Every finding on record at Woodway Rehabilitation and Healthcare Center

Based on observations, interviews and record review, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 3 residents (Resident #8) reviewed for pain. The facility failed to ensure Resident #8 was assessed and pre-medicated with prescribed pain medicine prior to wound care on 08/24/2026 which resulted in Resident #8 screaming in pain throughout the treatment, an 8-9 pain level as related to facial signs. This failure could place residents at risk of increased pain, hospitalization, and a decreased quality of life. Findings included: Review of Resident #8's face sheet printed 08/24/2026 reflected a [AGE] year-old-female with diagnoses including vascular dementia, severe without behavioral disturbances (a decline in thinking skills caused by conditions that block or reduce blood flow and oxygen to the brain), unstageable left hip pressure wound, arterial wound left first toe and stage 3 pressure wound of right lateral foot, unilateral primary osteoarthritis (a degenerative joint disease that causes the protective cartilage in a single joint on one side of the body to break down without a clear, known underlying cause). Review of Resident #8's care plan revised 7/26/2026 revealed that she had an unstageable pressure injury to Right lateral foot d/t impaired mobility & difficulty with offloading due to contracted legs; (Unstageable) pressure injury to (Left hip) d/t fragile skin, incontinent, impaired mobility, and that Resident #8 was at risk for pain and discomfort due to muscle weakness and arthritis with goal to have no complication from wound and with intervention to administer pain medication as ordered and may use the PainAd (pain assessment in advanced Dementia) scale due to cognitive loss. Review of Resident #8's quarterly MDS assessment dated [DATE] reflected Resident #8 had a BIMS score of 09-indicating moderately impaired cognition. Section M-Skin Condition reflected Resident #8 had an unhealed pressure ulcer, a stage 3 and unstageable pressure ulcers. Review of Resident #8's physician orders reflected: Acetaminophen Tab 325 MG Give 2 tablets orally every 6 hours as needed for Pain related to Pain, unspecified Active 06/07/2020 09/18/2024 traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth three times a day for Pain - Moderate Phone Active 01/25/2026 01/25/2026. In an observation on 08/24/2026 at about 2:04 pm while LVN A was providing wound care on Resident #8, Resident #8 was noted to be yelling and crying out whenever LVN A tried to clean the wounds on both feet. Resident #8 continued to yell and cry out with tears and facial grimacing when LVN A was applying boots after the wound care. It was observed that LVN A did not stop at any point to ask Resident #8 about her pain or assess Resident #8's pain. Record Review of Resident #8's MAR on 08/24/2026 at about 2:30 pm reflected Resident #8 did not get PRN Acetaminophen or Tramadol scheduled for 2:30 pm prior to wound care. In an interview on 08/25/2026 at about 10:53 am the DON stated when adjusting Resident #8's boots, Resident #8 would yell and she was not sure if Resident #8 was necessarily in pain or Resident #8 was just yelling. The DON stated, if a resident was complaining of pain or yelling, the staff should stop the treatment, give the resident pain medication and come back later to reassess. The DON stated they did not want the residents to be in pain and that was a quality-of-care issue. In an interview on 08/25/2026 at 11:12 am, LVN A stated prior to her performing wound care on Resident #1, she asked MA B to administer PRN pain medication to Resident #8. LVN A stated she did not check or verify that if MA B gave Resident #8 pain medication. LVN A stated she should have stopped but did not stop the wound care because she did not want Resident #8's wound to be infected. LVN A stated the wound on Resident #8's right foot had some foul odor, with that smell and the pain, she was concerned about osteomyelitis (an infection and inflammation of the bone and bone marrow ), due to Resident #8 being in so much pain. LVN A stated Resident #8 was not able to rate her pain, but from grimacing and the yelling during wound care, she would rate Resident #8's pain from 5-6 on the scale 0-10. In a phone interview on 08/25/2026 at 12:08 pm, Resident #8's family stated they visited Resident #8 at least once a week. Family stated they were aware of the wounds on Resident #8's hip and feet that were delayed in healing. Resident #8's family stated Resident #8 does not normally cry out in pain, she would say that she was hurting but was not able to say how bad her pain was. Attempt made to contact MA B on 08/25/2026 at 12:25 pm. Left a message with a call back number, no response or call back. In an interview on 08/25/2026 at 12:44 PM with the MD, he stated he was familiar with Resident #8. He stated that Resident #8 was declining. The MD stated he received a report that Resident #8 was uncomfortable during wound care treatment. He stated Resident #8 was on tramadol 50mg TID. The MD stated if a resident started hurting, they should assess the resident's pain level. The MD stated that Resident #8 was not able to ask for pain medication, so her Tramadol was scheduled. The MD stated the staff should stop and give something for pain if a resident is yelling during wound care, they should reassess to determine if they should come back later. The MD stated that infection could sometimes increase pain and it depends on where the infection was and what their pain sensation was. The MD stated pain has not been something they have been dealing with Resident #8, and this could be a change in condition if the resident previously did not express this much pain but did recently. The MD stated the facility did good about reaching out to him about increasing pain meds. In a phone interview on 08/25/2026 at 5:45 pm, the Wound Care Doctor stated Resident #8 does not usually complain of pain during wound care and that yesterday (08/24/2026) was different. The Wound Care Doctor said Resident #8 was screaming in pain, she could hear from outside the room. The Wound Care Doctor stated LVN A should have medicated Resident #8 with stand by pain medication. She stated she thought Resident #8 was hurting due to the movement during wound care due to her contractures (sudden, painful tightening of the muscles that can stem from simple dehydration or more serious underlying medical conditions). She stated they would look into premedicating Resident #8 prior to wound care. Review of facility's pain management policy revised 07/2026 reflected: Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Policy Explanation and Compliance Guidelines: The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g. after a fall, change in behavior or mental status, new pain or an exacerbation of pain). c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences Facility staff will observe nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to: a. Change in gait (e.g. limping), skin color, vital signs (e.g. increased heart rate, respirations, and/or blood pressure), perspiration b. Loss of function or inability to perform activities of daily living (ADLs) (e.g. rubbing a specific location of the body, or guarding a limb or other body parts) location of the body, or guarding a limb or other body parts) c. Fidgeting, increased or recurring restlessness d. Facial expressions (e.g. grimacing, frowning, fright, or clenching of the jaw) e. Behaviors such as resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities g. Weight loss i. Negative vocalizations (e.g. groaning, crying, whimpering, or screaming) J. Decline in activity level k. Skin condition

Based on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care within 48 hours of the residents' admission for 4 of 8 residents (Resident #41, Resident #48, Resident #79, and Resident #81). The facility failed to ensure Resident #41, Resident #48, Resident #79, and Resident #81 had baseline care plans within 48 hours of their respective admissions.This failure could place newly admitted residents at risk of not receiving safe, effective, person-centered care. Findings Included:Resident #41-Review of Resident #41's comprehensive MDS assessment dated [DATE] reflected an [AGE] year-old female who admitted to the facility on [DATE]. Resident #41's preferred language was Spanish. Resident #41 had a BIMS score of 00-indicating severely impaired cognition. Review of Resident #41's baseline care plan audit report reflected the first goals were initiated on 8/17/2026 at 3:29 pm by the SW. The baseline care plan was signed by the RN (DON) on 8/18/2026. Review of the last page revealed the due date was 8/14/2026.Review of Resident #41's baseline care plan revealed it was effective 8/17/2026. In the social services section, it was indicated that Resident #41 was Non-English Speaking, and there was a note that stated, Resident is primarily Spanish-speaking & is sometimes difficult to understand d/t loose dentures (bottom).Review of Resident #41's comprehensive care plan with an admission date of 8/13/2026 reflected the only areas accounted for within the 48-hour period were: Impaired thought processes and skin breakdown related to dementia, impaired visual function related to glaucoma, at risk for falls related to poor safety awareness, regular diet, code status, resides on memory care unit related to wandering behaviors.In an observation on 08/26/2026 at 11:21 AM Resident #41 was observed seated in her w/c in the dining room in a corner away from the other residents and staff. She was observed mumbling to herself in an unintelligible way. She looked at the CNA and pointed toward a chair and began mumbling, the CNA did not verbally engage with the resident during this observation. Resident #48-Review of Resident #48's baseline care plan audit report reflected the first goals were initiated on 8/4/2026 at 10:01 am. The baseline care plan was signed by the RN (DON) on 8/4/2026. Review of the last page revealed the due date was 7/31/2026.Review of Resident #48's baseline care plan revealed it was effective 8/3/2026. It detailed Resident #48's admission date was 7/30/2026.Resident #79-Review of Resident #79's comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old male who admitted to the facility on [DATE]. Resident #79 had a BIMS score of 12-indicating moderately impaired cognition.Review of Resident #79's baseline care plan audit report reflected the first goals were initiated on 7/6/2026 at 11:55am by the previous ADON. The baseline care plan was signed by the RN (DON) on 7/8/2026. Review of the last page revealed the due date was 7/3/2026.Review of Resident #79's baseline care plan revealed it was effective 7/6/2026. It detailed Resident #79's admission date was 7/2/2026.Review of Resident #79's comprehensive care plan with an admission date of 7/2/2026 reflected the only areas accounted for within the 48-hour period were: code status.Resident #81-Review of Resident #81's baseline care plan audit report reflected the first goals were initiated on 6/11/2026 at 5:17pm. Resident #81's admission date was 6/11/2026. The baseline care plan was signed by the RN (DON) on 6/15/2026. Review of the last page revealed the due date was 6/12/2026.Review of Resident #81's baseline care plan revealed it was effective 6/11/2026 and was not signed by the RN (DON) until 6/15/2026. In an interview on 08/26/2026 at 4:00 PM the SW stated that he was not responsible for opening the baseline care plans. He stated he thought it was the DON or another member of nursing staff.In an interview on 08/26/2026 at 4:45 PM the DON stated that they have an alert in the computer to 'open' the baseline care plan, but not to ensure its completion. The DON stated that Resident #41 was a fairly new admit and the AA had been trying to implement some culturally appropriate things. There was a resident in the MCU who was bilingual, she stated even with the best Spanish speaker, Resident #41's cognition was not always there. The DON stated the importance of the care plan identifying Resident #41's communication needs was to produce person-centered care for the resident. She stated that every staff had a phone that they could use [translate app], they could call the communication line if they needed someone to translate for them. She stated the posting of the translation line was outside the MCU. She did not think there was a communication/picture board for Resident #41 to use. She stated she knew there were Spanish television channels, and music could be played. She stated that she had not heard anything from the family or staff indicating they could not meet Resident #41's needs. She stated that the baseline care plan was her responsibility to lock it within 48 hours.In an interview on 08/26/2026 at 5:16 PM with the ADM she stated that the staff have 48 hours to complete the baseline care plan. She stated it is the IDT's responsibility to ensure the timeliness. She agreed that if a resident who admitted late in the week, and baseline care plan was due on the weekend, it should still get done. What is the importance? To get to know the resident, their needs, their d/c plans, their family involvement, preferences, dietary needs. She stated that the resident's history could not be known if the baseline care plan is not completed within that timeframe. She stated that the IDT was responsible for putting language onto the comprehensive care plan. Review of the facility's policy titled, Baseline Care Plan and last revised 1/2026 reflected The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.1. The baseline care plan will:a. Be developed within 48 hours of a resident's admission.b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to:i. Initial goals based on admission orders.ii. Physician orders.111. Dietary orders.1v. Therapy services.v. Social services.v1. PASARR recommendation, if applicable.

