loss, esophageal obstruction, Severe protein calorie malnutrition., initiated 06/28/24, with an intervention, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated., initiated 06/28/24. Record review of Resident #22's hospital discharge records for 05/18/24-05/25/24, dated 05/25/24, reflected patient was evaluated by gastroenterology due to recommendations per speech therapist secondary to high risk for aspiration due to esophageal stricture Patient with PEG placement with esophageal stent and patient has been cleared to discharge with instructions to have this esophageal stent removed in 6 weeks. And FOLLOW UP: [gastroenterologist] and GI will [coordinate] GI f/u with [GI doctor] to schedule EGD for esophageal stent removal in 4-6 wks. Record Review of Nurses Note, dated 05/26/24 at 02:32 AM and authored by LVN A, reflected Pt [Resident #22] is a readmit arrived at 4pm . Follow up with GI in 4 weeks to remove stent Record Review of Resident #22's hospital documents, dated 08/07/24, reflected reason for visit with the GI doctor was foreign body removal dysphagia. It further reflected the procedure as follows The stent had migrated into the stomach causing an unanticipated need for removal of the stent from the stomach. This removal caused some significant traumatic dilation of the esophagus at the level of the stricture and the stricture was widely patent at the end of the procedure. During an interview on 08/28/24 at 03:05 PM, LVN A was not able to provide specific details about Resident #22 being readmitted in May. She stated she did not recall who needed to make Resident #22's GI appointment, the facility or the GI doctor. During an interview on 08/28/24 at 03:27 PM, the DON revealed if a follow-up doctor's appointment was needed to be made in 4 to 6 weeks and the deadline was approaching, the facility would intervene and make this appointment to include finding a different doctor in the same specialty to have a resident seen in the time frame recommended from hospital discharge paperwork. The DON revealed LVN A could have created a doctor's order for a GI follow up appointment in 4 to 6 weeks from re-admission. She further revealed LVN B, who was to follow a clinical admission checklist to include reading the entirety of residents' hospital discharge paperwork that would allow for necessary doctor's appointments to be made timely. The DON revealed she oversaw these processes and should have caught that a follow up for the GI doctor was needed to be made for Resident #22 in a timely manner. She further revealed the receptionist was making medical appointments; however, the nursing staff were now [after survey investigations] going to start making medical appointments for residents as the nursing staff understood the urgency of making medical appointments. 2. Record Review of Resident #5's Admission Record, dated 08/29/24, reflected an [AGE] year-old female initially admitted [DATE] and readmitted [DATE] with diagnoses to include hypertension (high blood pressure), hypercholesterolemia (excess of cholesterol in the bloodstream), atrial fibrillation (a type of irregular heartbeat), and myocardial infarction (heart attack). Record Review of Resident #5's quarterly MDS assessment, dated 08/09/24, reflected Resident #5 had a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Record Review of Resident #5's hospital discharge paperwork, dated 07/27/24, reflected admitted [DATE] for dysarthria (slurred speech)/NSTEMI (type of heart attack) with discharge instructions to follow-up with [Cardiologist] within 1-2 weeks, which would be 08/03/24-08/10/24. Record Review of Resident #5's hospital records, dated 08/20/24, with admitted [DATE] reflected resident had diagnoses to include stable angina (type of chest pain that happens when your heart muscle needs more oxygen), severe pulmonary HTN (high blood pressure in your pulmonary arteries), CAD (coronary heart disease) status post stents, hypertensive urgency (urgency with elevated blood pressure), and CHF (congestive heart failure). Record Review of Medical Practitioner Note, dated 07/29/24 at 04:44 PM reflected, was originally admitted to [hospital] for NSTEMI . Her hospital stay was complicated with new onset afib, and acute ischemic stroke with transient dysarthria (a type of stroke) which was then resolved . is now admitted here for continuation of medical care and comprehensive (sp) rehabilitation Record Review of Resident #5's doctor's orders, dated 08/27/24, reflected no cardiologist appointment noted. During an interview on 08/28/24 at 06:30 PM, the Facility MD, the facility's Medical Director he stated Resident #22 should have been seen sooner and that geriatric residents were vulnerable. He said residents should be seen by the specialist as requested by the specialist. During an interview on 08/29/24 at 08:56 AM, the medical office specialist at Resident #5's cardiology clinic revealed Resident #5's cardiologist saw Resident #5 on January 25th, 2024 and needed a 4 week follow up appointment. He revealed in the January 25th appointment Resident #5 had acute CHF and needed to come back for her follow up appointment with the cardiologist to see where everything is at with Resident #5's CHF and if her cariologist saw anything alarming, they would have addressed any concerns quickly. He revealed Resident #5 had an appointment February 13th, 2024 but it appeared to be cancelled. He further revealed the nursing facility needed to call back and get this appointment rescheduled. He revealed the nursing facility had not called to make an appointment with Resident #5's cardiologist until 08/05/24. During an interview on 08/29/24 at 11:45 AM, the DON revealed Resident #5 had an appointment on January 25th, 2024 and they did not have paperwork uploaded in Resident #5's medical records to show if there were any follow up appointments needed to be made because the staff member who oversaw medical records did not upload this paperwork appropriately. The DON verbally confirmed after Resident #5's January 25th cardiologist appointment, Resident #5 did not get seen by a cardiologist until her 07/27/24 hospitalization . The DON revealed it was important for the paperwork to be uploaded and pertinent medical appointments to be scheduled to provide necessary care for the health of the residents. During an interview on 08/29/24 at 12:21 PM, the DON and ADON revealed it was important for residents to have doctor's appointments scheduled appropriately so doctors could give appropriate care to their residents. Left voicemail for cardiologist on 08/30/24 at 02:17 PM with no call back. Attempted to interview Resident #5 3 times on 08/30/24. She was not available . Record Review of the facility's policy, undated, Provision of Quality Care, reflected Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. An IJ was identified on 08/29/2024. The IJ template was provided to the Administrator and the DON on 08/29/2024 at 02:58 PM and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 08/30/2024 at 05:58 PM: POR Verification FACILITY: [Facility ID] SURVEY TYPE: Annual Survey ABATEMENT PLAN: F684 Quality of Care 8/29/24 This abatement plan is submitted to meet the applicable OBRA regulations. It is not to be construed as an admission of the truth of the factual allegations of the survey or the Department's theories of violation. Plan to remove immediate jeopardy Resident #22 was assessed by licensed nurse on 8/29/24, no adverse reactions noted. Resident #5 was assessed by licensed nurse on 8/29/24, no adverse reactions noted. On 8/29/24, licensed nurses physically present were educated in person regarding the community process for scheduling consults and medical appointments. Training conducted by DON and/or ADON. On 8/29/24 licensed nursing staff not physically present, to include those that are PRN and on leave, were contacted by the Administrator, ADON and/or DON via phone and provided education regarding the communities process on scheduling consults and medical appointments. Above mentioned training will be completed on 8/29/24, all licensed staff will be required to have training on community process of resident appointments before assuming resident care responsibilities. Process: New Residents: Licensed nurse, ADON and/or DON will review documentation from the hospital to confirm appointments are scheduled in the timeframe requested. Current Residents: Upon return from appointments Licensed nurse, ADON and/or DON will review documentation from resident appointments to confirm appointments are scheduled in the timeframe requested if follow up is documented. Once documentation mentioned above is received after resident returns from appointment or resident admits to the community it will be reviewed the Licensed Nurse, ADON or DON and will enter an order immediately upon notification/review into Point Click Care that will include the appointment details per the documentation received from the hospital and/or the appointment. Example: Consult needed for Dr. ABC in 4-6 weeks. DON and/or ADON will review orders the following business day and ensure that appointments are made per the recommendations of the physician. DON, ADON or Licensed Nurse will enter progress note after appointment is confirmed to ensure staff have the details for the appointment, this will be an ongoing process. If doctor/clinic is unable to coordinate in the specified timeframe DON, ADON or Licensed Nurse will work with the resident/family and physician to locate a different provider that can accommodate their needs if physician deems necessary. If an appointment is made outside of the timeframe requested by the physician the DON, ADON or Licensed Nurse will enter a progress note explaining the reason for the delay and confirm attending physician. The DON, ADON, MDS Coordinator or other designee will review re-admission paperwork as a secondary review from admitting nurse to ensure that residents care is followed up. Concerns found will be immediately reported to administrator and re-education provided. When the community is notified of a cancelled appointment, they will follow the process and enter a new order into PCC, stating that appointment was cancelled and needs to be rescheduled. This will alert DON or ADON when orders are reviewed the following business day. Appointments will be maintained in a calendar book to be located at nurses' station for appointment tracking. DON, ADON or other designee will be responsible for ensuring calendar is up to date and will be reviewed no less than three times a week. This new process will be effective immediately, 8/29/24, for current residents and any new residents. All residents that have appointments or consults outside the community have the potential to be affected by this alleged deficient practice. The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting on 8/29/24. The medical director was involved with the review and the plan of removal. All licensed staff will be required to have training on community process of resident appointments before assuming resident care responsibilities, to include new hires. The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process. The Administrator will be responsible for oversight to ensure the process is being completed and will complete an audit no less than one time per month and a report of findings will be reported to the facility's QAPI committee no less than one time per month for six months. The Administrator will ensure the plan is completed in full by 8/29/24. POR verification was as follows: A record review of resident #22's medical record revealed LVN C assessed on 08/30/2024 resident #22 without injuries. During an interview on 08/30/2024 at 12:39 pm LVN C stated she assessed Resident #22 without injuries. A record review of resident #5's medical record revealed LVN C assessed resident #5 without injuries. During an interview on 08/30/2024 at 12:39 pm LVN C stated she assessed Resident #5 without injuries. A record review of the facility's in-service Medical Appointments dated 08/29/2024 revealed, New Residents: Licensed nurse, ADON and/or DON will review documentation from the hospital to confirm appointments are scheduled in the timeframe requested. Current Residents: Licensed nurse, ADON and/or DON will review documentation from resident appointments to confirm appointments are scheduled in the timeframe requested if follow up is documented. Once documentation mentioned above is reviewed the Licensed Nurse, ADON or DON will enter an order into Point Click Care that will include the appointment details per the documentation received from the hospital and/or the appointment. Example: Consult needed for Dr. ABC in 4-6 weeks. DON and/or ADON will review orders the following business day and ensure that appointments are made per the recommendations of the physician. DON, ADON or Licensed Nurse will enter progress note after appointment is confirmed to ensure staff have the details for the appointment. If doctor/clinic is unable to coordinate in the specified timeframe DON, ADON or Licensed Nurse will work with the resident/family and physician to locate a different provider that can accommodate their needs if physician deems necessary. If appointment is made outside of the timeframe requested by the physician the DON, ADON or Licensed Nurse will enter a progress note explaining the reason for the delay and confirm attending physician. further review revealed the following nurses received the training on 08/29/2024: o DON o ADON o LVN A o LVN D o LVN K o LVN H o LVN C o LVN L o LVN J o LVN E o LVN F o LVN G o RN M o RN I During an interview on 08/30/2024 at 01:36 PM the DON stated she was trained by the corporate RN and she provided in-service training for all the nursing staff. The DON stated the training covered reviewing residents' discharge / doctors' recommendations paperwork and communicating the recommendations to the medical director for orders to support the residents needs for follow up appointments and or preprocedural orders. On 8/29/24 licensed nursing staff not physically present, to include those that are PRN and on leave, were contacted by the Administrator, ADON and/or DON via phone and provided education regarding the communities process on scheduling consults and medical appointments. Above mentioned training will be completed on 8/29/24, all licensed staff will be required to have training on community process of resident appointments before assuming resident care responsibilities. 