Based on interviews and record reviews, the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 6 (Resident #8) residents reviewed for accuracy of assessments. The facility failed to accurately document Resident #8's use of scheduled pain medication. This failure could place residents at risk of not receiving the appropriate care, treatment, and services due to inaccurate assessments. Findings included: Review of Resident #8's face sheet printed 08/24/2026 reflected a [AGE] year-old-female with diagnoses including vascular dementia, severe without behavioral disturbances (a decline in thinking skills caused by conditions that block or reduce blood flow and oxygen to the brain), unstageable pressure injury left hip, arterial wound left first toe and stage 3 pressure wound of right lateral foot, and unilateral primary osteoarthritis (a degenerative joint disease that causes the protective cartilage in a single joint on one side of the body to break down without a clear, known underlying cause). Review of Resident #8's care plan revised 7/26/2026 revealed that she had an unstageable pressure injury to (Right lateral foot) d/t impaired mobility & difficulty with offloading due to contracted legs; (Unstageable) pressure injury to (Left hip) d/t fragile skin, incontinent, impaired mobility, and that Resident #8 was at risk for pain and discomfort due to muscle weakness and arthritis with goal of maintaining adequate level of comfort as evidenced by no signs or symptoms of unrelieved pain or distress, verbalizing satisfaction with level of comfort within the next 90 days Interventions to administer pain medication as ordered and may use the PainAd scale (Pain Assessment in Advanced Dementia, a structured, observational tool designed to measure pain levels in people with advanced dementia or other severe cognitive impairments) due to cognitive loss. Review of Resident #8's quarterly MDS assessment dated [DATE] reflected Resident #8 had a BIMS score of 09-indicating moderately impaired cognition. Section M-Skin Condition reflected Resident #8 had an unhealed pressure ulcer, a stage 3 and unstageable pressure ulcers. Resident #8's MDS indicated Resident #8 did not receive scheduled pain medication. Review of Resident #8's physician orders reflected: Acetaminophen Tab 325 MG Give 2 tablets orally every 6 hours as needed for Pain related to Pain, unspecified Active 06/07/2020 09/18/2024 traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth three times a day for Pain - Moderate Phone Active 01/25/2026 01/25/2026. In an interview on 08/26/2026 at 1:50 PM with the MDSC, stated had worked at the facility since the end of March 2026, has been working on MDS since 2014. She stated that the MDS triggered the care plan, the CAA section triggered the things that needed to be added to the care plan. She stated if it was not triggered on the MDS it would not populate to the care plan. She stated that when she was completing an MDS assessment, it was supposed to represent a clear picture of the resident. She stated she gathered information from the IDT. She stated she assessed the patient herself as well for pain. She stated that for the pain portion of the MDS, the 5 day look back period was documented based off looking at the MAR. The MDSC stated that for a resident who was on routine pain medication, the box should indicate 'yes' as taking pain medication. She stated that the assessment should be accurate because they were supposed to paint a clear picture. She stated she could do a modification of the MDS assessment for Resident #8. In an interview on 08/26/2026 at 4:45 PM the DON stated she has been working at the facility for approximately 18 months. She stated the Social Worker schedules the 48-hour care plan with the resident/ family/ or both. She stated that the focus of the MDS assessment was to be an accurate representation of the resident, and that it depended on what part of the assessment was not accurate on how it would affect the resident. She stated that the 5-day look back period indicating the use of pain medication would not impact a resident's care. She stated the MDSC was responsible for accurately documenting the information on residents. Review of facility's policy titled Assessment frequency/Timelines revised 07/2026 reflected: Policy: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI Manual.

Based on observation, interviews and record review, the facility failed to implement a person-centered culturally competent comprehensive care plan that described the services to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #41) reviewed for care plans. The facility failed to care plan Resident #41's primary language as Spanish and implement culturally competent goals and/or objectives.This deficient practice placed residents at risk of not having their individualized needs met and communicated to providers that could result in a decline in physical well-being. Findings included:Review of Resident #41's comprehensive MDS assessment dated [DATE] reflected an [AGE] year-old female who admitted to the facility on [DATE]. Resident #41's preferred language was Spanish. Resident #41 had a BIMS score of 00-indicating severe cognitive impairment. Review of Resident #41's baseline care plan revealed it was effective 8/17/2026. In the social services section, it was indicated that Resident #41 was Non-English Speaking, and there was a note that stated, Resident is primarily Spanish-speaking & is sometimes difficult to understand d/t loose dentures (bottom).Review of Resident #41's social service note dated 8/17/2026 documented by the SW reflected, Resident admitted for LTC on MCU. Spanish-speaking; assessment was attempted in both English and Spanish, but resident was difficult to understand and required multiple unsuccessful redirections. Collateral info was provided by the RP. Full code. Resident did not answer depression screening questions, but staff report no symptoms. Cognitive deficits assessed in all areas except orientation to self. Negative trauma screen. No additional social services needs at this time.In an observation on 08/24/2026 at 2:47pm Resident #41 was observed ambulating throughout the MCU in her w/c and on multiple occasions she was observed speaking Spanish to everyone she passed and continued with conversation even as she would roll away from people. Overall, Resident #41 appeared pleasantly confused and disengaged. In an observation on 08/26/2026 at 11:21 AM Resident #41 was observed seated in her w/c in the dining room in a corner away from the other residents and staff. She was observed mumbling to herself in an unintelligible way. She looked at a CNA and pointed toward a chair and began mumbling, the CNA did not verbally engage with the resident during this observation. In an observation on 08/26/2026 at 11:23 AM of the dining room revealed an activity calendar posted on the wall in the English language. The TV was playing a movie in the English language and had English subtitles. The dining room contained posters on the wall that said, You Got This and Be Kind.In an observation on 08/26/2026 at 11:24 AM revealed Resident #41's room was not personalized, had no signs on the walls in any language. The TV was on and playing a television show in English and with English subtitles. There was no notice above the bed or anywhere that informed staff/visitors of Resident #41's language difference. In an interview on 08/26/2026 at 11:25 AM with CNA B who had been working at the facility for about 6 months and had been assigned to the MCU the whole time; she stated that she was not sure how long Resident #41 had been a resident but estimated about a month. She stated that Resident #41 did not speak any English. She stated Resident #41 could understand commands like, let's get out of bed. She stated 2 other residents spoke Spanish and could help translate because they understood and spoke English as well. She stated that as far as Resident #41 communicated to the staff; if Resident #41 was hungry she would take food from other residents. If she was in pain, she would make noises. If she was incontinent or had a BM, she would become quiet. She stated they try to communicate with the resident when they performed tasks, in English. She stated the Activity Director was talking about putting things in Spanish in the MCU for Resident #41 about a week ago. She stated that the resident would participate in some activities, but majority of the time she just roamed the halls. In an interview on 08/26/2026 at 11:37 AM with CNA A, she said she had been working at the facility through agency for about 2 years. She stated that she worked 6a-2p pretty much every day through agency. She stated that if Resident #41 needed something while she was working, the other CNAs would come get CNA A to speak to Resident #41 because she spoke Spanish. She stated she had questioned herself before on what the staff did when CNA A was not working, and how the staff who do not speak Spanish interacted with Resident #41. She stated that often Resident #41 would shout La Garte (which meant 'get out of here') to CNA A and to other staff, but if the other staff did not know what that meant, they would not know that Resident #41 was not wanting the staff in her room. She stated that Resident #41 liked to do her own thing (mainly roam about in her w/c), so they let her do that. She stated she had not witnessed any activities going on in Spanish. She stated that the resident often appeared more excited when this CNA spoke to her in her native language. In an observation 08/26/2026 at 11:40 AM of CNA A interacting with Resident #41 in Spanish, Resident #41's facial expressions changed into a brighter, more alert look. Instead of mumbling to herself she interacted in conversation with this CNA. She told the CNA she wanted to call someone named [male's name], the CNA asked Resident #41 if the food looked good and like something she wanted to eat and Resident #41 said yes, it looked good. She told CNA A that the kitchen people were lazy because they overcooked the bread. She told CNA A she was having a good day. She was observed taking the green bean out of her mouth and the CNA asked why she did that and Resident #41 stated it did not taste good. She told CNA A she was only going to eat the bread. The resident was observed eating the bread off her plate and dipping it into the green bean juice. In an interview on 08/26/2026 at 11:58 AM with the AA, who started as the Activity Assistant in July 2026. She stated she provides activities in the MCU everyday M-F. She stated that Resident #41 participated in morning exercises. The AA would show Resident #41 the motions of what to do. She stated that she could ask hi how are you doing? to Resident #41, and the resident would sometimes answer her back. She stated she did not know much Spanish so she could not communicate Spanish instructions to Resident #41. She stated they did have a set of headphones that contained a [NAME] card with Spanish music that played. She stated that she was unsure if the dining room television played Spanish shows or had Spanish subtitles. She stated that Resident #41 really enjoyed peanut butter and jelly sandwiches. She could ask Resident #41 if she wanted a PBJ, and the resident understood and would accept or decline. She stated she had not gotten with the AD about Spanish materials in the MCU. The only thing she had discussed was the wearing of the headphones. She stated that she felt bad that she did not understand or speak Spanish and has tried to learn it on her own at home. In an interview on 08/26/2026 at 4:45 PM the DON stated that Resident #41 was a fairly new admit and the AA had been trying to implement some culturally appropriate things. There was a resident in the MCU who was bilingual, she stated even with the best Spanish speaker, Resident #41's cognition was not always there. The DON stated the importance of the care plan identifying Resident #41's communication needs was to produce person-centered care for the resident. She stated that every staff had a phone that they could use [translate app], they could call the communication line if they needed someone to translate for them. She stated the posting of the translation line was outside the MCU. She did not think there was a communication/picture board for Resident #41 to use. She stated she knew there were Spanish television channels, and music could be played. She stated that she had not heard anything from the family or staff indicating they could not meet Resident #41's needs.In an interview on 08/26/2026 at 5:16 PM with the ADM she stated that the IDT was responsible for putting language onto the comp care plan. She stated that the resident could have signs/symptoms that the staff could assess to determine certain cues the resident is trying to communicate. Review of the facility's policy titled Culturally Competent Care last revised 7/2026 reflected:It is the policy of this facility to provide culturally competent care in accordance with professional standards of practice. The facility has established an environment that treats each resident with respect and dignity as an individual. The facility supports and/or enhances residents' feelings of self-worth and encourages personal control over choices and cultural preferences. Language Assistance Services is defined as language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. This may include oral interpretation, written language translation, or both.3. The facility will provide sufficient guidance for staff, including temporary staff, on how to communicate and deliver care for the resident. Many aspects of cultural preferences may impact the delivery of care. Once identified, these will be added to the resident's care plan.5. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. If indicated, language assistance services will be arranged for the resident. The care plan will identify the language spoken and tools used to communicate.6 If communication systems are used, all staff interacting with the resident will know where thosematerials are kept, will understand how to use them, and consistently implement use of those methods. Staff will demonstrate proficiency in communicating with the resident to assure that critical information can be conveyed, such as a change in condition, the presence of pain, explanation of routine care, and the ability to refuse care and services. Review of facility's policy titled Comprehensive Care Plans revised 04/2026 reflected: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the residents' comprehensive assessment.

Based on observation, interview and record reviews, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #8) reviewed for wound care.LVN A did not clean Resident #8's wound from inside out. LVN A did not change gloves while between 2 wounds while providing wound care for Resident #8. These failures could place residents at risk of infection, decreased wound healing, hospitalization and decreased quality of life. Findings included: Review of Resident #8's face sheet printed 08/24/2026 reflected a [AGE] year-old-female with diagnoses including vascular dementia, severe without behavioral disturbances (a decline in thinking skills caused by conditions that block or reduce blood flow and oxygen to the brain), unstageable left hip pressure wound, arterial wound left first toe and stage 3 pressure wound of right lateral foot, unilateral primary osteoarthritis (a degenerative joint disease that causes the protective cartilage in a single joint on one side of the body to break down without a clear, known underlying cause). Review of Resident #8's care plan revised 7/26/2026 revealed that she had an unstageable pressure injury to (Right lateral foot) d/t impaired mobility & difficulty with offloading due to contracted legs; (Unstageable) pressure injury to (Left hip) d/t fragile skin, incontinent, impaired mobility, and that Resident #8 was at risk for pain and discomfort due to muscle weakness and arthritis with goal with intervention to administer pain medication as ordered and may use the PainAd scale (Pain Assessment in Advanced Dementia, a structured, observational tool designed to measure pain levels in people with advanced dementia or other severe cognitive impairments) due to cognitive loss. Review of Resident #8's quarterly MDS assessment dated [DATE] reflected Resident #8 had a BIMS score of 09-indicating moderately impaired cognition. Section M-Skin Condition reflected Resident #8 had an unhealed pressure ulcer, a stage 3 and unstageable pressure ulcers. In an observation on 08/24/2026 at about 2:04 pm the Wound Care Doctor went into Resident #8's room, removed soiled dressing from Resident #8's wound on her left hip, left medial foot and right lateral foot. Wound Care Doctor assessed all 3 wounds and left room for LVN A to perform wound care. It was observed that LVN A went to the treatment cart next to the door, gathered supplies needed for wound care. LVN A applied a clean glove, tried to open normal saline bottle with gloved hands with difficulties. LVN A finally opened normal saline bottle, LVN A did not change her gloves or perform hand hygiene. LVN A put normal saline on 4x4 gauze, cleaned Resident #8's wound on left medial foot, cleaning in all directions, up to down and left to right and using the same gauze. LVN A did not pat dry Resident #8's wound. LVN A then applied honey to wound bed and covered with boarder dressing. LVN A did not change gloves or perform hand hygiene, she put normal saline on another 4x4 gauze, cleaned right hip in all directions, up to down and left to right and used the same gauze. This location took a while to clean due to drainage sticking to the skin. LVN A did not pat dry Resident #8's wound, applied honey and covered with boarder dressing. LVN A then was looking for pen to date the dressing on Resident #8's hip, she took off her soiled gloves, reached in her pocket for a pen and dated Resident #8's hip wound and right foot wound. LVN A again did not perform hand hygiene, applied clean gloves, normal saline on 4x4 gauze and cleaned Resident #8's wound on the right lateral foot cleaning in all directions, up to down and left to right and using the same gauze. LVN A did not pat dry Resident #8's wound, LVN A applied honey and covered with boarder dressing. LVN A changed gloves, no hand hygiene and applied Resident #8's boots. In an interview on 08/25/2026 at 10:34 am LVN A stated she already knew what the interview was about. LVN A stated it was about washing her hands and the bio-hazard box. LVN A stated she was supposed to perform hand hygiene in-between gloves changes, before and after the wound care. LVN A stated she was not supposed to move from one wound to the other with same soiled gloves, she was supposed to change her gloves after the first wound but that was her being nervous. LVN A stated she should have changed her gloves after opening the normal saline bottle. LVN A stated, when cleaning a wound, you have to clean it from inside out and get another gauze to clean thoroughly. LVN A stated all these issues were infection control problems. In an interview on 08/25/2026 at about 10:53 am the DON said staff were supposed to perform hand hygiene prior to putting on their gloves to start the wound care and with gloves change. The DON stated they were supposed to change gloves after you remove the soiled dressing, then clean the wound before putting the new dressing on. The DON stated it was not ok to move from one wound to the other with the same gloves because you do not want to spread infection from one wound to the other. The DON stated she would not put the gloves on until she had opened the normal saline bottle. These were all due to infection prevention. The DON stated, when cleaning a wound, you should go from inside out basically, because going from outside is moving the contamination inside, you want to get rid of the infection, not take it into the wound. The DON stated she was responsible for performing wound care since all the other floor nurses did not have wound care competencies. Review of facility's treatment nurse competency reflected the following: DRESSINGS, DRY I CLEAN The following equipment and supplies will be necessary when performing this procedure: clean dressing(s); cleaning solution, as ordered; tape; scissors; and personal protective equipment (e.g., gowns, gloves, mask etc. as needed) Clean bedside stand. Establish a clean field Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached. Tape a disposable bag on the bedside stand or use a waste basket below clean field. Position resident and adjust clothing to provide access to affected area. Perform hand hygiene or sanitize as appropriate. Put on clean gloves. Loosen tape and remove soiled dressing. Pull gloves over dressing and discard them into disposable bag. Perform hand hygiene or sanitize as appropriate. Open dry, clean dressing(s) by pulling comers of the exterior wrapping outward, touching only the exterior surf ace. Label tape or dressing with date and initials. Place on clean field. DRESSINGS, DRY /CLEAN Using clean technique, open other products (i.e., prescribed dressing; dry, clean gauze). Perform hand hygiene or sanitize as appropriate. Put on clean gloves. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). Use dry gauze to pat the wound dry. Apply the ordered dressing and secure with tape or bordered dressing per order. (Note: Use non-allergenic tape as indicated.) Label with date and initials to dressing. Discard items into the designated container. Remove gloves and discard into designated container. Perform hand hygiene or sanitize as appropriate. Reposition the bed covers. Make the resident comfortable. Place the call light within easy reach of the resident. Clean the bedside stand. Perform hand hygiene or sanitize as appropriate. Review of facility's policy titled Wound Treatment Management revised 05/2026 reflected: Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.

Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents reviewed for infection control. (Resident # 8) LVN A did not perform hand hygiene between gloves changes while performing wound care on Resident #8. LVN A did not change gloves when moving from one wound to the other. This failure could place residents at risk of infection, hospitalization and decreased quality of life. Findings included: Review of Resident #8's face sheet printed 08/24/2026 reflected a [AGE] year-old-female with diagnoses including vascular dementia, severe without behavioral disturbances(a decline in thinking skills caused by conditions that block or reduce blood flow and oxygen to the brain), unstageable left hip, arterial wound left first toe and stage 3 pressure wound of right lateral foot, unilateral primary osteoarthritis (a degenerative joint disease that causes the protective cartilage in a single joint on one side of the body to break down without a clear, known underlying cause). Review of Resident #8's care plan revised 7/26/2026 revealed that she had an unstageable pressure injury to (Right lateral foot) d/t impaired mobility & difficulty with offloading due to contracted legs; (Unstageable) pressure injury to (Left hip) d/t fragile skin, incontinent, impaired mobility, and that Resident #8 was at risk for pain and discomfort due to muscle weakness and arthritis with goal with intervention to administer pain medication as ordered and may use the Pain Ad scale due to cognitive loss. Review of Resident #8's quarterly MDS assessment dated [DATE] reflected Resident #8 had a BIMS score of 09-indicating moderately impaired cognition. Section M-Skin Condition reflected Resident #8 had an unhealed pressure ulcer, a stage 3 and unstageable pressure ulcers. Review of Resident #8's MAR reflected Resident #8 completed antibiotic on 08/24/2026 due to wound infection. Doxycycline Hyclate Oral Tablet 100 MG (Doxycycline Hyclate) Give 1 tablet by mouth two times a day related to LOCAL INFECTION OF THE SKIN AND SUBCUTANEOUS TISSUE, UNSPECIFIED for 7 Days, order dated 08/17/2026 and completed on 08/24/2026 In an observation on 08/24/2026 at about 2:04 pm the Wound Care Doctor went into Resident #8's room, removed soiled dressing from Resident #8's wound her left hip, left medial foot and right lateral foot. Wound Care Doctor assessed all 3 wounds and left room for LVN A to perform wound care. It was observed that LVN A went to the treatment cart next to the door, gathered supplies needed for wound care. LVN A applied a clean glove, tried to open normal saline bottle with gloved hands with difficulties. LVN A finally opened normal saline bottle, LVN A did not change her gloves or perform hand hygiene, LVN A put normal saline on 4x4 gauze, cleaned Resident #8's wound on left medial foot. LVN A then applied honey to wound bed and covered with boarder dressing. LVN A did not change gloves or perform hand hygiene, she put normal saline on another 4x4 gauze, clean right hip, applied honey and covered with boarder dressing. LVN A then was looking for pen to date the dressing on Resident #8's hip, she took off her soiled gloves, reached in her pocket for a pen and dated Resident #8's hip wound and right foot wound. LVN A again did not perform hand hygiene, applied clean gloves, normal saline on 4x4 gauze and cleaned Resident #8's wound on the right lateral foot. LVN A applied honey and covered with boarder dressing. LVN A change gloves, no hand hygiene and applied Resident #8's boots. In an interview on 08/25/2026 at 10:34 am LVN A stated she already knew what the interview was about. LVN A stated it was about washing her hands and the bio-hazard box. LVN A stated she was supposed to perform hand hygiene in-between gloves changes, before and after the wound care. LVN A stated she was not supposed to move from one wound to the other with same soiled gloves, she was supposed to change her gloves after the first wound but that was her being nervous. LVN A stated she should have changed her gloves after opening the normal saline bottle. LVN A stated all these issues were infection control problems. In an interview on 08/25/2026 at about 10:53 am the DON staff were supposed to perform hand hygiene prior to