14 of 14 licensed nursing staff were interviewed. The breakdown is as follows: Shift 6 AM- 2 PM (5 of 5 licensed nursing staff interviewed, including 1 DON and 1 ADON) Shift 2 PM-10 PM (2 of 2 licensed nursing staff interviewed) Shift 10 PM-6 AM (3 of 3 licensed nursing staff interviewed) Weekend shift (4 of 4 licensed nursing staff interviewed) Shift 6 AM- 2 PM (5 of 5 licensed nursing staff interviewed, including 1 DON and 1 ADON) During an interview on 08/30/24 at 12:37 PM, LVN D revealed she was in-serviced to review all documents when residents returned from clinics, doctor appointments, and / or hospital visits for follow up appointments and new orders. LVN D stated she would SBAR the Medical Director for an order for the follow-up visits and document in the residents' chart. During an interview on 08/30/24 at 12:38 PM, LVN F revealed she received an in-service on 08/29/2024 which covered expectations for nurses to review all residents' documents when a resident was admitted and / or returned from a doctor's visit. LVN F stated if the documents revealed any recommendations like a follow up visit, she would ask the doctor for an order for the appointment and document the appointment in the resident's chart and document the appointment in the calendar appointment book at the nurse's station. During an interview on 08/30/24 at 12:39 PM, LVN C revealed she received in-service training on 08/29/2024 which covered reviewing return from clinic hospital documents for follow up appointments. LVN C stated she would document new orders for follow up appointments in the resident's chart and the calendar appointment book at the nurse's station. During a combined interview on 08/30/24 at 01:26 PM, the DON and the ADON stated they were in-serviced by the corporate RN to review residents' discharge/doctors' recommendations paperwork and create appointments in a timely manner, as recommended. Shift 2 PM-10 PM (2 of 2 licensed nursing staff interviewed) During an interview on 08/30/24 at 02:19 PM, LVN J revealed he received training on 08/29/2024 for reviewing documents when residents return from appointments and or clinics. LVN J stated he would review the documents for any follow-up appointments and if there were he would document the order in the resident's chart and in the appointment book. During an interview on 08/30/24 at 03:46 PM, RN M stated he received training on 08/29/2024 which covered reviewing all documents from residents' doctors' appointments and if the resident needed a follow up appointment, he would document a new doctors order for the follow up appointment in the resident's chart and the appointment book. Shift 10 PM-6 AM (3 of 3 licensed nursing staff interviewed) During an interview on 08/30/24 at 01:10 PM, RN I revealed he received training on 08/29/2024 which covered documenting and supporting residents with their needs with follow-up appointments and or future procedures. RN I stated he would do so by reviewing the documents upon the residents return from the doctor's visit / hospitalization and writing orders and utilizing the appointment book. During an interview on 08/30/24 at 02:57 PM, LVN K revealed she received training on 08/29/2024 which covered reviewing documents after residents were admitted and / or returned from clinic appointments. LVN K stated she would make a doctor's order for follow-up appointments and / or procedures and document the details in the appointment book at the nurse's station. During an interview on 08/30/24 at 03:19 PM, LVN L revealed she was trained on making medical appointments for residents in a timely manner. She further revealed the nursing staff have doctor's orders and a calendar to follow to prepare residents for their appointments. Weekend shift (4 of 4 licensed nursing staff interviewed) During an interview on 08/30/24 at 12:20 PM, LVN E and LVN H revealed they had received training for reviewing and documenting any needed follow up appointments and / or procedures after residents returned from appointments or were admitted . LVN E and LVN H stated they would document the follow-up appointments as orders in the resident's record and document the appointments in the appointment book / calendar at the nurse's station. During an interview on 08/30/24 at 01:10 PM, LVN A revealed she was in-serviced on 08/29/2024 which covered a system to document follow-up appointments and / or procedures by reviewing all documents returned to the facility after an admission and / or a doctor's visit. During an interview on 08/30/24 at 01:27 PM, LVN G revealed she received in-service training on 08/29/2024 which re-enforced residents' documents after a clinic or admission were reviewed for follow-up appointments. LVN G stated she would document the follow-up appointment in the resident's chart and the appointment book. During an interview on 08/30/24 at 03:35 PM, the ADON revealed there were 2 new admissions since 08/29/24, and they did not have any instructions to have any medical appointments scheduled. The ADON presented a calendar book to show how the nursing staff has already used the calendar book at 1 of 1 nurse's station to write down all residents' medical appointments. Record review of 1 of 2 new admissions revealed no medical appointments were needed to be scheduled. Record Review of Resident #5's medical record revealed she was readmitted [DATE] after a hospitalization from [DATE] to 08/28/24. Record Review of Resident #5's Nurses Note, dated 08/29/24 at 09:01 AM and authored by the DON, reflected Resident #5 went to a cardiology appointment at 10:30 AM on 08/29/24. Record Review of Nurses note, dated 08/29/24 at 02:24 PM and authored by LVN D, reflected a 3 month follow up appointment was scheduled for 11/19/24 at 11:00 AM for Resident #5. Record Review of Resident #5's doctor's orders, dated 08/30/24, reflected, 3 month follow up [appointment] on Tuesday 11/19/24 @1100 [cardiologist], receptionist to schedule transportation Observation and record review on 08/30/24 at 03:35 PM at 1 of 1 nurse's station revealed a calendar book with medical appointments. Record review of this calendar book revealed medical appointments have been added for the residents. During an interview on 08/30/24 at 04:05 PM, the administrator revealed they had a QAPI meeting with the DON, ADON, and the doctor to discuss this plan of removal. An Immediate Jeopardy (IJ) situation was identified on 08/29/24. The IJ template was provided to the facility on [DATE] at 02:58 PM. While the IJ was removed on 08/30/24, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's continuation of in-servicing and monitoring the Plan or Removal.

Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 6 Residents (Resident #1) reviewed for treatment and services. The facility failed to ensure Resident #1 received assessments and interventions including a physician ordered STAT (immediately, without delay) Lab CBC (complete blood count) on 6/14/2022 when Resident #1 experienced a change of condition on 6/11/2022 until discharge to the hospital within the ICU on 6/16/2022 where Resident#1 was intubated (breathing tube) and was not responsive to voice or touch, with an infection to the brain. This failure resulted in the identification of Immediate Jeopardy (IJ) on 6/22/2022 at 2:48 p.m. While the immediacy was removed on 6/25/2022, the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR. This failure could affect residents with a change of condition and place them at risk for a delay in treatment, a decline in health, hospitalization and/or death. The findings were: Record review of Resident #1's face sheet dated 6/21/2022 revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .with foot ulcer and unspecified complications, and [CONDITION(S)][abnormally low activity of the [CONDITION(S)], resulting in [CONDITION(S)] of growth and mental development in children and adults]. Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed an order with a start date of 03/03/2022 for: check shunt to right upper chest for signs and symptoms of infection, bleeding, bruising, pulsation or aneurysm. Another order dated 03/03/2022 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Care Plan dated 3/03/2022 revealed the resident received in-house hemodialysis ([CONDITION(S)]) related to [CONDITION(S)] and had a catheter to her right upper chest wall with interventions which included: check and change dressing daily at access site-document, monitor labs and report to doctor as needed, monitor/document/report as needed for signs and symptoms of renal insufficiency changes in level of consciousness changes in skin turgor, oral mucosa, changes in heart and lung sounds, monitor/document/report as needed for signs and symptoms of bleeding, hemorrhage, bacteremia and septic shock. Record review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #'1 progress note, titled Medication Administration Note dated 6/10/2022 at 9:41 p.m. documented by MA E revealed: resident refused [medications] nurse notified. Record review of Resident #1's Nurse Progress Notes dated 6/11/2022 at 8:37 p.m. documented by LVN F revealed: Resident resting in bed with eyes closed, responsive to tactile stimuli with no signs of distress observed .Respirations even and unlabored during rounds. During meal resident observed sleepy and refused to eat dinner and refused evening medications. Patient teaching regarding importance of compliance and resident encouraged to eat dinner or snacks due to diabetes but resident insists on resting at this time. Resident completed less than 10% dinner with minimal fluids. Staff to continue to monitor for any change. Record review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a facility 24-hour report sheet dated 6/12/2022 revealed Resident #1 refused vitals on night shift. (unknown staff) Record review of Resident #1's Medication Administration Notes dated 6/12/2022 revealed LVN H documented 23 medication refusals by resident #1 between 12:33 p.m. to 8:47 p.m. with notes that read: refused. Record review of a laboratory results marked final report dated 6/12/2022 at 3:28 a.m. for Resident #1 a CBC with differential (complete blood count with automated differential, a test that looks for illness in the blood) which showed abnormal blood work. Resident #1's WBCs (white blood cell count) was elevated to 18.5 (normal 3.9-10.3) and the neutrophils (type of WBC, an elevation indicates infection) was elevated to 16.46 (normal 1.56-6.13) [a combination of elevated WBC and elevated neutrophils indicates bacterial infection]. The CBC lab also demonstrated abnormal low RBC (red blood cell count, a blood cell made from bone marrow which carries oxygen), low hemoglobin (protein responsible for transporting oxygen), low hematocrit (the ratio of volume of red blood cells to the total blood volume) and other abnormalities. The CMP (comprehensive metabolic panel, blood test to check glucose levels, fluid and electrolyte balance, kidney, and liver function) had high BUN and creatinine (can indicate dehydration or kidney disease). The laboratory results revealed the lab was ordered on 6/10/2022. Record review of a facility 24-hour report sheet dated 6/13/2022 revealed Resident #1 refused all meals yesterday (6/12/2022) and was refusing treatment on night shift and refused medications on evening shift. (unknown staff) Record review of Resident #1's [CONDITION(S)] Hand Off Communication Report dated 6/13/2022 revealed LVN D documented the resident was not eating and had no signs or symptoms of infection prior to [CONDITION(S)]. The [CONDITION(S)] staff documented Resident #1 did not consume any food or fluids during [CONDITION(S)]. Record review of Resident #1's Nurse Progress Notes dated 6/13/2022 at 11:57 p.m., the DON documented she spoke with Resident #1's RP regarding [CONDITION(S)] medications [MEDICATION(S)] tablet 50 mg and [MEDICATION(S)] tablet 25 mg. RP does not consent to having these medications as believes these are causing resident to sleep all day. Medications will be discontinued, and MD notified of RP wishes, also referral to Elder care for evaluation of residents mental health status. Record review of Resident #'1 progress note, titled Medication Administration Note dated 6/13/2022 at 1:46 p.m. documented by MA H revealed: refused. Record review of Resident #'1 progress note, titled Medication Administration Note dated 6/13/2022 at 9:18 p.m. documented by MA E revealed: resident refused. Record review of a facility 24-hour report sheet dated 6/14/2022 revealed Resident #1 refused both breakfast and lunch on day shift, refused dinner on evening shift with a note to monitor resident's intake. (unknown staff) Record review of Resident #1's [CONDITION(S)] Hand Off Communication Report dated 6/14/2022 revealed facility staff failed to document the pre-[CONDITION(S)] assessment, which was left blank. [CONDITION(S)] staff documented Resident #1 did not consume any food or fluids during [CONDITION(S)]. The post [CONDITION(S)] assessment was also left blank and not completed by facility staff. Record review of Resident #1's Nurse Progress Notes dated 6/14/2022 at 8:33 a.m. documented by the ADON revealed 25% or less for 2 or more meals in 