putting on their gloves to start the wound care and with gloves change. The DON stated, change gloves after you remove the soiled dressing, then to clean and then before you put the new dressing on. The DON stated, it is not ok to move from one wound to the other with the same gloves because you do not want to spread infection from one wound to the other. The DON stated she would wouldn't put the gloves on until she had opened the normal the saline bottle. These are all due to infection prevention. Review of facility's policy titled Infection Prevention and Control Program revised 07/2026 reflected: Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe sanitary and has comfortable environment to help prevent the transmission and development of communicable diseases and infections as per accepted national standards and guidelines. Definitions: Staff includes all facility staff (direct and indirect care the functions), contracted staff, consultants, volunteers, others who provide care and services to residents on behalf of the facility, and students in the facility's nurse aide training programs or from affiliated academic institutions. Review of facility's policy titled Hand Hygiene revised 02/2026 reflected: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 resident of 20 residents (Res#1) reviewed for quality of care. The facility failed to answer Res#1's call light after Res#1 pressed the call light button for 34 minutes. This failure could place residents at risk of not trusting the facility, physical harm, and mental anguish.Findings included: Record review of Res#1's admission's record dated 06/30/26 indicated she was a [AGE] year-old female admitted to the facility 09/29/25. Her diagnoses included other specified diabetes mellitus (group of diseases that affect how the body uses blood sugar) with diabetic neuropathy (common complication of diabetes, characterized by nerve damage that can lead to pain, numbness, and other disfunctions in the body) chronic obstructive pulmonary disease (a progressive lung disease that restricted air flow), unspecified, metabolic encephalopathy (brain dysfunction caused by chemical imbalances in the body rather than a structural injury), paroxysmal atrial fibrillation (an intermittent, irregular heart rhythm where the upper chambers of the heart (atria) beat chaotically), and acute kidney failure, and memory deficit following unspecified cerebrovascular disease (umbrella term for conditions that impact the blood vessels in your brain). Record review on 06/30/26 of Res#1's MDS assessment revealed her BIMS score was 13(normal cognitive function with little to no impairment. During an interview on 06/30/26 at 11:49 AM with Res#1, she said that she pressed her call light button the night before and no one came to her room. She said she called her FM and left a message for them to call the front desk to see if someone could take her to the restroom. She said there had been times when she pressed her call light and staff came about an hour later. Observation on 06/30/26 at 11:51 AM revealed that Res#1 pressed her call light button at 11:51 AM and a staff member did not come to her room until 12:25 PM. Observation also revealed that there was a light above her door that came on when she pressed the call light button. Observation on 06/30/26 at 12:15 PM of the nurse's station revealed there were two people sitting down behind the counter (positions unknown) at the nurse's station. Observation on 06/30/26 at 12:25PM revealed the REC came into the resident's room and asked her if she needed anything. The REC turned the call light button off by pushing the put on the wall connected to the cord of the call light. Observation revealed that the light above the door was off after REC pressed the button on the wall. During an interview on 06/30/26 at 12:25 PM with REC, she said that any staff member could answer a call light request. She stated that Res#1's FM called right before she came in the room on 06/30/26 and asked her to check Res#1's call light button because Res#1 called FM last night and left a message for FM to call the facility and ask if someone was available to take Res#1 to the bathroom. During an interview with the ADM 06/30/26? at 1:11 PM, she advised that the facility did not have a printed call light policy. She said she expected staff to answer call lights as soon as possible. She said she preferred staff to answer call lights within 15 minutes from the time a resident pushed it. She stated that there was a call light system on the wall directly behind the nurse's station. She stated that there was a red light that would come on by each room number when a resident pushed their call light button. She stated that the lights would make a beeping sound ADM said that delayed responses to call lights could lead to noncompliance with federal regulations and increased complaints from residents. Observation on 06/30/26 at 1:17PM of the call light system revealed it was located in the middle of the wall behind the nurse's station. Observation revealed there were blinking red lights on the wall next to the room numbers which indicated a resident pressed their call light button. Observation revealed the lights made a beeping sound. During an interview on 06/30/26 at 1:19PM with CN, she said there was not a printed call light policy. She stated that any staff member could answer a call light. She stated that staff should answer call lights as soon as possible. She stated that there was not a specific time limit because it could vary depending on what was going on in the facility. CN said it should not take staff longer than 30 minutes to answer a call light. She stated not answering a call light within a certain time limit could cause residents to be at risk of being in danger or in pain. During an interview on 06/30/26 at 4:22 PM with DON, she said there was not a call light policy printed. DON said that there was not a specific time limit for answering call lights because it depended on what staff were doing at the time. She said any staff member could answer a call light. DON said it should not take longer than 30 minutes to answer a call light DON advised she did not know why it took over 30 minutes for the call light to be answered. She stated not answering a call light within a certain time limit could cause a resident to experience emotional distress, feel anxious, or feel ignored and lose trust in staff.

Based on interview and record review, the facility failed to implement their written policies and procedures regarding investigating abuse for two (Resident #1 and Resident #2) of five residents reviewed for abuse and neglect. The facility failed to ensure a thorough investigation was completed by the abuse coordinator after an allegation of abuse was made on 10/11/2025 by Resident #2. This failure could place residents at risk of abuse, trauma, and psychosocial harm. Findings included:Review of Resident #1's comprehensive MDS assessment, dated 09/10/2025, reflected a [AGE] year-old male, admitted [DATE]. His diagnoses included progressive neurological conditions (gradual decline in neurological function), diabetes mellitus (chronic condition that affects how your body processes blood sugar), Alzheimer's disease (memory impairment), seizure disorder (abnormal electrical activity in the brain), anxiety (feelings of worry, fear, or unease), depression (persistent feeling of sadness), and psychotic disorder (severe mental health conditions). His BIMS score was a 3, indicating severe cognitive impairment. Review of Resident #1's care plan, dated 9/28/25, revealed he was care planned for having a behavior problem of wandering with interventions of, Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.Review of a nursing incident/accident investigation worksheet, dated 10/10/25 by agency LVN A, revealed that on 10/10/25 at 2:15 p.m. physical aggression was initiated by Resident #1 and there was resident to resident contact. Under the investigation summary section, it was indicated that the resident did not say what happened, the staff did not know what caused the incident, and there were no witnesses. The statement also reflected, When staff arrived at D/R this resident [Resident #1] had the other resident [Resident #2] on the floor-holding him down. The other resident [Resident #2] was noted lying on the floor with his shoulders up-trying to release himself from the resident.Review of Resident #1's progress note, dated 10/10/25, documented by agency LVN A revealed, Nurse and medication aide heard resident calling out for Help When we arrived at the d/r this resident had the other resident on the floor holding him down. The other resident was noted lying on the floor with his shoulders up-trying to release himself from the resident. No apparent injuries noted to RESIDENTS. NP was informed via phone with orders for U/A. Psych NP here with new orders: Depakote and Hydroxyzine-See Orders.Review of Resident #1's progress note, dated 10/23/25, revealed he was admitted to a behavioral health inpatient facility.Review of Resident #2's quarterly MDS assessment, dated 09/01/25, reflected a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included: heart failure, renal failure (medical condition in which the kidneys can no longer filter waste products from the blood), diabetes mellitus (chronic condition that affects how your body processes blood sugar), non-Alzheimer's dementia, anxiety (feelings of worry, fear, or unease), depression (persistent feeling of sadness), insomnia (inability to sleep), and malnutrition. His BIMS score was a 4, indicating severe cognitive impairment. Review of Resident #2's care plan, dated 9/12/25, revealed he was care planned for the potential to be physically aggressive when he pushed another resident on 1/25/25. His interventions included monitoring for agitation, redirection, give the resident choices, and to intervene before agitation escalates. Review of the facility's incident/accident reports from the last three months revealed an incident occurred on 10/10/25 where physical aggression was received by Resident #2, and physical aggression was initiated by Resident #1.Review of a nursing incident/accident investigation worksheet, dated 10/10/25 by agency LVN A, revealed that on 10/10/25 at 2:15PM Physical Aggression was received by Resident #2 and there was resident to resident contact. Under the investigation summary section, it was indicated that the resident said, I don't know why he just walked up and hit me., and the staff did not know what caused the incident, and there were no witnesses. It indicated the resident was not injured. It also revealed a staff statement, Staff heard residents calling for HELP When staff arrived at D/R resident was on the floor-and the other resident was noted holding him down. Resident was noted lying on the floor with his shoulders up-trying to release himself from the residentReview of a typed document on a piece of paper provided to the surveyor by the DON and VPHR revealed: [Resident #2] and [Resident #1]Completed by [previous ADM], 10.10.25Staff heard a cry for help and went to dining room. Found [Resident #2] on the floor with [Resident #1] holding his shoulders. No staff on duty witnessed the incident. Staff escorted [Resident #2] back to room. Nursing staff immediately notified DON and ADONof incident. DON, came to notify me of incident. [Resident 1] unable to retell events of what occurred. He was witnessed walkingdown hall and appears to be calm at this time. [Resident 2] stated I don't know why he just walked up and hit me.Psych NP notified 10.10.25 of incident, came to facility, spoke with [Resident 1] and wrote new orders. Staff will continue to monitor for any adverse affects.An interview was attempted with the previous ADM on 11/20/2025 at 10:55 a.m. but the surveyor did not receive a return call after leaving a voicemail. In an interview on 11/20/2025 at 11:10 a.m. with the DON she stated that it was not Resident #1's normal behavior to act in the way he did with Resident #2. She stated that she did not consider the incident to be abuse because no one saw the incident happen and neither resident could tell them what happened, and that neither resident received injuries. She stated that resident to resident abuse would be if one resident was seeking out another resident, like intentionally following them around, trying to push the other resident, and that Resident #1 had not been exhibiting those behaviors. An observation and interview was attempted on 11/20/2025 at 12:20 p.m. of Resident #1 and Resident #2 but both were pleasantly confused and unable to participate in interviews due to severe cognitive impairments. They both appeared well groomed and dressed appropriately. In an interview on 11/20/2025 at 1:03 p.m. with the VPHR who was serving the facility as the interim ADM, she stated that resident to resident abuse would be any unprovoked physical contact between residents. She stated that the incident on 10/10 was an instance that would warrant an investigation by the AC. She stated the DON investigated the incident from 10/10/25, which resulted in the facility unable to determine if resident abuse occurred due to no witnesses of the incident and no new injuries, but the only investigation she could locate that the AC conducted was what she provided the surveyor typed on a blank sheet of paper. She stated the AC was responsible for investigating abuse allegations. She stated that on 10/10 the previous ADM was the AC.Review of the facility's Abuse, Neglect and Exploitation policy dated last reviewed 05/2025 reflected: 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property orinjury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported no later than 24 hours after the allegation is made to the administrator of the facility and to HHSC, if the events that cause the allegation do not involve abuse, and do not result in serious bodily injury for 2 (Resident #1 and Resident #2) of five residents reviewed for reporting abuse and neglect. The facility failed to report an allegation of abuse made by Resident #2 on 10/10/25 that did not result in bodily injury within 24 hours to the state agency. This failure could place residents at risk of abuse, trauma, and/or psychosocial harm. Findings included:Review of Resident #1's comprehensive MDS assessment, dated 09/10/25, reflected a [AGE] year-old male who was on 09/10/2021. His diagnoses included: progressive neurological conditions (gradual decline in neurological function), diabetes mellitus (chronic condition that affects how your body processes blood sugar), Alzheimer's disease (memory impairment), seizure disorder (abnormal electrical activity in the brain), anxiety (feelings of worry, fear, or unease), depression (persistent feeling of sadness), psychotic disorder (severe mental health conditions). His BIMS score was a 3, indicating severe cognitive impairment. Review of Resident #1's care plan, dated 9/28/25, revealed he was care planned for having a behavior problem of wandering with interventions of, Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.Review of a nursing incident/accident investigation worksheet, dated 10/10/25 by agency LVN A, revealed that on 10/10/25 at 2:15 p.m. physical aggression was initiated by Resident #1 and there was resident to resident contact. Under the investigation summary section, it was indicated the Resident #2 did not say what happened, the staff did not know what caused the incident, and there were no witnesses. The statement also reflected, When staff arrived at D/R this resident [Resident #1] had the other resident [Resident #2] on the floor-holding him down. The other resident [Resident #2] was noted lying on the floor with his shoulders up-trying to release himself from the resident.Review of Resident #1's progress note, dated 10/10/25 documented by agency LVN A, revealed, Nurse and medication aide heard resident calling out for help. When we arrived at D/R this resident had the other resident on the floor holding him down. The other resident was noted lying on the floor with his shoulders up-trying to release himself from the resident. No apparent injuries noted to residents. The NP was informed via phone with orders for U/A. Psychiatric NP here with new orders: Depakote and Hydroxyzine-See Orders.Review of Resident #1's progress note, dated 10/23/25, revealed he was admitted to a behavioral health inpatient facility.Review of Resident #2's quarterly MDS assessment, dated 09/01/25, reflected a [AGE] year-old male who admitted on [DATE]. His diagnoses included: heart failure, renal failure (medical condition in which the kidneys can no longer filter waste products from the blood), diabetes mellitus (chronic condition that affects how your body processes blood sugar), non-Alzheimer's dementia, anxiety (feelings of worry, fear, or unease), depression (persistent feeling of sadness), insomnia (inability to sleep), and malnutrition. His BIMS score was a 4, indicating severe cognitive impairment. Review of Resident #2's care plan, dated 9/12/25, revealed he was care planned for the potential to be physically aggressive when he pushed another resident on 1/25/25. His interventions included monitoring for agitation, redirection, give the resident choices, and to intervene before agitation escalates. Review of the facility's incident/accident reports from the last 3 months revealed that an incident occurred on 10/10/25 where physical aggression was received by Resident #2, and physical aggression was initiated by Resident #1.Review of a typed document on a piece of paper provided to the surveyor on 11/20/2025 at 1:05 p.m. by the DON and VPHR revealed: [Resident #2] and [Resident #1]Completed by [previous ADM], 10.10.25Staff heard a cry for help and went to dining room. Found [Resident #2] on the floor with [Resident #1] holding his shoulders. No staff on duty witnessed the incident. Staff escorted [Resident #2] back to room. Nursing staff immediately notified DON and ADONof incident. DON, came to notify me of incident. [Resident 1] unable to retell events of what occurred. He was witnessed walkingdown hall and appears to be calm at this time. [Resident 2] stated I don't know why he just walked up and hit me. Psych NP notified 10.10.25 of incident, came to facility, spoke with [Resident 1] and wrote new orders. Staff will continue to monitor for any adverse affects.An interview was attempted with the previous ADM on 11/20/2025 at 10:55 a.m. but the surveyor did not receive a return call after leaving a voicemail. In an interview on 11/20/2025 at 11:10 a.m. with the DON she stated it was not Resident #1's normal behavior to act in the way he did with Resident #2. She stated that she did not consider the incident to be abuse because no one saw the incident happen and neither resident could tell them what happened, nor did either resident receive injuries. She stated that a resident-to-resident altercation would be if one resident was seeking out another resident, intentionally following them around, trying to push the other resident, and that Resident #1 had not been exhibiting those behaviors. In an interview on 11/20/2025 at 1:03 p.m. with the VPHR who was serving the facility as the interim ADM, stated that resident to resident abuse would be unprovoked physical contact between residents. She stated that the incident on 10/10/25 was an instance that would warrant an investigation by the AC. When asked if it warranted a report to the state agency, she stated that would be determined after the investigation by the AC. She stated the DON investigated the incident from 10/10/25, which resulted in the facility unable to determine if resident abuse occurred due to no witnesses of the incident and no new injuries, but the only investigation she could locate that the AC conducted was what she provided the surveyor typed on a blank sheet of paper. She stated the AC was responsible for investigating abuse allegations and reporting it to the necessary entities. She stated that on 10/10/25 the previous ADM was the AC.Review of the facility's Abuse, Neglect and Exploitation policy, dated 05/2025, reflected: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies:a. The state licensing/certification agency responsible for surveying/licensing the facility.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1of 2 medication storage rooms (Nurse's Station Room). The facility failed on 6/4/25 to ensure that expired lab testing supplies were removed from 1 of 2 medication storage rooms (Nurse's Station Room). This failure could place residents at risk for misdiagnosis from expired and possibly ineffective lab testing supplies. Use of these expired supplies would not meet acceptable standards of medical practice and could cause a resident to receive an incorrect treatment, which would allow their medical condition to worsen. Findings included: Observation on 6/4/25 at 3:55 PM of the Medication Storage Room located by the nurse's station revealed the following: 3 Lab swabs expired 2/9/2023. 4 Gray lab tubes expired 4/30/2023. 1 Gold lab tube expired 12/31/2023. 5 Lab swabs expired 7/1/2024. 3 Red tubes expired 9/19/2024. 6 Culture swabs expired 1/12/2025. In an interview on 6/5/25 at 1:20 PM, LVN-A stated the policy on expired medications and expired lab supplies was to pull them from stock, log them and destroy them. She stated the facility's contracted lab usually brings their own supplies. She stated MA's, nurses, and unit managers (including herself) were responsible for checking the medication rooms for expired items. She stated the negative outcome to residents if expired items were used (example lab tubes/cultures) was the expired cultures could cause inaccurate lab results. In an interview on 6/5/25 at 1:30 PM, MA-A stated the policy on expired lab supplies was to toss them in the trash if they didn't have needles. If they had needles, they were disposed of in the sharp's container. She stated MA's and nurses were responsible for checking the medication rooms for expired items and the negative outcome to residents if expired items were used (example lab tubes/cultures) was they could give false readings/results on their test. In an interview on 6/5/25 at 1:40 PM, the DON stated the policy on expired medications and expired lab supplies was to not use them. She stated expired lab supplies were given to the lab to dispose of properly. She stated the MA, ADON and herself were responsible for checking the medication rooms. She stated the negative outcome to residents if expired items were used (example lab tubes/cultures) could be false lab results on their test. In an interview on 6/5/25 at 1:56 PM, the ADM stated the policy on expired medications and expired lab supplies was to dispose of them. He stated nursing staff was responsible for checking the medication rooms for expired supplies. He stated the negative outcome to residents if expired items were used (example lab tubes/cultures) could be inconsistent test results. Record review of the facility policy titled Medication Storage with a date of 5/2023, reflected that all medication rooms were to be routinely inspected by the pharmacist for discontinued or outdated medications and they were to be destroyed.