24-hours. Resident is offered snacks in between meals and encouraged to eat during mealtimes. Record review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Medical Practitioner Note dated 6/14/2022 at 4:00 p.m. (entered as a late entry on 6/18/2022 at 5:37 p.m. after the resident was discharged to the hospital), by MD G revealed: decreased appetite, overall stable vitals: blood pressure 93/68, pulse 46, respirations 18, oxygen 95%. Labs: WBC 7 (This note did not reflect latest labs on 6/12/2022 ) Record review of Resident #1's progress note, titled Medication Administration Note dated 6/14/2022 at 9:11 p.m. revealed: Resident refused. Record review of Resident #1's Nurse Progress Notes, dated 6/14/2022 at 10:32 p.m. documented by LVN B revealed: Resident refused breakfast, lunch and dinner. Record review of a facility 24-hour report sheet dated 6/15/2022 revealed Resident #1 had a decreased appetite on the night shift and refused dinner on the evening shift. (unknown staff) Record review of Resident #1's [CONDITION(S)] Hand Off Communication Report dated 6/15/2022 revealed documented no signs and symptoms of infection on the pre-[CONDITION(S)] assessment signed by an unknown LVN. [CONDITION(S)] staff documented the resident did not consume any food or fluids during [CONDITION(S)]. The post-[CONDITION(S)] assessment was left blank, and the form was not completed. Record review of Resident #'1 progress note, titled Medication Administration Note dated 6/15/2022 at 12:39 p.m. documented by MA H revealed: refused. Record review of Resident #'1 progress note, titled Medication Administration Note dated 6/15/2022 at 8:54 p.m. documented by MA H revealed: resident refused. Record review of Resident #'1 progress note, titled Medication Administration Note dated 6/16/2022 at 9:52 a.m. documented by MA H revealed: sleeping [medication not administered]. Record review of Resident #1's Physician Notes dated 6/16/2022 at 2:40 p.m. entered into the electronic medical record on 6/20/2022 at 7:23 a.m. as a late entry by MD G revealed: increased lethargy, no appetite .vitals: blood pressure 93/68, temperature 97, pulse 46, respirations 18, oxygen 95%. Labs: WBC 7. (This note did not reflect the last lab with WBC dated 6/12/2022 with a WBC of 18). Record review of Resident #1's [CONDITION(S)] Hand Off Communication Report dated 6/16/2020 revealed the [CONDITION(S)] staff had documented yellowish/purulent drainage/discharge noted, culture swab taken. [MEDICATION(S)] 1 gm IV given during [CONDITION(S)]. Resident #1 consumed 0% of meal and 0% of fluids and was signed by the [CONDITION(S)] RN. The bottom of the form marked Nursing Home Use Only-Upon Return to Facility Following [CONDITION(S)] was marked no for signs and symptoms of infection. The form was not signed by the facility staff nurse. Attached to the form were telephone orders from Resident #1's nephrologist dated 6/16/2022 at 11:00 a.m., 1. Obtain wound culture from CVS site 2. Obtain blood cultures x 2 (two). 3. Apply triple antibiotic ointment to CVS site 4. [MEDICATION(S)] 1 gram x 1 dose today signed by the [CONDITION(S)] nurse. Record review of a Change in Condition Evaluation dated 6/16/2022 at 5:41 p.m. documented by LVN B and signed by the DON revealed: Resident #1 had abnormal vital signs, a decrease or unable to eat and/or drink adequate amounts which started on 6/14/2022 in the afternoon. The vital signs are documented as blood pressure 93/68, pulse 46 (low, normal 60-100), temperature of 97.0 (low) and 96.6 change in level of consciousness, decreased mobility, and decreased/absent bowel sounds. The note stated resident declined, refused scheduled meds, abnormal vital signs . Record review of Resident #1's [CONDITION(S)] blood cultures collected 6/16/2022 and reported to the facility on [DATE] (after Resident #1 was hospitalized on [DATE]) revealed Resident #1's blood was positive for bacteria in both sets of blood cultures (which indicated systemic infection) with gram positive cocci in clusters identified as staphylococcus aureus documented as heavy growth. Record review of Resident #1's Nurse Progress Notes dated 6/16/2022 at 9:43 p.m. written by LVN B revealed: 6 a.m.-2 p.m. Resident refused breakfast; RP notified. MD G [physician] in the building requested Resident sent to hospital for evaluation and treatment. Resident was transported to the hospital at approximately 7:30 p.m. Upon departure resident was alert, and responsive, vital signs: blood pressure 93/49, pulse 49 [low, normal 60-100], oxygen 94% on 2 LPM oxygen. Resident's family was present at the time of departure. Record review of Resident #1's Nursing Home to Hospital Transfer Form dated 6/17/2022 and documented by the DON revealed Resident #1 has been sleeping most of the day, refused all meals, abnormal vital signs on 6/16/2022. MD in the building requested resident sent out to the hospital to evaluate and treat. Record review of Resident #1's hospital records dated 6/18/2022 revealed: Resident #1 arrived at the emergency department with decrease level of consciousness, [CONDITION(S)] (low blood pressure) and pinpoint pupils (can indicate the brain is not functioning correctly). On admission she was noted to be severely anemic as well as [CONDITION(S)] (abnormally low level of platelets which can lead to uncontrolled bleeding) and received a blood transfusion and transfusion of platelets and was emergency intubated due to respiratory distress (tube in the throat in order to place patient on mechanical ventilator). diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The document stated This is likely multifactorial to include [CONDITION(S)] from chronic kidney disease, bone marrow suppression from infection (MSSA-[CONDITION(S)]-Susceptible Staphylococcus Aureus, a bacteria), [CONDITION(S)] likely multifactorial to included effects from infection, antibiotics, [CONDITION(S)] (urinary tract infection), elevated procalcitonin (blood test, when elevated is a strong indicator of [CONDITION(S)] or infection in the blood stream), and cavitary lesion of lung (lesion on the lung, most lung [CONDITION(S)] develop as a result of bacterial infection). During an interview on 6/21/2022 at 12:40 p.m. MA H stated before Resident #1 was hospitalized she was better. He stated she would occasionally refuse medications, but most of the time she took the medications. MA H stated since Resident #1 returned from the hospitalization (6/10/2022) she would say, no, no, no. He stated he did not really know how to explain what was different, but stated she appeared too weak from [CONDITION(S)]. MA H stated Resident #1 was always sleeping. He stated he would try to wake her up, but she was refusing medications and refusing to eat. MA H stated he was sometimes able to wake the resident up but sometimes he was not able to. MA H stated he told the nurse (unknown name) because he always told the nurse when something was different. MA H stated he could not remember which days or which nurse he told. He stated everyday there is a different nurse. He stated he remembered telling a nurse Resident #1 refused her medication. During an interview on 6/21/2022 at 12:52 p.m. CNA J stated Resident #1 was a [CONDITION(S)] resident. CNA J stated she tried to feed Resident #1 her meals, but she refused. CNA J stated Resident #1 did not typically refuse all meals and medications, but she had been since returning from the hospital (6/10/2022). CNA J stated she notified LVN B that Resident #1 was refusing to eat. She stated LVN B responded by continuing to type into her computer and then asked, Did you try to feed her? CNA J stated she told LVN B yes, she had tried to feed Resident #1, but the resident did not want it. CNA J stated the resident did urinate even though she was on [CONDITION(S)] but not a lot, just a little bit. She stated she did not notice a color or odor. CNA J stated she did change a urine brief in the days prior to 6/16/2022 but was unsure what days. During an interview on 6/21/2022 at 1:54 p.m. Resident #1's RP stated the resident was normally happy and talkative with occasional moments where she is feisty and wants to be left alone, but always returns to baseline of a generally happy person. Resident #1 stated the resident went to the hospital two weeks ago for a clogged [CONDITION(S)] catheter and had since returned to the nursing home facility. The RP stated since the return to the facility on Friday 6/10/2022, Resident #1 has been refusing medications and had only eaten a few bites of food. The RP stated on Sunday 6/13/2022 Resident #1 was just wanting to be left alone and was not her typical self. The RP stated on Monday 6/14/2022 she met with the DON and another nurse (unknown name) and told them something was wrong with Resident #1. The RP stated she told the DON that something was really wrong, and she didn't think Resident #1 was all there. The RP stated she thought something was wrong because Resident #1 would not wake up and that was not normal for her. The RP stated she requested to speak with the physician which did not occur. She stated she told the DON she was worried Resident #1's depression medication was making the resident sleepy, so she asked for it to be stopped. The RP stated Resident #1 is typically feisty about going to [CONDITION(S)] and will sometimes refuse but the past week Resident #1 had not been refusing and was just asleep. The RP stated the [CONDITION(S)] nurse stated they were not removing any fluids from the resident, only cleaning the blood because the resident had not been drinking fluids. The RP stated on Thursday 6/16/2022 when she visited the nursing home, Resident #1 slept before, during, and after [CONDITION(S)] and would not wake up. The RP stated she asked a nurse (unknown name) why they were not doing anything to help Resident #1 and the nurse said she did not know. The RP stated she again asked to speak with Resident #1's doctor. The RP stated the doctor stated he was sending Resident #1 to the hospital because the resident was not responding and was not eating. The RP stated the facility did not call 911, instead waited for a transportation company to arrive and it took over 2 hours for Resident #1 to arrive at the hospital. The RP stated she went with Resident #1 to the hospital, when they arrived the ER staff put a breathing tube in the resident right away because she was in a coma and not responding. The RP stated the ER staff noticed she had milky pus coming from the [CONDITION(S)] port. The RP stated a doctor came right away and removed the infected port. The RP stated Resident #1 had been in the ICU since 6/16/2022 because she had an infection in her blood stream that was affecting the lungs and brain and causing her to have little strokes. During an interview on 6/21/2022 at 3:02 p.m., LVN A stated her job duties included reviewing lab work, notifying physicians of lab work and documented what the physician said during notification. She stated she also updated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN A stated she had talked to Resident #1's doctor (unknown name, unknown date and time) and he said to send Resident #1 out (to the hospital) to make sure everything was okay. LVN A stated she did not remember anything about Resident #1's lab work or orders. During an interview on 6/21/2022 at 3:10 p.m. LVN A stated after reviewing Resident #1's medical record, Resident #1 had a STAT (without delay or immediately) order for a CBC (complete blood count) ordered on 6/14/2022 at 1:08 p.m. that had been marked not completed on 6/20/2022 because the resident was already in the hospital. LVN A stated the order for the STAT CBC had not been completed as ordered. LVN A stated LVN B was the Charge Nurse for Resident #1 but she (LVN A) was helping out. LVN A stated she could not be certain that she followed up to ensure the labs for Resident #1 were completed because it was the Charge Nurses responsibility to follow up that labs were completed. LVN A stated she was just trying to help by getting the order. LVN A stated did not review any of Resident #1's refusals of care and could not remember the last time she had assessed Resident #1. LVN A stated she did assist a CNA (unknown) with a Hoyer transfer of the resident from the [CONDITION(S)] chair to bed (unknown date and time) and the resident appeared tired but responded with little noises like mm mm. LVN A stated Resident #1 normally did not talk and normally like to sleep following [CONDITION(S)] so she appeared normal to her. LVN A stated Resident #1 was not typically on oxygen but had been using some since returning from the hospital. During an interview on 6/21/2022 at 3:34 p.m. LVN B stated she worked at the facility for 3 months and had worked double shifts from 6 a.m. to 10 p.m. LVN B stated Resident #1 only spoke Spanish, was hard of hearing and was blind. LVN B stated the CNA staff translated for the resident. LVN B stated on Tuesday, 6/14/2022 the CNA's (unknown names) informed her Resident #1 did not eat breakfast or lunch and when they tried to feed her dinner, she refused. LVN B stated Resident #1 did not eat or drink on Tuesday. LVN B stated she came on duty at 2 p.m. on Wednesday 6/15/2022, Resident #1 was not eating but drank a little water, LVN B called Resident #1's RP so she could bring the resident tacos. LVN B stated she instructed the RP to encourage Resident #1 to eat. LVN B stated on Wednesday, 6/15/2022 when she observed Resident #1, was sleeping and, refusing care, but her vital signs were okay. LVN B stated she did not do a head-to-toe assessment but thought Resident #1 might be constipated, so she brought the resident [MEDICATION(S)] (medication that causes loose bowel movements) but the resident refused. LVN B stated a CNA (unknown name or date) told her that the resident stated I do not want to do this no more but the resident