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 reviewed for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility nurses failed to hold Resident #1s health shakes and administered them through a 60ML syringe by mouth while she was not responsive on 3/10/25 at 10:20pm and 3/11/25 at 12:10pm. These failures resulted in an identification of an Immediate Jeopardy (IJ) On 3/12/2025 at 4:35 p.m. While the IJ was removed on 3/14/25, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents who have had a decline or change in condition at risk for aspiration, choking, and death. Findings included: Record review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of Alzheimer Disease (A brain disorder that slowly destroys a person's memory), Dementia (the loss of cognitive function, remembering, thinking, and reasoning), Hypertension (elevated blood pressure), Bradycardia (a slow heart rate). Record review of Resident #1's Significant change in status MDS dated [DATE] reflected she Had a BIMS score of 00 indicating she had severe cognitive impaired. Resident #1 required substantial/maximal assistance indicating the helper does more than half the effort or the helper lifts or holds trunk or limbs and provides more than half the effort for ADL care showering, upper and lower body dressing, and toileting hygiene. The MDS reflected Resident #1 required set up or clean up assistance with eating and was receiving hospice services. Record review of Resident #1's care plan dated 02/06/2025 reflected a significant/Un-expected weight loss due to decline in overall health and decline in oral intake. Goal: Will receive adequate nutrition and fluid intake and weight will stabilize through the next review. Interventions included Provide supplements as ordered. Provide/offer hydration throughout the day. Serve diet as ordered and offer substitution if intake less than 50%. Record review of Resident #1s progress notes dated 3/10/25 at 10:20pm reflected Resident was able to consume 180ml of Ensure (health shake) via syringe. No signs or symptoms of chocking noted. Head of bed up right. No signs and symptoms of pain or distress noted. Resident Family Member notified of residents' intake of Ensure. Call light within reach. Care needs met. Signed by LVN C. Record review of Resident #1s' Physician orders for March 2025 reflected an order for a fortified diet, mechanical soft ground meats dated 01/02/2025 and health shakes or equivalent three times a day dated 02/23/2025. The physicians' orders also reflected that Resident #1 was admitted to Hospice services on 01/20/2025. Resident #1 had an order for a stat (without delay) chest x-ray to rule our aspiration dated 03/11/2025. Record review of Resident #1s Chest X ray ordered for Resident #1 on 3/11/25 at 5:59pm reflected there was no aspiration seen. In an observation completed on 3/11/25 at 11:00am Resident #1was fidgeting with her fingers in the air, unresponsive to verbal stimuli. The head of her bead was elevated 45 degrees, she had her mouth open, and head leaned back looking upward to the ceiling. There was a bottle of health shake with a straw in it next to a 60cc syringe in a clear package on the bedside table. In a second observation and interview of Resident #1 and CNA A on 3/11/25 at 12:10 when Resident #1 appeared in the same position. At 12:13pm CNA A entered the room as this surveyor was inquiring about Resident #1s lunch tray. CNA A stated Resident #1 was too weak to eat. She stated the Resident #1 had not been offered a food tray. CNA A was putting on gloves and drawing up a 60cc syringe full of health shake. As CNA A was talking with the surveyor, she then proceeded over to the Resident #1 and placed the syringe in the resident's mouth. This surveyor asked CNA A to stop at that time. CNA A Stated she worked with agency and today was her first day in the facility. She stated there was an orientation on the agency app prior to taking a shift at the facility, she did not know if feeding was part of that orientation. CNA A Stated Resident #1 did not have the strength to eat and that she was told in report (employee to employee review of residents' conditions) this morning by the night nurse to feed and give fluids to Resident #1 with the syringe so she would not be dehydrated. CNA A stated she had given Resident #1 two full 60 cc syringes of health shake this morning. She stated she had not been instructed by the building DON or ADON to feed or give fluids to a resident with a syringe. In an interview on 3/11/25 at 12:20pm the DON stated Resident #1 had been unresponsive for about 2-3 days. The DON stated it was not normal practice to feed or give fluids to residents with a syringe. She stated The Family Member was insistent with hospice that it could be done. The DON stated the CNAs have not been trained to feed or give fluids using a syringe unless the hospice nurse instructed them to do so. She stated Resident #1 could get aspiration pneumonia (an infection that is the results of food or fluids going into the lungs instead of the stomach). The DON stated feeding residents with a syringe is not facility protocol. She stated the 60cc syringe came from Hospice. In an interview on 3/11/25 at 1:02pm LVN B stated she had worked at the facility for 3 days and she was the charge nurse for Resident #1. She stated she was aware Resident #1 was on hospice for a cardiac condition and Resident #1 had a hip injury that was nonoperational. She stated Resident #1s family was upset she was not eating, and she had talked to the family about reasons including end of life. She stated she also explained to the family that she could aspirate (a condition where the fluid goes into the lung) if she was not swallowing. LVN B stated at no time did CNA A report that the night nurse had instructed her to feed or give fluids to Resident #1 with a syringe. She stated it also was not passed along in their nursing report from the night nurse. She stated the Resident #1 was unresponsive this morning. LVN B stated feeding or giving fluids through a syringe to a resident who was not responsive could lead to the resident aspirating. LVN B stated she did an assessment on Resident #1, and her lungs were clear (free from abnormal sounds of respirations). LVN B stated a Chest x ray was ordered by the physician, and the facility was waiting on that to be completed. Attempted to contact LVN C who works night shift (6pm -6am) on 3/10/25 on 3/11/25 at 1:42 pm with no answer. In an interview with a Family Member of Resident #1 on 3/11/25 at 2:51 stated when she had mentioned giving Resident #1 fluids through a syringe, she was not talking about a large syringe full of fluids. She stated she was asking for the staff to give her drips out of a small syringe. She stated something to keep Resident #1's mouth moist. She stated she did not ask for them to force feed her. She stated she just wanted Resident #1s mouth moist, not as dry; she wanted her to have oral care, swab her mouth out, not force feed her though a syringe. In an interview on 3/11/25 at 3:00 pm with The Medical Director and Primary Care Physician for Resident #1 stated it was not recommend feeding or give fluids by mouth a resident with a syringe. He stated he was over the Resident#1s hospice company as well and he had called hospice, and they had no recommendations for feeding or giving fluids through a syringe either. He stated if a person were to squirt a bunch of thin liquids at one time into Resident#1s mouth she would aspirate, causing choking, and pneumonia. He stated the resident was not eating. He stated he did listen to Resident #1s lungs, and they sounded clear and did not see any harm from the resident receiving the thin liquids per the syringe. He stated he did instruct the nursing staff not to feed or give fluids to her through the syringe. He stated he ordered routine oral care to be completed to ensure the residents mouth was moist. In an interview on 3/11/25 at 3:46 pm RN D Resident #1's hospice nurse stated hospice did not recommend feeding or giving fluids to Resident #1 with a syringe. He stated The Family Member had called him and was upset that the facility would not feed Resident #1 with a syringe. He stated he educated the family on risk of feeding and giving fluids with a syringe. He stated that he instructed the family that hospice would not feed or give fluids to Resident #1 with a syringe. He stated there was never an order to do that. The Family Member stated the night nurse told her that she got her to take a half of a bottle of health shake and she did not elaborate how she got her to take the fluid. He stated he had instructed the family on the death and dying process and that it was a traumatic event such as a hip fracture that causing the resident to further decline and that not having an appetite and not eating was part of that decline. He stated the resident has not been responsive the last 3-4 days. In an interview with the DON and ADM on 3/12/25 at 3:09 when the DON stated there was never any formal training to feed or give residents any fluids through a syringe because it was not the facility practice to do so. She stated here was never any order for food or fluids to be given through a syringe because that it not the facility practice. The DON stated agency staff were aware of the Residents#1s plan or care through verbal report. She stated the agency staff were also given a point click care password so they could access the plan or care and be aware of resident's needs. The DON stated there was a book with specific instructions at the nurses' station on how to navigate point click care and facility policy and procedures provided to agency staff. She stated they encourage agency staff to ask questions if needed. Record review of facility policy titled Competency Evaluation dated 04/2024 and revised 01/2025 reflected: It is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skills for performing their job. An Immediate Jeopardy was identified on 3/12/2025 at 4:35 p.m. and an IJ template was provided to the ADM and DON. The following Plan of Removal submitted by the facility was accepted on 03/13/2025 at 10:28 a.m. PLAN OF REMOVAL Problem: The facility failed to ensure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychological well-being. An audit was completed by nurse management to ensure no other residents were at risk. Resident #1 had a chest x-ray completed on 3/11/25 that showed no aspiration. Resident # 1 was assessed by the DON & the facility medical director. Resident #1 remains in the facility in stable condition. Immediate action: 11. As soon as the DON was made aware of the situation on 3/11/25 she immediately removed the syringe from the resident's room. 12. CNA #1 was given a one-on-one education by ADON on 3/11/25 that a resident should never be syringe fed. Our investigation revealed that an overnight nurse instructed the CNA to administer the resident ensure through a syringe. A telephone call was placed to the night nurse & a message left for her to call the facility. The night nurse had not returned our phone call. A message was left that she could not return to the facility until she spoke with the DON. 13. DON started In-servicing facility & agency licensed nurses & CNAS on 3/11/25 at 1300 that residents were never to fed via a syringe. All 6-2 & 2-10 nursing staff on duty were educated. In-services for facility licensed nurses & CNAS will be completed on 3/13/25. Any agency staff that has not previously been in-serviced will be required to complete the in-services prior to starting their shift. 14. DON/ADON started In-servicing on 3/12/25 with agency staff to ensure they were educated on where to find the residents plan of care. 15. DON/ADON started In-servicing on 3/12/25 with all CNAs both facility & agency on the importance of not attempting to feed a resident that is unresponsive. Any new facility or agency CNA will be provided the education prior to working. 16. The agency binder was reviewed to ensure that agency staff know where to look to review the residents plan of care. Interventions 17. Any new agency staff will be in-serviced by nurse management on how to find the residents plan of care prior to starting their shift. The education started on 3/12/25 & will be ongoing when new facility or agency staff are scheduled. 18. Shift Key will download the process of where to find the residents plan of care prior to accepting a shift. The ADON will be responsible for the communication to Shift Key. 19. Nurse management will review the residents' care plan to ensure that it reflects the resident's needs. The care plan review will be completed by 3/14/25. 20. When a resident experiences a change of condition the care plan will be updated to reflect the resident's current needs. The DON/ADON/ Unit Manager will be responsible for updating resident care plan when a change of condition is identified. Ongoing Projected completion 3/13/25 for facility nursing staff. Care Plan review will be completed by 3/14/25. Any staff member who was not present during initial in-servicing/training will not be allowed to assume their duties until in-service was completed. The DON/ADON/WC NURSE will complete Ongoing In-service/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring 5. Nurse management will question random CNAs 3 X's a week to ensure they understand Resident #1s plan of care. Nurse management will perform random questions 3 X's a week for 6 weeks. 6. Staff will complete a questionnaire related to providing care that reflects the resident's needs. 7. On 3/13/25 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DON/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 3/14/25. 8. On 3/12/25 An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. 3/13/25 Surveyor Monitoring included the following: 10. Observation completed on 3/13/25 at 12:50PM reflected there was no longer a syringe for feeding In Resident #1s room. 11. Record review of Momentum Skilled Services 1:1 in service dated 3/11/25 signed by CNA#1 reflected that CNA A was given a one-on-one education by The ADON that read a resident should never be syringe fed. 12. Record review of Inservice dated 03/11/25 and 03/12/25 provided to licensed nurses and certified nurse aides reflected they had been educated by The DON that no residents would be fed or given fluids orally with a syringe for any reason. 13. Record review of facility in-service provided to agency staff working within the building dated 3/12/25 reflected that the residents plan of care was in the EMR (electronic medical record) under the Kardex tab (a tab that contains certain needs for residents that staff may review). If they were to have any questions after reading the residents plan of care they must find their charge nurse for clarification. 14. Record review of facility in-service dated 03/12/25 provided to all certified nursing assistance both agency and facility staff reflected staff members must never attempt to feed or give fluids to a resident that was unresponsive. If they had a resident that was unresponsive, they must find the charge nurse for clarification. 15. The DON reviewed the agency binder to ensure the agency staff would be able to locate the residents plan of care to provide services. 16. Interviewed 22 nursing staff (CNA D, E,F,G,H,I,J,K,L,M,N,O,P,Q and LVN R,S,T,U,V,W,X) from all shifts and they stated they had been educated on not syringe feeding residents. They stated they had been educated on not attempting to feed unresponsive residents. They stated the risk for resident would be aspiration or choking. They stated they had been educated on where and how to locate a resident's plan of care to provide and meet the resident's needs. The agency staff were able to locate the facility binder with their expectations and EMR directions to provide services and care to residents. They stated if a plan of care did not seem accurate for a resident they would go to their charge nurse for clarification. They stated even if a nurse told them to do something that was out of their scope, they would report it to the ADON or DON for further clarification. The agency staff stated they were instructed prior to their shift to review the blue binder at the nurses' station. They stated within the binder there was current in-services for staff, policy and procedures for pain and falls, abuse, and neglect, also directions on how to navigate the electronic medical record to see the residents current plan of care. The binder also included current in-services for staff. Included in in-services within the blue binder were: no resident will be fed by syringe, Staff members must never attempt to feed a resident that is unresponsive, and where the plan of care is located within the EMR. 17. In an interview with The ADON on 3/13/25 at 2:46PM- The ADON stated the facility had posted an automatic notification that must be acknowledged to review in-services prior to the start of agency staffs shift instructing staff they must sign in at the nurses' station and all agency staff must read and abide by the blue binder located at the nurse's station. Within the blue binder was found an emergency phone list, items to report immediately, sign in sheets, facility management contacts. The binder also included current in-services for staff. Included in in-services within the blue binder were: no resident will be fed by syringe, Staff members must never attempt to feed a resident that is unresponsive, and where the plan of care is located within the EMR. Record review of shift key logs reflected the notification of in-services prior to coming on shift had been signed and acknowledged by 6 agency staff working 3/13/25. 18. Record review of a Care Plan Audit on 3/14/25 completed by the DON was 100% completed. The DON stated there were no further negative findings within the Care plan audit for all residents. She stated the care plans were accurate for Residents to reflects the resident's needs. 10. Signed QAPI minutes reviewed for 3/12/25 and reflected a meeting was held that included the facilities ADM, DON, ADON, MDS, and Medical Director The ADM and DON were informed the Immediate Jeopardy was removed on 03/14/2025 at 11:53 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of Isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to assure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being for 1 (Resident #1) of 5 residents reviewed. The facility nurses failed to hold Resident #1's health shakes and administered them through a 60 ML syringe by mouth while she was not responsive on 3/10/25 at 10:20pm and 3/11/25 at 12:10pm. These failures resulted in an identification of an Immediate Jeopardy (IJ) On 3/12/2025 at 4:35 p.m. While the IJ was removed on 3/14/25, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents who have had a decline or change in condition at risk for aspiration, choking, and death. Findings included: Record review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of Alzheimer Disease (A brain disorder that slowly destroys a person's memory), Dementia (the loss of cognitive function, remembering, thinking, and reasoning), Hypertension (elevated blood pressure), Bradycardia (a slow heart rate). Record review of Resident #1's Significant change in status MDS dated [DATE] reflected she Had a BIMS score of 00 indicating she had severe cognitive impaired. Resident #1 required substantial/maximal assistance indicating the helper does more than half the effort or the helper lifts or holds trunk or limbs and provides more than half the effort for ADL care showering, upper and lower body dressing, and toileting hygiene. The MDS reflected Resident #1 required set up or clean up assistance with eating and was receiving hospice services. Record review of Resident #1's care plan dated 02/06/2025 reflected a significant/Un-expected weight loss due to decline in overall health and decline in oral intake. Goal: Will receive adequate nutrition and fluid intake and weight will stabilize through the next review. Interventions included Provide supplements as ordered. Provide/offer hydration throughout the day. Serve diet as ordered and offer substitution if intake less than 50%. Record review of Resident #1's progress notes dated 3/10/25 at 10:20pm reflected Resident was able to consume 180 ml of Ensure (health shake) via syringe. No signs or symptoms of chocking noted. Head of bed up right. No signs and symptoms of pain or distress noted. Resident Family Member notified of residents' intake of Ensure. Call light within reach. Care needs met. Signed by LVN C. Record review of Resident #1's Physician orders for March 2025 reflected an order for a fortified diet, mechanical soft ground meats dated 01/02/2025 and health shakes or equivalent three times a day dated 02/23/2025. The physicians' orders also reflected that Resident #1 was admitted to Hospice services on 01/20/2025. Resident #1 had an order for a stat (without delay) chest x-ray to rule our aspiration dated 03/11/2025. Record review of Resident #1's Chest X ray ordered for Resident #1 on 3/11/25 at 5:59pm reflected there was no aspiration seen. In an observation completed on 3/11/25 at 11:00am Resident #1 was fidgeting with her fingers in the air, unresponsive to verbal stimuli. The head of her bead was elevated 45 degrees, she had her mouth open, and head leaned back looking upward to the ceiling. There was a bottle of health shake with a straw in it next to a 60 cc syringe in a clear package on the bedside table. In a second observation and interview of Resident #1 and CNA A on 3/11/25 at 12:10 when Resident #1 appeared in the same position. At 12:13pm CNA A entered the room as this surveyor was inquiring about Resident #1's lunch tray. CNA A stated Resident #1 was too weak to eat. She stated the Resident #1 had not been offered a food tray. CNA A was putting on gloves and drawing up a 60 cc syringe full of health shake. As CNA A was talking with the surveyor, she then proceeded over to the Resident #1 and placed the syringe in the resident's mouth. This surveyor asked CNA A to stop at that time. CNA A Stated she worked with agency and today was her first day in the facility. She stated there was an orientation on the agency app prior to taking a shift at the facility, she did not know if feeding was part of that orientation. CNA A Stated Resident #1 did not have the strength to eat and that she was told in report (employee to employee review of residents' conditions) this morning by the night nurse to feed and give fluids to Resident #1 with the syringe so she would not be dehydrated. CNA A stated she had given Resident #1 two full 60 cc syringes of health shake this morning. She stated she had not been instructed by the building DON or ADON to feed or give fluids to a resident with a syringe. In an interview on 3/11/25 at 12:20pm the DON stated Resident #1 had been unresponsive for about 2-3 days. The DON stated it was not normal practice to feed or give fluids to residents with a syringe. She stated The Family Member was insistent with hospice that it could be done. The DON stated the CNAs have not been trained to feed or give fluids using a syringe unless the hospice nurse instructed them to do so. She stated Resident #1 could get aspiration pneumonia (an infection that is the results of food or fluids going into the lungs instead of the stomach). The DON stated feeding residents with a syringe is not facility protocol. She stated the 60 cc syringe came from Hospice. In an interview on 3/11/25 at 1:02pm LVN B stated she had worked at the facility for 3 days and she was the charge nurse for Resident #1. She stated she was aware Resident #1 was on hospice for a cardiac condition and Resident #1 had a hip injury that was nonoperational. She stated Resident #1's family was upset she was not eating, and she had talked to the family about reasons including end of life. She stated she also explained to the family that she could aspirate (a condition where the fluid goes into the lung) if she was not swallowing. LVN B stated at no time did CNA A report that the night nurse had instructed her to feed or give fluids to Resident #1 with a syringe. She stated it also was not passed along in their nursing report from the night nurse. She stated the Resident #1 was unresponsive this morning. LVN B stated feeding or giving fluids through a syringe to a resident who was not responsive could lead to the resident aspirating. LVN B stated she did an assessment on Resident #1, and her lungs were clear (free from abnormal sounds of respirations). LVN B stated a Chest x ray was ordered by the physician, and the facility was waiting on that to be completed. Attempted to contact LVN C who works night shift (6pm -6am) on 3/10/25 on 3/11/25 at 1:42pm with no answer. In an interview with a Family Member of Resident #1 on 3/11/25 at 2:51pm stated when she had mentioned giving Resident #1 fluids through a syringe, she was not talking about a large syringe full of fluids. She stated she was asking for the staff to give her drips out of a small syringe. She stated something to keep Resident #1's mouth moist. She stated she did not ask for them to force feed her. She stated she just wanted Resident #1's mouth moist, not as dry; she wanted her to have oral care, swab her mouth out, not force feed her though a syringe. In an interview on 3/11/25 at 3:00pm with The Medical Director and Primary Care Physician for Resident #1 stated it was not recommend feeding or give fluids by mouth a resident with a syringe. He stated he was over the Resident#1's hospice company as well and he had called hospice, and they had no recommendations for feeding or giving fluids through a syringe either. He stated if a person were to squirt a bunch of thin liquids at one time into Resident#1's mouth she would aspirate, causing choking, and pneumonia. He stated the resident was not eating. He stated he did listen to Resident #1's lungs, and they sounded clear and did not see any harm from the resident receiving the thin liquids per the syringe. He stated he did instruct the nursing staff not to feed or give fluids to her through the syringe. He stated he ordered routine oral care to be completed to ensure the residents mouth was moist. In an interview on 3/11/25 at 3:46pm RN D Resident #1's hospice nurse stated hospice did not recommend feeding or giving fluids to Resident #1 with a syringe. He stated The Family Member had called him and was upset that the facility would not feed Resident #1 with a syringe. He stated he educated the family on risk of feeding and giving fluids with a syringe. He stated that he instructed the family that hospice would not feed or give fluids to Resident #1 with a syringe. He stated there was never an order to do that. The Family Member stated the night nurse told her that she got her to take a half of a bottle of health shake and she did not elaborate how she got her to take the fluid. He stated he had instructed the family on the death and dying process and that it was a traumatic event such as a hip fracture that causing the resident to further decline and that not having an appetite and not eating was part of that decline. He stated the resident has not been responsive the last 3-4 days. In an interview with the DON and ADM on 3/12/25 at 3:09pm when the DON stated there was never any formal training to feed or give residents any fluids through a syringe because it was not the facility practice to do so. She stated here was never any order for food or fluids to be given through a syringe because that it not the facility practice. The DON stated agency staff were aware of the Residents#1's plan or care through verbal report. She stated the agency staff were also given a point click care password so they could access the plan or care and be aware of resident's needs. The DON stated there was a book with specific instructions at the nurses' station on how to navigate point click care and facility policy and procedures provided to agency staff. She stated they encourage agency staff to ask questions if needed. Record review of facility policy titled Competency Evaluation dated 04/2024 and revised 01/2025 reflected: It is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skills for performing their job. An Immediate Jeopardy was identified on 3/12/2025 at 4:35pm and an IJ template was provided to the ADM and DON. The following Plan of Removal submitted by the facility was accepted on 03/13/2025 at 10:28am PLAN OF REMOVAL Problem: The facility failed to ensure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychological well-being. An audit was completed by nurse management to ensure no other residents were at risk. Resident #1 had a chest x-ray completed on 3/11/25 that showed no aspiration. Resident # 1 was assessed by the DON & the facility medical director. Resident #1 remains in the facility in stable condition. Immediate action: 1. As soon as the DON was made aware of the situation on 3/11/25 she immediately removed the syringe from the resident's room. 2. CNA #1 was given a one-on-one education by ADON on 3/11/25 that a resident should never be syringe fed. Our investigation revealed that an overnight nurse instructed the CNA to administer the resident ensure through a syringe. A telephone call was placed to the night nurse & a message left for her to call the facility. The night nurse had not returned our phone call. A message was left that she could not return to the facility until she spoke with the DON. 3. DON started In-servicing facility & agency licensed nurses & CNAS on 3/11/25 at 1:00pm that residents were never to fed via a syringe. All 6-2 & 2-10 nursing staff on duty were educated. In-services for facility licensed nurses & CNAS will be completed on 3/13/25. Any agency staff that has not previously been in-serviced will be required to complete the in-services prior to starting their shift. 