did not specify what she did not want, and she did not ask for clarification from the resident or perform an assessment. LVN B stated on Thursday, 6/16/2022 she got really concerned that Resident #1 was not eating. LVN B stated Resident #1 was not unconscious, but she wasn't responding the way she normally did. LVN B stated Resident #1 was not eating, had refused [CONDITION(S)], so she assessed the resident and notified MD G. LVN B stated after MD G saw the resident, he told her to send Resident #1 out (to the hospital). LVN B stated Resident #1 had been sleepy all 3 days. LVN B stated Resident #1's baseline was that she slept when she wanted to sleep but does not sleep all the time. She stated Resident#1 eats when she wants to, sometimes refuses to eat and is picky, but will at least eat one meal a day. LVN B stated LVN A was responsible for lab work. LVN B stated as Charge Nurse she was responsible for 35 residents on her shift. She stated they were supposed to have 3 nurses, but only had two so LVN A was assigned to assist with lab work to lighten the workload. LVN B stated LVN A were responsible for reviewing lab work and giving results of the lab work to the physicians and putting in new lab work orders. LVN B stated she did not personally review Resident #1's lab work, she did not put Resident #1's lab work into the computer. LVN B stated she could not remember if LVN A told her a STAT CBC needed to be drawn on 6/14/2022. LVN B stated she was trained to perform an assessment, call the physician and complete the form for a resident's change of condition as soon as she sees the change of condition. LVN B stated she did not notify the physician or complete the change of condition form before 6/16/2022 because she didn't know if the resident's family member fed the resident or not and she didn't get worried about the lack of eating until 2-3 days had passed. LVN B stated she assessed the resident for constipation but did not complete a head-to-toe assessment. LVN B stated she facility nurses did not deal with permacath site, [CONDITION(S)] staff assessed permacath. LVN B stated she just made sure dressing was intact and can look around the dressing. LVN B stated the resident was still urinating the last time she checked (unknown date). During an interview on 6/21/2022 at 4:20 p.m. the ADON stated she had been the facility ADON since December 2021. She stated her job duties included running reports, checking up with nurses to ensure they are following up with labs, filling in for staff when they are short and checking infection control. She stated her job duties also included nursing staff oversite. The ADON stated Resident #1 had good days and bad days but had recently become more non-compliant with care. The ADON stated Resident #1 was refusing medications, sleeping more and no longer wanted to complete [CONDITION(S)]. The ADON stated Resident #1 was doing well until her RP had COVID and was not able to visit as much. The ADON stated Resident #1 was hospitalized on [DATE] for failure to thrive. The ADON stated she was aware Resident #1 was not eating prior to 6/16/2022 but did not know about the change of condition until 6/16/2022. The ADON stated on 6/13/2022, Resident #1's RP had a meeting and spoke with the DON and herself. The ADON stated the RP expressed concerns about the resident's sleepiness. The ADON stated the RP thought medications were making the resident sleepy and she wanted the medications discontinued. The ADON stated she did not assess the resident after the RP had expressed concerns of Resident #1's sleepiness because the DON reached out to Resident #1's doctor to have the medications discontinued. The ADON stated she could not remember if any other staff reported a change of condition. The ADON stated she didn't review lab work, she just followed up with nurses by sending them text messages or telling them in person to follow up, but she does not talk to the nurses specifically about labs. The ADON stated LVN A was responsible for clearing up most of the labs because she was part of the management team. The ADON stated she documented on Resident #1's medical record that she had not voided (urinated) in 24 hours because it was an automatic pop up as part of clinical review. The ADON stated Resident #1 was a [CONDITION(S)] resident and not urinating could be typical. The ADON stated she did not investigate any further to see if it was typical for Resident #1 and she did not assess the resident. She stated she just told the aides to feed her and give her fluids. She stated she told all the aides, but did not remember which aides she told or what date she addressed them. The ADON stated she did not assess the resident, did not talk to the resident, did not talk to the nursing staff and did not follow up with Resident #1's physician when she learned the resident was not eating or drinking because the aides were supposed to follow up with the nurse and the nurse was supposed to notify the physician. The ADON stated the nurses should have followed up with the physician when Resident #1 first started refusing medications. During an interview on 6/21/2022 at 4:45 p.m. the ADON stated she had not reviewed Resident #1's lab work dated 6/12/2022 and was not aware of the elevated WBC and neutrophils until shown the lab by the surveyor. The ADON stated an elevated WBC and elevated neutrophils count could indicate infection. The ADON also stated the BUN and Creatinine were elevated. She stated residents on [CONDITION(S)] often have elevated BUN and Creatinine. The ADON also reviewed lab Resident #1's STAT CBC ordered 6/14/2022 and stated the laboratory was showing they could not draw the lab because Resident #1 was in the hospital when lab came to draw it. The ADON stated a lab tech approached her on 6/19/2022 and asked her to sign the lab sheet because the resident was in the hospital on 6/19/2022. The ADON stated staff must call lab and keep on them and if the resident had a change of condition, then staff should advocate for the resident by telling the family and request for the resident to be sent to the ER. The ADON reviewed PCC for lab orders for Resident #1 and stated the STAT lab ordered on 6/14/2022 was never put into the computer (PCC). The ADON stated that was LVN A's responsibility and LVN B should have followed up. The ADON stated it was important for staff to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/21/2022 at 5:21 p.m. MD G stated he was notified of Resident #1's abnormal CBC (dated 6/12/2022) and he ordered a repeat STAT CBC. MD G stated he expected to have the results of the STAT CBC within 24-hours. MD G stated he sees lot of patients and could not give details of notifications or details of the patient care, although he did see Resident #1 on 6/16/2022 the date she was discharged to the hospital. He stated Resident #1 was the Medical Directors patient and he was just covering for the Medical Director for a couple of days. MD G referred further questions to the Medical Director. During an interview on 6/21/2022 at 5:31 p.m. the DON stated had only been the DON for approximately 2 weeks and was still getting familiar with the facility's processes. The DON stated she became aware of Resident #1 when the resident's RP came to speak with her (unknown date). The DON stated the RP had concerns over medications, antidepressants, and antipsychotics. The DON stated the RP felt like the medications were causing the resident to sleep all day and she didn't want the resident to have them (the medications). The DON stated the RP had previously consented to the medications but wanted to revoke consent. The DON stated she then called the residents physician and discontinued the medications. The DON stated she could not remember which physician she called. The DON stated she told the doctor Resident #1's RP felt like the medications were causing the resident to sleep too much and that she didn't think the resident was depressed and she didn't want the resident to have the medications. The DON stated the doctor responded by saying if this is the family'swish it is okay to discontinue. The DON stated they did not do a taper of the medications because Resident #1 had been refusing them. The DON stated she told the doctor and the RP the resident was refusing medications. The DON stated she looked back at the medication administration and felt like the refusals were something new, she wasn't refusing medications until she came back from the hospital. The DON stated she did not do an assessment of Resident #1 because she learned Resident #1 was going out to the hospital (6/16/2022) and the only concerns the RP told me about were the resident sleeping too much. The DON stated when LVN B notified her Resident #1 went to the hospital it was more of the RP wanting the resident to go and not a change of condition. LVN B reported Resident #1 was refusing to eat, was more tired and didn't have energy and the RP wanted Resident #1 sent out (to the hospital). The DON stated MD G came in, saw the resident and said to send her out. During an interview on 6/21/2022 at 5:46 p.m., the DON stated she was aware Resident #1 was sleeping and refusing medication but was not notified of her not eating or drinking. The DON stated she read the nurse progress notes about reduced urine output but was told by the ADON that it was an auto populated note. The DON stated Resident #1 was a [CONDITION(S)] resident and did not normally produce a lot or urine at baseline. The DON stated she was not aware of Resident #1's [CONDITION(S)] Communication Report dated 6/16/2022 and was not aware of the reports of purulent drainage from Resident #1's [CONDITION(S)] port. The DON stated LVN B probably reported no signs and symptoms of infection on the report despite the documentation there was purulent drainage because the port was wrapped up and

Based on interview and record review, the facility failed to provide laboratory services to meet the needs of the resident, for 1 of 4 residents (Residents # 1) reviewed for laboratory services, in that; The facility failed to obtain a STAT CBC prescribed by a physician on [DATE] for Resident #1 who had previous abnormal CBC on [DATE] with a change in condition and resulted in hospitalization on [DATE] for severe [CONDITION(S)] (the body's extreme response to an infection which is a life-threatening emergency) and death on [DATE]. This failure resulted in identification of Immediate Jeopardy (IJ) on [DATE] at 2:48 p.m. While the immediacy was removed on [DATE], the facility remained out of compliance at actual harm that was not immediate jeopardy with a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its POR. This failure could place residents at risk for delays in treatment, a decline in health which could result in hospitalization and/or death. The findings were: Record review of Resident #1's face sheet dated [DATE] revealed a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Care Plan dated [DATE] revealed the resident was full code status with interventions which included: monitor for decline of resident's health status. Report finding to the physician. Record review of Resident #1's Care Plan dated [DATE] revealed the resident received in-house hemodialysis ([CONDITION(S)]) related to [CONDITION(S)] and had a catheter to her right upper chest wall with interventions which included: monitor labs and report to doctor as needed, monitor/document/report as needed for signs and symptoms of renal insufficiency changes in level of consciousness changes in skin turgor, oral mucosa, changes in heart and lung sounds, monitor/document/report as needed for signs and symptoms of bleeding, hemorrhage, bacteremia and septic shock. Record review of Resident #'1 progress note, titled Medication Administration Note dated [DATE] at 9:41 p.m. documented by MA E revealed: resident refused [medications] nurse notified. Record review of Resident #1's Nurse Progress Notes dated [DATE] at 8:37 p.m. documented by LVN F revealed: Resident resting in bed with eyes closed, responsible to tactile stimuli with no signs of distress observed .Respirations even and unlabored during rounds. During meal resident observed sleepy and refused to eat dinner and refused evening medications. Patient teaching regarding importance of compliance and resident encouraged to eat dinner or snacks due to diabetes but resident insists on resting at this time. Resident completed less than 10% dinner with minimal fluids. Staff to continue to monitor for any change. Record review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a facility 24-hour report sheet dated [DATE] revealed Resident #1 refused vitals on night shift. (unknown staff) Record review of a laboratory results marked final report dated [DATE] at 3:28 a.m. for Resident #1 a CBC with differential (complete blood count with automated differential, a test that looks for illness in the blood) which showed abnormal blood work. Resident #1's WBCs (white blood cell count) was elevated to 18.5 (normal 3.,d+[DATE].3) and the neutrophils (type of WBC, an elevation indicates infection) was elevated to 16.46 (normal 1.,d+[DATE].13) [a combination of elevated WBC and elevated neutrophils indicates bacterial infection]. The CBC (complete blood count) lab work also demonstrated abnormal low RBC (red blood cell count, a blood cell made from bone marrow which carries oxygen), low hemoglobin (protein responsible for transporting oxygen), low hematocrit (the ratio of volume of red blood cells to the total blood volume) and other abnormalities. The CMP (comprehensive metabolic panel, blood test to check glucose levels, fluid and electrolyte balance, kidney, and liver function) had high BUN and creatinine (can indicate dehydration or kidney disease). The laboratory results revealed the lab was ordered on [DATE], was drawn on [DATE] but not read until [DATE] at 1:14 pm by LVN A. Record review of Resident #1's Medication Administration Notes dated [DATE] revealed LVN H documented 23 medication refusals by resident #1 between 12:33 pm to 8:47 p.m. with notes that read: refused. Record review of a facility 24-hour report sheet dated [DATE] revealed Resident #1 refused all meals yesterday ([DATE]) and was refusing treatment on night shift and refused medications on evening shift. (unknown staff) Record review of Resident #1's [CONDITION(S)] Hand Off Communication Report dated [DATE] revealed LVN D documented the resident was not eating and had no signs or symptoms of infection prior to [CONDITION(S)]. The [CONDITION(S)] staff documented Resident #1 did not consume any food or fluids during [CONDITION(S)]. Record review of Resident #'1 progress note, titled Medication Administration Note dated [DATE] at 1:46 p.m. documented by MA H revealed: refused. Record review of Resident #'1 progress note, titled Medication Administration Note dated [DATE] at 9:18 p.m. documented by MA E revealed: resident refused. Record review of a facility 24-hour report sheet dated [DATE] revealed Resident #1 refused both breakfast and lunch on day shift, refused dinner on evening shift with a note to monitor resident's intake. There was no documentation for night shift. (unknown staff) Record review of Resident #1's [CONDITION(S)] Hand Off Communication Report dated [DATE] revealed facility staff failed to document the pre-[CONDITION(S)] assessment, which was left blank. [CONDITION(S)] staff documented Resident #1 did not consume any food or fluids during [CONDITION(S)]. The post [CONDITION(S)] assessment was also left blank and not completed by facility staff. Record review of Resident #1's Nurse Progress Notes dated [DATE] at 8:33 a.m. documented by the ADON revealed 25% or less for 2 or more meals in 24-hours. Resident is offered snacks in between meals and encouraged to eat during mealtimes. Record review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Medical Practitioner Note dated [DATE] at 4:00 p.m. entered as a late entry on [DATE] at 5:37 p.m. after the resident was discharged to the hospital, by MD G revealed: decreased appetite, overall stable vitals: blood pressure ,d+[DATE], pulse 46, respirations 18, oxygen 95%. Labs: WBC 7 .(note these are the same vitals and same labs documented on [DATE] MD note) (This note does not reflect latest labs on [DATE] which demonstrated a WBC count of 18) Record review of Resident #1's progress note, titled Medication Administration Note dated [DATE] at 9:11 p.m. revealed: Resident refused [medication not administered]. Record review of Resident #1's Nurse Progress Notes, dated [DATE] at 10:32 p.m. documented by LVN B revealed: Resident refused breakfast, lunch and dinner. Record review of a facility 24-hour report sheet dated [DATE] revealed Resident #1 had a decreased appetite on the night shift and refused dinner on the evening shift. (unknown staff) Record review of Resident #1's [CONDITION(S)] Hand Off Communication Report dated [DATE] revealed documented no signs and symptoms of infection on the pre-[CONDITION(S)] assessment signed by an unknown LVN. [CONDITION(S)] staff documented the resident did not consume any food or fluids during [CONDITION(S)]. The post-[CONDITION(S)] assessment was left blank, and the form was not completed. Record review of Resident #'1 progress note, titled Medication Administration Note dated [DATE] at 12:39 p.m. documented by MA H revealed: refused. Record review of Resident #'1 progress note, titled Medication Administration Note dated [DATE] at 8:54 p.m. documented by MA H revealed: resident refused. Record review of Resident #1's quarterly MDS dated [DATE] Resident #1 had a BIMs of 4 (scale of ,d+[DATE]) which indicated a severe cognitive impairment. The assessment revealed Resident #1 had no behaviors and no refusals of care. Record review of Resident #'1 progress note, titled Medication Administration Note dated [DATE] at 9:52 a.m. documented by MA H revealed: sleeping [medication not administered]. Record review of Resident #1's Physician Notes dated [DATE] at 2:40 p.m. entered into the electronic medical record on [DATE] at 7:23 a.m. as a late entry by MD G revealed: increased lethargy, no appetite .vitals: blood pressure ,d+[DATE], temperature 97, pulse 46, respirations 18, oxygen 95%. Labs: WBC 7. (note these are the same vitals and same labs documented on [DATE] MD note) (This note did not reflect the last lab with WBC dated [DATE] with a WBC of 18). Record review of Resident #1's [CONDITION(S)] Hand Off Communication Report dated [DATE] revealed the [CONDITION(S)] staff had documented yellowish/purulent drainage/discharge noted, culture swab taken. [MEDICATION(S)] 1 gm IV given during [CONDITION(S)]. Resident #1 consumed 0% of meal and 0% of fluids and was signed by the [CONDITION(S)] RN. The bottom of the form marked Nursing Home Use Only-Upon Return to Facility Following [CONDITION(S)] was marked no for signs and symptoms of infection. The form was not signed by the facility staff nurse. Attached to the form were telephone orders from Resident #1's nephrologist dated [DATE] at 11:00 a.m., 1. Obtain wound culture from CVS site 2. Obtain blood cultures x 2 (two). 3. Apply triple antibiotic ointment to CVS site 4. [MEDICATION(S)] 1 gram x 1 dose today signed by the [CONDITION(S)] nurse. Record review of a Change in Condition Evaluation dated [DATE] at 5:41 p.m. documented by LVN B and signed by the DON revealed: Resident #1 had abnormal vital signs, a decrease or unable to eat and/or drink adequate amounts which started on [DATE] in the afternoon. The vital signs are documented as blood pressure ,d+[DATE], pulse 46 (low, normal ,d+[DATE]), temperature of 97.0 (low) and 96.6 [low temperature can sometimes indicate infection/[CONDITION(S)]] with a decreased level of consciousness which is documented as gradual change in level of consciousness, decreased mobility, and decreased/absent bowel sounds. The note stated resident declined, refused scheduled meds, abnormal vital signs . Record review of Resident #1's Nurse Progress Notes dated [DATE] at 9:43 p.m. written by LVN B revealed: 6am-2pm Resident refused breakfast; RP notified. MD G [physician] in the building requested Resident sent to hospital for evaluation and treatment. Resident was transported to the hospital at approximately 7:30 p.m. Upon departure resident was alert, and responsive, vital signs: blood pressure ,d+[DATE], pulse 49 [low, normal ,d+[DATE]], oxygen 94% on 2 LPM oxygen. Record review of Resident #1's [CONDITION(S)] blood cultures collected [DATE] and reported to the facility on [DATE] (after Resident #1 was hospitalized on [DATE]) revealed Resident #1's blood was positive for bacteria in both sets of blood cultures (which indicated systemic infection) with gram positive cocci in clusters identified as staphylococcus aureus documented as heavy growth. Record review of Resident #1's Nursing Home to Hospital Transfer Form dated [DATE] and documented by the DON revealed Resident #1 has been sleeping most of the day, refused all meals, abnormal vital signs on [DATE]. MD in the building requested resident sent out to the hospital to evaluate and treat. Record review of Resident #1's hospital records dated [DATE] revealed: Resident #1 arrived at the emergency department with decrease level of consciousness, [CONDITION(S)] (low blood pressure) and pinpoint pupils (can indicate the brain is not functioning correctly). On admission she was noted to be severely anemic and well as [CONDITION(S)] (abnormally low level of platelets which can lead to uncontrolled bleeding) and received a blood transfusion and transfusion of platelets and was emergency intubated due to respiratory distress (tube in the throat in order to place patient on mechanical ventilator). diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Laboratory Record dated [DATE] revealed Resident #1's STAT CBC (ordered on [DATE]) was not completed and the test cancelled due to hospitalization of the resident per the ADON on [DATE] at 2:58 p.m. Record review of the laboratory's on-line portal on [DATE] for lab tests ordered for Resident #1 revealed a STAT CBC order had been placed in the laboratory portal on [DATE] at 1:06 p.m. by LVN A with a note that read order not collected. During an interview on [DATE] at 12:52 p.m. CNA J stated she tried to feed Resident #1 her meals, but she refused. CNA J stated Resident #1 did not typically refuse all meals and medications, but she had been since returning from the hospital. CNA J stated she notified LVN B that Resident #1 was refusing to eat. She stated LVN B responded by continuing to type into her computer and then asked, Did you try to feed her? CNA J stated she told LVN B yes, she had tried to feed Resident #1, but the resident did not want it. During an interview on [DATE] at 1:54 p.m. Resident #1's RP stated the resident was normally happy and talkative with occasional moments where she is feisty and wants to be left alone, but always returns to baseline of a generally happy person. Resident #1 stated the resident went to the hospital two weeks ago for a clogged [CONDITION(S)] catheter and had since returned to the nursing home facility. The RP stated since the return to the facility on Friday [DATE], Resident #1 has been refusing medications and had only eaten a few bites of food. The RP stated on Sunday [DATE] Resident #1 was just wanting to be left alone and was not her typical self. The RP stated on Monday [DATE] she met with the DON and another nurse (unknown name) and told them something was wrong with Resident #1. The RP stated she told the DON that something was really wrong, and she didn't think Resident #1 was all there. The RP stated she thought something was wrong because Resident #1 would not wake up and that was not normal for her. The RP stated she requested to speak with the physician. She stated she told the DON she was worried Resident #1's depression medication was making the resident sleepy, so she asked for it to be stopped. The RP stated Resident #1 is typically feisty about going to [CONDITION(S)] and will sometimes refuse but the past week Resident #1 had not been refusing and was just asleep. The RP stated the [CONDITION(S)] nurse stated they were not removing any fluids from the resident, only cleaning the blood because the resident had not been drinking fluids. The RP stated on Thursday [DATE] when she visited the nursing home, Resident #1 slept before, during, and after [CONDITION(S)] and would not wake up. The RP stated she asked a nurse (unknown name) why they were not doing anything to help Resident #1 and the nurse said she did not know. The RP stated she again asked to speak with Resident #1's doctor. The RP stated the doctor stated he was sending Resident #1 to the hospital because the resident was not responding and was not eating. The RP stated the facility did not call 911, instead waited for a transportation company to arrive and it took over 2 hours for Resident #1 to arrive at the hospital. The RP stated she went with Resident #1 to the hospital, when they arrived the ER staff put a breathing tube in the resident right away because she was in a coma and not responding. The RP stated the ER staff noticed she had milky pus coming from the [CONDITION(S)] port. The RP stated a doctor came right away and removed the infected port. The RP stated Resident #1 had been in the ICU since [DATE] because she had an infection in her blood stream that was affecting the lungs and brain and causing her to have little strokes. During an interview on [DATE] at 3:02 p.m., LVN A stated she was a Charge Nurse but was transitioning to Medical Records. She stated her job duties included reviewing lab work, notifying physicians of lab work and documented what the physician said during notification. She stated she also updated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LVN A stated she had talked to Resident #1's doctor (unknown name, unknow date and time) and he said to send Resident #1 out (to the hospital) to make sure everything was okay. LVN A stated she did not remember anything about Resident #1's lab work or orders. During an interview on [DATE] at 3:10 p.m. LVN A stated after reviewing Resident #1's medical record, that Resident #1 had a STAT (without delay or immediately) order for a CBC ordered on [DATE] at 1:08 p.m. that had been marked not completed on [DATE] because the resident was already in the hospital. LVN A stated LVN B was the Charge Nurse for Resident #1 but she (LVN A) was helping out. LVN A stated they had been having problems with the lab. She stated it used to be they could be an order into the computer for STAT labs and the lab would show up within 2 hours, but they had been short staff. LVN A stated the facility was having to wait for labs to be drawn and they were having to call the lab and say, hey I hope you didn't forget us. LVN A stated the lab would typically say, Our techs are running behind. LVN A stated as a last resort the facility could send a resident to the ER to get STAT labs drawn. LVN A stated she did tell LVN B that her patient Resident #1 had new orders for STAT lab but could not remember how LVN B responded. LVN A stated usually LVN B would say, okay, thank you. LVN A stated she did tell LVN B the same day but could not remember the time. LVN A stated she could not be certain that she followed up to ensure the labs for Resident #1 were completed because it was the Charge Nurses responsibility to follow up that lab was completed. LVN A stated she was just trying to help by getting the order. LVN A stated she did not review [CONDITION(S)] communication sheets very often. She did not review any of Resident #1's refusals of care and could not remember the last time she had assessed Resident #1. LVN A stated she did assist a CAN with a Hoyer transfer of the resident from the [CONDITION(S)] chair to bed (unknown date and time) and the resident appeared tired but responded with little noises like mm mm LVN A stated Resident #1 normally did not talk and normally like to sleep following [CONDITION(S)], so she appeared normal to her. LVN A stated Resident #1 was not typically on oxygen but had been using some since returning from the hospital. LVN A stated it was important to follow through with labs, so a situation did not get worst. She stated the facility policy for obtaining labs was to get an order from a doctor, put the order into the computer system, she stated staff have a number to call the lab for STAT labs but instead of calling they could also put them into the lab computer system, let the Charge Nurse know, let the family know what was going on and why labs were ordered. LVN A stated the facility then had to wait for a lab tech to come draw the lab, and then staff had to keep an eye out in the system for lab results. During an interview on [DATE] at 3:34 p.m. LVN B stated she had worked at the facility for 3 months and had worked double shifts from 6 a.m. to 10 p.m. LVN B stated on Tuesday, [DATE] the CNA's (unknown names) informed her Resident #1 did not eat breakfast, lunch and when they tried to feed her dinner, she refused. LVN B stated Resident #1 did not eat or drink on Tuesday. LVN B stated she came on duty at 2 p.m. on Wednesday [DATE], Resident #1 was not eating but drank a little water, so LVN B called Resident #1's RP so she could bring the resident tacos. LVN B stated she instructed the RP to encourage Resident #1 to eat. LVN B stated on Wednesday, [DATE] when she observed Resident #1, she was sleeping, she was refusing care, but her vital signs were okay. LVN B stated she did not do a head-to-toe assessment but thought Resident #1 might be constipated, so she brought the resident [MEDICATION(S)] (medication that causes loose bowel movements and requires prescription) but the resident refused. LVN B stated a CNA (unknown name or date) told her that the resident stated I do not want to do this no more but the resident did not specify what she did not want, and she did not ask for clarification from the resident or perform an assessment. LVN B stated on Thursday, [DATE] she got really concerned that Resident #1 was not eating. LVN B stated Resident #1 was not unconscious, but she wasn't responding the way she normally did. LVN B stated Resident #1 was not eating, had refused [CONDITION(S)], so she assessed the resident and notified MD G. LVN B stated after MD G saw the resident, he told her to send Resident #1 out (to the hospital). LVN B stated Resident #1 had been sleepy all 3 days. LVN B stated Resident #1's baseline was that she slept when she wanted to sleep but does not sleep all the time, she eats when she wants to, sometimes refuses to eat and is picky, but will at least eat one meal a day. LVN B stated LVN A was responsible for lab work. LVN B stated as Charge Nurse she was responsible for 35 residents on her shift. She stated they were supposed to have 3 nurses, but only had two so LVN A was assigned to assist with lab work to lighten the workload. LVN B stated LVN A was responsible for reviewing lab work and giving results of the lab work to the physicians and putting in new lab work orders. LVN B stated she did not personally review Resident #1's lab work, she did not put Resident #1's lab work into the computer. LVN B stated the facility had been having trouble with the lab company, they were not coming to the facility and they were not reliable. LVN B stated management was aware of the difficulties. LVN B stated the ADON sometimes works the floor so she was aware, and the lab difficulties had been discussed (unknown date). LVN B stated she could not remember if LVN A told her a STAT CBC needed to be drawn on [DATE]. LVN B stated she was trained to call the physician and form for a resident change of condition as soon as she sees the change of condition. LVN B stated she did not notify the physician or complete the change of condition form before [DATE] because she didn't know if the resident's family member fed the resident or not and she didn't get worried about the lack of eating until ,d+[DATE] days had passed. LVN B stated Resident #1 would normally sleep when she wanted to and wake up to eat. LVN B stated the resident was still urinating the last time she checked (unknown date). LVN B stated she did not notify the physician about the medication refusals because the tell the doctor when he comes to the facility to see the resident. During an interview on [DATE] at 4:20 p.m. the ADON who is a Licensed Vocation Nurse, stated she had been the facility ADON since [DATE]. She stated her job duties included running reports, checking up with nurses to ensure they are following up with labs, filling in for staff when they are short and checking infection control. She stated her job duties also included nursing staff oversite. The ADON stated Resident #1 had good days and bad days but had recently become more non-compliant. The ADON stated Resident #1 was refusing medications, sleeping more and no longer wanted to complete [CONDITION(S)]. The ADON stated Resident #1 was doing well until her RP had COVID and was not able to visit as much. The ADON stated Resident #1 was hospitalized on [DATE] for failure to thrive. The ADON stated she was aware Resident #1 was not eating prior to [DATE] but did not know about the change of condition until [DATE]. The ADON stated on [DATE], Resident #1's RP had a meeting and spoke with the DON and herself. The ADON stated the RP expressed concerns about the resident's sleepiness. The ADON stated the RP thought the medications were making the resident sleepy and she wanted the medications discontinued. The ADON stated she did not assess the resident after the RP had expressed concerns of Resident #1's sleepiness because the DON reached out to Resident #1's doctor to have the medications discontinued. The ADON stated she could not remember if any other staff reported a change of condition. The ADON stated she didn't review lab work, she just followed up nurses by sending them text messages or telling them in person to follow up, but she does not talk to the nurses specifically about labs. The ADON stated LVN A was responsible for clearing up most of the labs because she was part of the management team. During an interview on [DATE] at 4:45 p.m. the ADON stated she had not reviewed Resident #1's lab work dated [DATE] and was not aware of the elevated WBC and neutrophils until shown the lab by the surveyor. The ADON stated an elevated WBC and elevated [CONDITION(S)] count could indicate infection. The ADON also stated the BUN and Creatinine were elevated. She stated residents on [CONDITION(S)] often have elevated BUN and Creatinine. The ADON also reviewed lab Resident #1's STAT CBC ordered [DATE] and stated the laboratory was showing they could not draw the lab because Resident #1 was in the hospital when lab came to draw it. The ADON stated a lab tech approached her on [DATE] and asked her to sign the lab sheet because the resident was in the hospital on [DATE]. The ADON stated when the facility gets a doctor order for lab, they put it into PCC (electronic medical record), then put it in the laboratory computer system or call the lab by phone. The ADON stated the lab used to come to the facility on Tuesday, Thursday, and Sunday but they could not commit to the schedule, so they do not have specific days to come to the facility because the lab is short staffed. The ADON stated for STAT labs they must call the laboratory and get a confirmation number which is then documented in the 24-hour notes. The ADON stated STAT labs used to be drawn within 2 hours, but the lab does not do STAT labs anymore. The ADON stated the DON and Administrator were aware of the lab issues and she had discussed with the DON about switching labs. The ADON stated she called the lab manager and the Administrator sent him a letter. The ADON stated the lab manager asked for examples of resident's names, dates, and times last week but he has not called back. The ADON stated staff must call lab and keep on them and if the resident had a change of condition, then staff should advocate for the resident by telling the family and request for the resident to be sent to the ER. The ADON reviewed PCC for lab orders for Resident #1 and stated the STAT lab ordered on [DATE] was never put into the computer. The ADON stated that was LVN A's responsibility and LVN B should have followed up. The ADON stated it was important for staff to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on [DATE] at 5:21 p.m. MD G stated he was notified of Resident #1's abnormal CBC (dated [DATE]) and he ordered a repeat STAT CBC. MD G stated he expected to have the results of the STAT CBC within 24-hours. MD G stated he sees lot of patients and could not give details of notifications or details of the patient care, although he did see Resident #1 on [DATE] the date she was discharged to the hospital. He stated Resident #1 was MD K's patient and he was just covering for MD K for a couple of days. MD G referred further questions to MD K. During an interview on [DATE] at 5:31 p.m. the DON stated had only been the DON for approximately 2 weeks and was still getting familiar with the facility processes. The DON stated she became aware of Resident #1 when the resident's RP came to speak with her (unknown date). The DON stated the RP had concerns over medications, antidepressants, and antipsychotics. The DON stated the RP felt like the medications were causing the resident to sleep all day and she didn't want the resident to have them. The DON stated the RP had previously consented to the medications but wanted to revoke consent. The DON stated she then called the residents physician (unknown name) and discontinued the medications. The DON stated she told the doctor Resident #1's RP felt like the medications were causing the resident to sleep too much and that she didn't think the resident was depressed and she didn't want the resident to have the medications. The DON stated the doctor responded by saying if this is the families wish it is okay to discontinue. The DON stated she told the doctor and the RP the resident was refusing medications. The DON stated she looked back at the medication administration and felt like the refusals were something new, she wasn't refusing medications until she came back from the hospital. The DON stated she did not do an assessment of Resident #1 because she learned Resident #1 was going out to the hospital ([DATE]) and the only concerns the RP told me about were the resident sleeping too much. The DON stated LVN B notified her Resident #1 went to the hospital it was more of the RP wanting the resident to go and not change of condition. LVN B reported Resident #1 was refusing to eat, was more tired and didn't have energy and the RP wanted Resident #1 sent out (to the hospital). The DON stated MD G came in, saw the resident and said to send her out. During an interview on [DATE] at 5:50 p.m. the DON stated she was aware LVN A notified the doctor of abnormal lab work and that he had ordered repeat lab. The DON stated the lab was not done because the resident was at the hospital when lab came to draw it. The DON stated she was under the impression the repeat lab order was received by the facility on the same day the resident went to the hospital ([DATE]) until looking into it. The DON stated the repeat lab should have been drawn on [DATE] and stated it had not been done. The DON stated her expectations of staff would be to place pending lab on the 24-hour report, put the order into PCC, put the order into lab computer system and for STAT labs the staff need to call the lab and get a confirmation that the order was received by lab. The DON stated the laboratory had expanded their STAT lab time from 4 to 8 hours. The DON stated the laboratory only comes to the facility 3 days a week and did not know if the lab was doing STAT lab. The DON stated the ADON would know. The DON stated the facility was looking into changing labs. The DON stated she was responsible for labs are followed through and she does this by looking at the PCC dashboard and looking for lab orders to make sure the lab was draw and results were complete. The DON stated this method relies on staff entering lab orders into PCC. The DON stated the Charge Nurse is responsible for reviewing completed lab and notifying the physician before the end of their shift, ev

Based on observations, interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice based on the comprehensive assessment of a resident and the comprehensive person centered care plan, and the residents' choices for 4 of 4 residents (#13, #31, #60, and #62) reviewed for [MEDICATION NAME] administration (a drug which raises blood pressure) in that: The facility did not ensure correct administration of [MEDICATION NAME] for Residents #62, #31, #13 and #60. The medication to raise blood pressure was given conflicting to physician order, when blood pressures were assessed to be in normal or high ranges, or without parameters for administration from the prescriber. This deficient practice placed residents at risk for serious injury and death by adverse drug effects of administering drug when not clinically indicated. These failures resulted in identification of Immediate Jeopardy (IJ) on [DATE] at 8:30 p.m. While the IJ was removed [DATE], the facility remained out of compliance at a severity level of no actual harm with a scope identified as a pattern until interventions were put in place to ensure measures were in place to prevent the mis-administration of the drug [MEDICATION NAME], as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. The findings: A closed record review of Resident #62's clinical resident profile dated [DATE], revealed an admission date of [DATE] with a discharge date of [DATE]. A closed record review of Resident #62's medical [DIAGNOSES REDACTED]. A closed record review of Resident #62's [MEDICATION NAME] order dated [DATE] read, order date [DATE], 1337 (1:37 p.m.), communication method verbal . medication [MEDICATION NAME] HCL tablet 10 mg, medication class vasopressors (drugs that raise blood pressure), route of administration pe[DEVICE] (a surgically established tube into the stomach). Order Summary: [MEDICATION NAME] HCl Tablet 10 MG, Give 1 tablet via PE[DEVICE] two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD IF SBP<120 (systolic blood pressure less than 120). A closed record review of Resident #62's care plan dated [DATE] revealed a risk which read, Resident #1 has hypertension and is at risk for blurred vision, [MEDICAL CONDITION], headache, and nosebleeds. With a nursing intervention which read, Check blood pressure before administering medication and record on MAR (medication administration record). A record review of Resident #62's (MAR) for the period of [DATE] to [DATE] revealed Resident was administered the drug [MEDICATION NAME] on: 1. [DATE] by Licensed Vocational Nurse (LVN) D with a blood pressure of ,[DATE], 2. [DATE] by LVN R with a blood pressure of ,[DATE], 3. [DATE] by LVN S with a blood pressure of ,[DATE], 4. [DATE] by LVN R with a blood pressure of ,[DATE], 5. [DATE] by LVN D with a blood pressure of ,[DATE], 6. [DATE] by LVN D with a blood pressure of ,[DATE], 7. [DATE] by LVN S with a blood pressure of ,[DATE], 8. [DATE] by LVN S with a blood pressure of ,[DATE], 9. [DATE] by LVN C with a blood pressure of ,[DATE], 10. [DATE] by LVN G with a blood pressure of ,[DATE], 11. [DATE] by LVN R with a blood pressure of ,[DATE], 12. [DATE] by LVN D with a blood pressure of ,[DATE], 13. [DATE] by LVN D with a blood pressure of ,[DATE], 14. [DATE] by LVN D with a blood pressure of ,[DATE], 15. [DATE] by LVN D with a blood pressure of ,[DATE], 16. [DATE] by LVN R with a blood pressure of ,[DATE]. A record review of Resident #62's progress notes read; [DATE] 10:40 (a.m.) Nursing Progress Note Note Text: Resident went into [MEDICAL CONDITION] during [MEDICAL TREATMENT] treatment code blue called, CPR started @ 1018, 911 called @1020 EMS paramedics and SAFD arrived to facility @1030. CPR continued by EMS. NP (T) and granddaughter notified @1033 to xxx-xxx-[MEDICAL CONDITION]. Resident left via stretcher @1054 to be transported to (hospital) by EMS. In an interview on [DATE] at 2:50p.m. the DON confirmed Resident #62 had been sent to the hospital and readmitted several times prior to [DATE] and stated, after reviewing Resident #62's closed record the DON thinks what happened was a transcription error on Resident #62's readmission order for [MEDICATION NAME]. The DON further confirmed that upon readmission on [DATE], when the nurse was entering medication orders in the Electronic Medical Record (EMR) the system asked for a [DIAGNOSES REDACTED]. A record review of Resident #31's face sheet dated [DATE], revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. A record review of Resident #31's physicians order for [MEDICATION NAME] dated [DATE], read [MEDICATION NAME] HCL tablet 10mg give 1 tablet by mouth three times a day for [MEDICAL CONDITION], give for BP (blood pressure) less than ,[DATE] or HR (heart rate) less than 60. A record review of Resident #31's MAR for the period [DATE] to [DATE], revealed she was administered the drug [MEDICATION NAME] 4 times for blood pressures outside of the prescriber's parameters detailed as follows: 1. [DATE] by Certified Medication Aide (CMA - facility utilized position title) O with a blood pressure of ,[DATE], 2. [DATE] by CMA O with a blood pressures of ,[DATE], 3. [DATE] by CMA O with a blood pressure of ,[DATE], 4. [DATE] by CMA O with a blood pressure of ,[DATE], Record review of Resident #13's face sheet dated [DATE] revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #13's [DATE] consolidated orders revealed he was ordered [MEDICATION NAME] 10 mg give 1 tablet by mouth three times a day for [MEDICAL CONDITION]. (no parameters were revealed.) Record review of Resident #13's Admission MDS dated [DATE] revealed BIMs summary score was documented as severely impaired, Special Treatments was documented for [MEDICAL TREATMENT] and Swallowing/Nutritional Status - Nutritional Approaches was documented feeding tube (nasogastric of abdominal tube). Record review of Resident #13's [DATE] MAR indicated [REDACTED] [DATE] by LVN I at 3 p.m. with a b/p of ,[DATE], at 9 p.m. with a b/p of ,[DATE], [DATE] by ADON/LVN F at 3 p.m. with a b/p was,[DATE], [DATE] administered by LVN B at 3 p.m. with a b/p of ,[DATE] and at 9 p.m. with a b/p of ,[DATE], [DATE] administered by ADON/LVN F at 9 p.m. with a b/p of ,[DATE], [DATE] administered by LVN G at 3 p.m. with a b/p of ,[DATE], [DATE] administered by LVN I at p.m. with a b/p of ,[DATE], [DATE] by ADON/LVN F at 3 p.m. with a b/p of ,[DATE] and at 9 p.m. with a b/p of ,[DATE], [DATE] administered by LVN E at 9 a.m. with a b/p of ,[DATE], [DATE] administered by LVN D at 3 p.m. with a b/p of ,[DATE], and at 9 p.m. with a b/p of ,[DATE], [DATE] administered by LVN E at 9 a.m. with a b/p of ,[DATE], [DATE] administered by ADON/LVN F at 3 p.m. with a b/p of ,[DATE], and at 9 p.m. with a b/p of ,[DATE], [DATE] administered by LVN G at 3 p.m. with a b/p of ,[DATE], and at 9 p.m. with a b/p of ,[DATE]. Interview on [DATE] at 9:25 a.m. with LVN E confirmed she administered the [MEDICATION NAME] on [DATE], [DATE] and the b/p was ,[DATE] and ,[DATE]. LVN E stated she did monitor Resident #13 after administration of [MEDICATION NAME]. Interview on [DATE] at 10:34 a.m. with LVN D confirmed he did administer the [MEDICATION NAME] to Resident # 13 with a Blood Pressure (B/P) of ,[DATE] on [DATE]. LVN D stated a standing order for b/p for [MEDICAL TREATMENT] was to not to give [MEDICATION NAME] if blood pressure is less than ,[DATE] and should call the pharmacy if have questions, and that on the card, it had parameters. LVN D stated he follows the order and calls the MD if he had any questions about a medication. LVN D stated Resident #13 did not have side effects after giving his medications. During an interview on [DATE] at 1:48 p.m., the DON stated normal blood pressure was ,[DATE] and if staff had questions regarding resident medication they should consult with DON, MD or pharmacy. Interview on [DATE] at 2:05 p.m. with ADON/LVN F stated normal blood/pressure was ,[DATE]. The ADON/LVN F stated if b/p was 110, she would administer the [MEDICATION NAME] medication. The ADON/LVN F stated if she had a question about b/p then she would consult a nurse. LVN/ADON F confirmed she administered Resident #13's [MEDICATION NAME] on [DATE], [DATE], [DATE] and [DATE]. Interview on [DATE] at 3:23 p.m. with LVN G confirmed he administered Resident #13 the [MEDICATION NAME] on [DATE] at 3 p.m. b/p at ,[DATE], [DATE] at 3 p.m. with b/p of ,[DATE] and at 9 p.m. a b/p of ,[DATE]. LVN G said he would administer [MEDICATION NAME] for a b/p under 120. Interview on [DATE] at 4:10 p.m. with LVN B confirmed she administered Resident #13 the [MEDICATION NAME] on [DATE] at 3 p.m. for a b/p of ,[DATE] and [DATE] at 9 p.m. for b/p of ,[DATE]. LVN B confirmed she should have not administered the [MEDICATION NAME] for Resident #13. Interview on [DATE] 4:12 PM with LVN I confirmed [DATE] for 3 p.m., 9 p.m. and [DATE] at 9 p.m. she administered and used her nursing judgment of normal b/p of ,[DATE]. The LVN was not able to confirm if she called the MD. Record review of Resident #60's face sheet (undated) revealed an admitted on [DATE] with [DIAGNOSES REDACTED]. The tube is inserted through a cut in the neck below the vocal cords. This allows air to enter the lungs) status, and amyotrophic lateral [MEDICAL CONDITION] (ALS, is a progressive nervous system disease that affects nerve cells in the brain and spinal cord, causing loss of muscle control). Record review of Resident #60's Physician orders [REDACTED]. (no parameters indicated). Record review of Resident #60's [DATE] MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Record review of Resident #60's [DATE] MAR indicated [REDACTED] [DATE] with a SBP of 131, [DATE] SBP 138, ,[DATE] SBP 133, on ,[DATE] 1 p.m. dose with a SBP of 127 and 10 p.m. dose with a SBP of 127, and on ,[DATE] with a SBP of 128. Record review of Resident #60's physician orders [REDACTED]. Record review of Resident #60's [DATE] MAR indicated [REDACTED]. Record review of Resident #60's nursing notes revealed no documentation that the physician was contacted regarding parameters for [MEDICATION NAME] or that the physician was contacted regarding administering [MEDICATION NAME] with a normal or elevated SBP. In an interview on [DATE] at 10:55 a.m. LVN D reported he knew [MEDICATION NAME] was to treat low blood pressure and knew the possible side effects of [MEDICATION NAME] usage. LVN D further reported he takes blood pressures of residents before administration of [MEDICATION NAME]. LVN D further reported his documentation of administering [MEDICATION NAME] to Resident #62 twice on [DATE] for a SBP of 196 and twice on [DATE] with a SBP of 169, and once on [DATE] with a SBP of 169 stating must be a computer error. Interview on [DATE] at 3:18 p.m. with the Medical Director confirmed [MEDICATION NAME] is prescribed for [MEDICAL CONDITION] and is usually prescribed with the prescriber's parameters for administration. A record review of the Centers for Disease Control and Prevention's website, accessed [DATE], titled High Blood Pressure Symptoms and Causes read: What do blood pressure numbers mean? Blood pressure is measured using two numbers: The first number, called systolic blood pressure, measures the pressure in your arteries when your heart beats. The second number, called diastolic blood pressure, measures the pressure in your arteries when your heart rests between beats. What is high blood pressure (hypertension)? High blood pressure, also called hypertension, is blood pressure that is higher than normal. Your blood pressure changes throughout the day based on your activities. Having blood pressure measures consistently above normal may result in a [DIAGNOSES REDACTED]. The higher your blood pressure levels, the more risk you have for other health problems, such as [MEDICAL CONDITIONS], and stroke. Record review of the American Heart Association Understanding blood pressure readings ,[DATE] read, a normal SBP is 120 or lower, elevated is SBP ,[DATE], high blood pressure is SBP ,[DATE], stage 2 high blood pressure is SBP 140 or higher, and hypertensive crisis is SBP higher than 180. A record review of Mosby's Dictionary of Medicine, Nursing and health professions, 8th edition defined hypertension as a common disorder that is a known cardiovascular disease risk factor, characterized by elevated blood pressures over the normal values of ,[DATE]mm hg in an adult over [AGE] years. A record review of the National Library of Medicine's website titled [MEDICATION NAME] accessed [DATE] read: IMPORTANT WARNING: [MEDICATION NAME] may cause supine hypertension (high blood pressure that occurs when lying flat on your back). This medication should only be used by people whose low blood pressure severely limits their ability to perform daily activities and who could not be treated successfully with other therapies. Record review of the facility's undated policy titled Medication Administration, General read: Licensed Nurse or other individual administering medication is to be aware of the side effects of each drug given. Consult a drug reference or PDR for more information. The individual administering any medication must also be aware of the reason/[DIAGNOSES REDACTED]. For example, take the resident's apical pulse before administering [MEDICATION NAME]/[MEDICATION NAME]. Follow physician orders [REDACTED]. Record review of the facility's undated policy titled Medication Reconciliation read: Upon each admission and/or readmission to this facility, carefully review the physician orders [REDACTED]. On [DATE] at 8:30 p.m. the Administrator was notified an Immediate Jeopardy (IJ) situation for the above failures and a completed IJ template was provided the Administrator. A Plan of Removal was requested. On [DATE] at 1:15 p.m., the facility's Revised Plan of Removal was accepted and included the PoR (Plan of Removal quoted as written and provided by the manager. Edits provided in parenthesis as clarification for reader.) Plan of Removal - Facility ID # 7 Plan to remove immediate jeopardy Correction: 1 resident is no longer in the facility and three residents are still residing at the facility. Resident #62 is no longer a resident at San Antonio Residence and Rehabilitation Center. Physician notified of transcription error. Resident #60 was assessed by a Licensed Nurse on [DATE] at 8:30 p.m. for any adverse reactions to [MEDICATION NAME] medication given. Blood pressure and vitals were taken immediately upon knowledge of allegation and No adverse reactions noted. Blood pressure was within normal limits. Physician was contacted by Director of Nursing to request parameters be added to the order for [MEDICATION NAME]. Resident #31 was assessed by a Licensed Nurse on [DATE] at 8:41 p.m. for any adverse reactions to [MEDICATION NAME] medication given. No adverse reactions noted. Blood pressure and vitals were taken immediately upon knowledge of allegation and No adverse reactions noted. Blood pressure was within normal limits. Physician notified of medication error. Resident #13 was assessed by a Licensed Nurse on [DATE] at 8:53 p.m. for any adverse reactions to [MEDICATION NAME] medication given. No adverse reactions noted. Blood pressure and vitals were taken immediately upon knowledge of allegation and No adverse reactions noted. Blood pressure was within normal limits. Physician was contacted by Director of Nursing to request parameters be added to the order for [MEDICATION NAME]. Director of Nursing called Medical Director and Dr. A for clarification regarding the administration of [MEDICATION NAME] orders. Clarification from both physicians provided to Director of Nursing, orders updated for each resident per each physician's orders [REDACTED].>Residents with orders for [MEDICATION NAME] were audited on [DATE] for accuracy of transcription including parameters by the Director of Nursing and reviewed with the physicians to ensure [MEDICATION NAME] orders were transcribed correctly as ordered by physician(s) and then read back to physician for verification of accuracy. Director of Nursing provided education to Licensed Nurses and Medication Aides regarding proper transcription of medications and administering medications with parameters. Licensed Nurses and Medication Aides were reeducated that they are to consult with DON or facility RN for any questions regarding medication transcriptions. In-services were initiated on [DATE] and will be completed in person or via phone on [DATE]. The following policies and procedures were reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting on [DATE]: General Medication Administration and Medication Reconciliation. Identification of potentially affected other residents: All residents receiving [MEDICATION NAME] have the potential to be affected by this alleged deficient practice. A facility-wide audit was conducted on [DATE] to ensure [MEDICATION NAME] orders are all transcribed correctly as ordered by physician(s) and parameters are set for each resident per physician order. No other residents were affected by this alleged deficient practice. Measures/Systemic Changes: 1. During morning meeting, Director of Nursing, and Assistant Director of Nursing will review new MEDICATION ORDERS FOR [REDACTED] 2. Upon admission, Licensed Nurse will contact resident's admitting physician to confirm orders with proper transcription and necessary vital sign parameters for all [MEDICATION NAME] orders. Director of Nursing and Assistant Director of Nursing will be notified and review all new admission orders [REDACTED] 3. Licensed Nurses will now be responsible for administering [MEDICATION NAME] as of [DATE]. Education provided to Medication Aides and Licensed Nurses regarding the new protocol for [MEDICATION NAME] administration. 4. Director of Nursing conducted in-service on [DATE] with Licensed Nurses relating to the use of [MEDICATION NAME], the potential side effects, and when to administer medication with specified parameters. 5. Licensed Nurse will obtain necessary vital signs prior to [MEDICATION NAME] administration ensuring they are within parameters set forth by the physician. 6. Facility wide audit of resident MAR indicated [REDACTED]. All parameters for [MEDICATION NAME] are in place as ordered by physician. 7. Pharmacist, conducted an audit of all residents receiving [MEDICATION NAME] on [DATE] and this was completed. 8. Facility wide audit conducted for all residents receiving medications requiring parameters including insulin, blood pressure, and anti-coagulants on [DATE] by the Director of Nursing and MDS Coordinator. No adverse findings noted. 9. Medications requiring parameters which include, but not limited to, insulin, blood pressure, anti-coagulants, will be reviewed by the DON or ADON upon admission and daily. New orders will be reviewed by the Licensed Nurse, Director of Nursing and/or Assistant Director of Nursing for compliance and clarifications will be reviewed with the physicians as needed. 10. Director of Nursing and or Assistant Director of Nursing will conduct daily audits of medication administration related to compliance with parameters and transcription. Daily audits will be conducted for no less than 30 days to ensure compliance. Subsequent auditing will occur for an addition two months thereafter and findings will be reported to the facilities QAPI team. Surveyor Verification of PoR: DATE OF PoR REVIEW: [DATE] Verification of the Plan to remove immediate jeopardy Corrections: 1 Resident #62 is no longer in the facility. Residents #60, #31 and #13 are still residing at the facility. A closed record review of Resident #62's admission record dated, [DATE], revealed a discharge to the hospital via 911 on [DATE]. A record review of Resident #60's admission record dated [DATE], revealed admission date of [DATE] with [DIAGNOSES REDACTED]. An observation on [DATE] at 5:28 p.m. of Resident #60 revealed him in his bedroom dressed in a gown and covered by blankets. Resident #60 presents with a [MEDICAL CONDITION]. During an interview on [DATE] at 5:29 p.m., Resident #60 stated he feels safe, has no complaints, and is content in the medications he receives. A record review of Resident #31's admission record dated [DATE], revealed admission date of [DATE] with [DIAGNOSES REDACTED]. An observation on [DATE] at 5:31 p.m. of Resident #31 revealed her in her bedroom in bed watching television. Resident #31 presented alert and oriented. During an interview on [DATE] at 5:31, Resident # 31 confirmed she feels safe and is satisfied with her medication administration. A record review of Resident #13's admission record dated [DATE], revealed admission date of [DATE] with [DIAGNOSES REDACTED]. An observation on [DATE] at 5:38 p.m. of Resident #13 revealed him in bed completing the dinner service. An interview was attempted on [DATE] at 5:38 with Resident # 13. Resident #13 did not respond to questioning and an interview was not possible. Resident #62 is no longer a resident at San Antonio Residence and Rehabilitation Center. Physician notified of transcription error. Record review of Resident #62's closed record revealed a discharge date of [DATE]. Resident #60 was assessed by a Licensed Nurse on [DATE] at 8:30 p.m. for any adverse reactions to [MEDICATION NAME] medication given. Blood pressure and vitals were taken immediately upon knowledge of allegation and no adverse reactions noted. Blood pressure was within normal limits. Physician was contacted by Director of Nursing to request parameters be added to the order for [MEDICATION NAME]. Record review of Resident #60's Situation Background and Recommendation note dated [DATE] revealed blood pressure ,[DATE], pulse 98, respirations 18, oxygen saturation 99% via 4l oxygen via mask. The physician's new order read [MEDICATION NAME] HCL 10mg give 1 tab via G tube every 8 hours as needed for low blood pressure. Administer for systolic blood pressure less than 110. Interview on [DATE] at 2:56 p.m. with the DON confirmed nursing assessed Resident #60 and a Situation, Background, Assessment, and Recommendation (SBAR) notification was sent to the Physician on [DATE]. Resident #31 was assessed by a Licensed Nurse on [DATE] at 8:41 p.m. for any adverse reactions to [MEDICATION NAME] medication given. No adverse reactions noted. Blood pressure and vitals were taken immediately upon knowledge of allegation and no adverse reactions noted. Blood pressure was within normal limits. Physician notified of medication error. Record review of Resident #31's Situation, Background, Assessment, and Recommendation note dated [DATE] revealed blood pressure ,[DATE], pulse 70, respirations 17, oxygen saturation 96% room air. The report read notified MD resident received 4 doses of [MEDICATION NAME] outside of parameters from [DATE] to [DATE]. The physician's orders [REDACTED]. Interview on [DATE] at 3:09 p.m. with the DON confirmed nursing assessed Resident #60 and SBAR'ed the Physician on [DATE]. Resident #13 was assessed by a Licensed Nurse on [DATE] at 8:53 p.m. for any adverse reactions to [MEDICATION NAME] medication given. No adverse reactions noted. Blood pressure and vitals were taken immediately upon knowledge of allegation and no adverse reactions noted. Blood pressure was within normal limits. Physician was contacted by Director of Nursing to request parameters be added to the order for [MEDICATION NAME]. Record review of Resident #13's Situation Background and Recommendation note dated [DATE] revealed blood pressure ,[DATE], pulse 75, respirations 16, oxygen saturation 96% room air. The report read call out to MD to request order clarification [MEDICATION NAME] order needs parameters no adverse reactions noted at this time. The physician's new order dated [DATE]/2021 read [MEDICATION NAME] HCL 10mg give 1 tab per peg tube 1 time a day on Monday, Tuesday, Wednesday, Thursday, and Friday give if systolic blood pressure is less than 110. Interview on [DATE] at 3:13 p.m. with the DON confirmed nursing assessed Resident #13 and SBAR'ed the Physician on [DATE]. Director of Nursing called Medical Director, and Dr. A for clarification regarding the administration of [MEDICATION NAME] orders. Clarification from both physicians provided to Director of Nursing, orders updated for each resident per each physician's orders [REDACTED].> Interview on [DATE] with DON at 3:15 pm confirmed Resident #21 and Resident #7 received orders to discontinue [MEDICATION NAME]. Record review of resident # 21 discontinued orders read discontinue [MEDICATION NAME] Record review of resident #7 discontinued orders read discontinue [MEDICATION NAME] Record review of the facility's order listing report dated [DATE] read: o Resident #12 [MEDICATION NAME] hcl tablet 10mg give 1 tablet by mouth every 8 hours as needed for low blood pressure, give for systolic blood pressure less than 110. o Resident #57 Midodrie hcl 10mg give 1 tablet by mouth every 8 hours as needed for [MEDICAL CONDITION]. Give if systolic blood pressure is less than 110. o Resident #5 [MEDICATION NAME] hcl tablet 10mg by mouth every 8 hours as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION] of [MEDICAL TREATMENT]. Give if systolic blood pressure is less than 110. Interview on [DATE] at 3:30 p.m. with the DON confirmed she called the physicians on [DATE] and [DATE]. Residents with orders for [MEDICATION NAME] were audited on [DATE] for accuracy of transcription including parameters by the Director of Nursing and reviewed with the physicians to ensure [MEDICATION NAME] orders were transcribed correctly as ordered by physician(s) and then read back to physician for verification of accuracy. Interview on [DATE] at 3:15 pm confirmed Resident #21 and Resident #7 received orders to discontinue [MEDICATION NAME]. Record review of resident #21 discontinued orders read discontinue [MEDICATION NAME] Record review of resident #7 discontinued orders read discontinue [MEDICATION NAME] Record review of the facility's order listing report dated [DATE] read: o Resident #12 [MEDICATION NAME] hcl tablet 10mg give 1 tablet by mouth every 8 hours as needed for low blood pressure, give for systolic blood pressure less than 110. o Resident #57 Midodrie hcl 10mg give 1 tablet by mouth every 8 hours as needed for [MEDICAL CONDITION]. Give if systolic blood pressure is less than 110. o Resident #5 [MEDICATION NAME] hcl tablet 10mg by mouth every 8 hours as needed for [MEDICAL CONDITION] related to [MEDICAL CONDITION] of [MEDICAL TREATMENT]. Give if systolic blood pressure is less than 110. Interview on [DATE] at 3:30 p.m. with the DON confirmed she called the physician's [DATE] and [DATE] and reviewed all residents whom receive [MEDICATION NAME] with a telephone order read back to ensure accuracy of the [MEDICATION NAME] orders. Director of Nursing provided education to Licensed Nurses and Medication Aides regarding proper transcription of medications and administering medications with parameters. Licensed Nurses and Medication Aides were reeducated that they are to consult with DON or facility RN for any questions regarding medication transcriptions. In-services were initiated on [DATE] and will be completed in person or via phone on [DATE]. Record review of the facility's nursing employee roster dated [DATE] revealed 15 employees, plus 1 DON. 1. 10 licensed vocational nurses LVN B LVN C LVN D LVN E LVN F LVN G LVN H LVN I LVN J LVN K 2. 2 Registered nurses' RN L RN DON 3. 4 medication aides CMA N CMA O CMA P CMA Q Record review of the in-service sign in sheets dated from [DATE] to [DATE], revealed all employees signed the document. 1. Record review of the in-service reinforced training titled [MEDICATION NAME] treatment of [REDACTED]. [MEDICATION NAME] is used to treat low blood pressure [MEDICAL CONDITION]. It may cause dizziness or a light-headed feeling like you might pass out. This medicine is used only when low blood pressure affects daily life. Blood pressure must be checked prior to administration. Please see parameters before administering the medication. CMA's if [MEDICATION NAME] is found in your cart please give charge nurse. Adverse reactions supine hypertension if given at inappropriate time. Dosing should not be given after 6 p.m. slow heartbeat, unusual feeling in the chest, [MEDICAL CONDITION], confusion, weakness, or vision problems, for any new admissions re-admissions medication reconciliations must be completed with the MD and ensure that [MEDICATION NAME] parameters are reviewed and obtained. If you have any questions, please see the DON [MEDICATION NAME] is only to administered by a Licensed Vocational nurse / Registered Nurse, medication aides CMA are not allowed to administer medications. 2. During an interview on ,[DATE]/ 2021 at 2:31 p.m., LVN H confirmed she received a phone call in-service from the DON on [DATE] followed up with an in person in-service from the DON on [DATE] for [MEDICATION NAME] administration stating, do not give if blood pressure is less than 100 systolic and side effects can be d (TRUNCATED)