4. DON/ADON started In-servicing on 3/12/25 with agency staff to ensure they were educated on where to find the residents plan of care. 5. DON/ADON started In-servicing on 3/12/25 with all CNAs both facility & agency on the importance of not attempting to feed a resident that is unresponsive. Any new facility or agency CNA will be provided the education prior to working. 6. The agency binder was reviewed to ensure that agency staff know where to look to review the residents plan of care. Interventions 7. Any new agency staff will be in-serviced by nurse management on how to find the residents plan of care prior to starting their shift. The education started on 3/12/25 & will be ongoing when new facility or agency staff are scheduled. 8. Shift Key will download the process of where to find the residents plan of care prior to accepting a shift. The ADON will be responsible for the communication to Shift Key. 9. Nurse management will review the residents' care plan to ensure that it reflects the resident's needs. The care plan review will be completed by 3/14/25. 10. When a resident experiences a change of condition the care plan will be updated to reflect the resident's current needs. The DON/ADON/ Unit Manager will be responsible for updating resident care plan when a change of condition is identified. Ongoing Projected completion 3/13/25 for facility nursing staff. Care Plan review will be completed by 3/14/25. Any staff member who was not present during initial in-servicing/training will not be allowed to assume their duties until in-service was completed. The DON/ADON/WC NURSE will complete Ongoing In-service/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring 1. Nurse management will question random CNAs 3 X's a week to ensure they understand Resident #1s plan of care. Nurse management will perform random questions 3 X's a week for 6 weeks. 2. Staff will complete a questionnaire related to providing care that reflects the resident's needs. 3. On 3/13/25 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DON/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 3/14/25. 4. On 3/12/25 An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. 3/13/25 Surveyor Monitoring included the following: 1. Observation completed on 3/13/25 at 12:50pm reflected there was no longer a syringe for feeding In Resident #1's room. 2. Record review of Momentum Skilled Services 1:1 in service dated 3/11/25 signed by CNA#1 reflected that CNA A was given a one-on-one education by The ADON that read a resident should never be syringe fed. 3. Record review of Inservice dated 03/11/25 and 03/12/25 provided to licensed nurses and certified nurse aides reflected they had been educated by The DON that no residents would be fed or given fluids orally with a syringe for any reason. 4. Record review of facility in-service provided to agency staff working within the building dated 3/12/25 reflected that the residents plan of care was in the EMR (electronic medical record) under the Kardex tab (a tab that contains certain needs for residents that staff may review). If they were to have any questions after reading the residents plan of care they must find their charge nurse for clarification. 5. Record review of facility in-service dated 03/12/25 provided to all certified nursing assistance both agency and facility staff reflected staff members must never attempt to feed or give fluids to a resident that was unresponsive. If they had a resident that was unresponsive, they must find the charge nurse for clarification. 6. The DON reviewed the agency binder to ensure the agency staff would be able to locate the residents plan of care to provide services. 7. Interviewed 22 nursing staff (CNA D, E,F,G,H,I,J,K,L,M,N,O,P,Q and LVN R,S,T,U,V,W,X) from all shifts and they stated they had been educated on not syringe feeding residents. They stated they had been educated on not attempting to feed unresponsive residents. They stated the risk for resident would be aspiration or choking. They stated they had been educated on where and how to locate a resident's plan of care to provide and meet the resident's needs. The agency staff were able to locate the facility binder with their expectations and EMR directions to provide services and care to residents. They stated if a plan of care did not seem accurate for a resident they would go to their charge nurse for clarification. They stated even if a nurse told them to do something that was out of their scope, they would report it to the ADON or DON for further clarification. The agency staff stated they were instructed prior to their shift to review the blue binder at the nurses' station. They stated within the binder there was current in-services for staff, policy and procedures for pain and falls, abuse, and neglect, also directions on how to navigate the electronic medical record to see the residents current plan of care. The binder also included current in-services for staff. Included in in-services within the blue binder were: no resident will be fed by syringe, Staff members must never attempt to feed a resident that is unresponsive, and where the plan of care is located within the EMR. 8. In an interview with The ADON on 3/13/25 at 2:46pm- The ADON stated the facility had posted an automatic notification that must be acknowledged to review in-services prior to the start of agency staffs shift instructing staff they must sign in at the nurses' station and all agency staff must read and abide by the blue binder located at the nurse's station. Within the blue binder was found an emergency phone list, items to report immediately, sign in sheets, facility management contacts. The binder also included current in-services for staff. Included in in-services within the blue binder were: no resident will be fed by syringe, Staff members must never attempt to feed a resident that is unresponsive, and where the plan of care is located within the EMR. Record review of shift key logs reflected the notification of in-services prior to coming on shift had been signed and acknowledged by 6 agency staff working 3/13/25. 9. Record review of a Care Plan Audit on 3/14/25 completed by the DON was 100% completed. The DON stated there were no further negative findings within the Care plan audit for all residents. She stated the care plans were accurate for Residents to reflects the resident's needs. 10. Signed QAPI minutes reviewed for 3/12/25 and reflected a meeting was held that included the facilities ADM, DON, ADON, MDS, and Medical Director The ADM and DON were informed the Immediate Jeopardy was removed on 03/14/2025 at 11:53am The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of Isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to implement a comprehensive care plan to meet the medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being of 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to complete an accurate comprehensive care plan for Resident #1, by not care planning her Hospice services received on 1/20/25. This failure could place residents at risk of not having their care and treatment needs met to ensure necessary care and services were provided for specific to Hospice specialized services. Findings included: Record review of Resident #1's undated face sheet reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of Alzheimer Disease (A brain disorder that slowly destroys a person's memory), Dementia (the loss of cognitive function, remembering, thinking, and reasoning), Hypertension (elevated blood pressure), Bradycardia (a slow heart rate). Record review of Resident #1's Significant change in status MDS dated [DATE] reflected she Had a BIMS score of 00 indicating she had severe cognitive impaired. Resident #1 required Substantial/maximal assistance indicating the helper does more than half the effort or the helper lifts or holds trunk or limbs and provides more than half the effort for ADL care showering, upper and lower body dressing, and toileting hygiene. The MDS reflected Resident #1 was receiving hospice services. Record review of Resident #1's care plan dated 02/06/2025 reflected there was no care plan in place for her hospice services provided. Record review of Resident #1s' Physician orders for March 2025 reflected an order to admit to Hospice services on 01/20/2025. In an interview on 3/12/25 at 12:05 the MDS Coordinator RN stated upon a significant change MDS she was required to update the comprehensive care plan. She stated Resident #1 should have had a care plan updating the resident's services to include hospice care. She stated she just missed it. The MDS Coordinator stated it was important to update the plan of care as changes occur in residents' status to ensure the staff were aware of changes in care needs provided by staff. She stated the charge nurses the unit mangers were responsible for updating the care plan with acute changes. The MDS Coordinator stated the negative effects for not updating a care plan would be the resident would not receive proper care or care that was ordered. In an interview on 3/12/25 at 12:15PM the Unit Manager for Resident #1 stated The MDS coordinator should have initiated the hospice care plan. She stated she would update the care plan with acute changes in status. She stated updates were necessary for communication with staff resident's care needs. By not updating the care plan it could cause miscommunications and changes in condition that would not be noted or documented. Record review of facility policy titled Care Plan Revision Upon Status Change dated 04/2024 and revised on 01/2025 reflected: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: Upon identification of a change in status, the nurse will notify the MDS Coordinator, the physician, and the resident representative, if applicable. The care plan will be updated with the new or modified interventions. Staff involved in the care of the resident will report resident response to new or modified interventions. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse for one (Resident #1) of five residents reviewed for abuse. The facility failed to protect Resident #1 from physical abuse when CNA A was slapped by Resident #1 across the face and CNA A slapped Resident #1 back across their face on 1/5/2025. An Immediate Jeopardy (IJ) was identified on 01/22/2025. The IJ template was provided to the facility on [DATE] at 5:43 PM. While the IJ was removed on 01/23/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse/neglect. This failure placed residents at risk of abuse, trauma, and/or psychosocial harm. Findings included: Review of Resident #1's Quarterly MDS dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including traumatic bran dysfunction (an injury to the brain caused by external mechanical force), dementia (a group of symptoms affecting memory, thinking, and social abilities), senile degeneration of brain (progressive deterioration of brain tissue and function that occurs beyond what's considered normal aging), and age-related physical debility. Resident #1 had a BIMS score of 00 indicating severe cognitive impairment. Review of Resident #1's care plan, dated last reviewed 01/12/2025, reflected she had impaired cognitive function and impaired thought processes with interventions to cue, reorient, and supervise as needed, and to not correct her if she gets confused to reality. Review of a witness statement, dated 1/5/2025 and documented by CNA B, reflected the following: I witnessed [Resident #1] coming up to [CNA A] and hit her in the face [CNA A] slapped [Resident #1] on the left cheek and [Resident #1] sat by her afterwards. I went to the restroom afterwards came back got the administrators number called then went to inform the nurse. I did ask 2 coworkers on what to do I've never experienced situation before. Review of a written statement dated 1/5/25 and documented by CNA A, reflected the following: I was sitting on the brown table when [Resident #1] walked up to me and started talking to me from there she slapped me in my face from there I did reach and pushed her back with my hand in her face. Just to make myself clear I did not slap the resident on the face I put my heel of my hand on her left cheek and pushed her back. When I realized I may contact with her I apologized to the resident. Review of a video footage provided by the facility with a date/time stamp of 01/05/2025 11:51 am reflected CNA A seated on a bench/table with Resident #1 to her right-side adjusting items on the bench/table. Resident #1 then walked to the front of CNA A and the two appeared to be in conversation. Resident #1 could be seen moving both of her arms while talking and then raised her right arm and slapped CNA A across the right side of her face. CNA A was then seen raising her right arm all the way up and slapping Resident #1 back across the left side of her face and Resident #1 can be seen being turned about 45-degrees due to the slap. After that, Resident #1 and CNA A can be seen in conversation again, and Resident #1 turns to walk to her left when CNA A grabbed the back of Resident #1's shirt and pulled toward her, making Resident #1 fall into a seated position to the right side of CNA A on the bench/table. Review of CNA A's time stamp card dated 01/05 revealed she clocked in at 06:02 AM and clocked out at 10:04 PM, working a total of 16.03 hours. During a phone interview on 01/22/2025 at 12:37 PM with RN A she stated that she was the charge nurse during the morning of 01/05/2025 and that CNA A did not tell her that she had slapped Resident #1 back. It was not until after CNA B contacted the ADM and then went to speak with RN A that she was notified that CNA A had slapped the resident. She stated that after she was informed by CNA B, she immediately went to go assess Resident #1, who exhibited no signs of trauma, and had no redness or signs of bruising. During a phone interview on 01/22/2025 at 12:47 PM with CNA B, she revealed from her phone log that she called the ADM on 01/05/2025 at 2:17 PM to notify him of the alleged abuse of Resident #1 by CNA A that happened earlier that day at 11:51 AM. CNA B was instructed by the ADM to then go and write a statement of the events that occurred as well as to inform the charge nurse. During a phone interview on 01/22/2025 at 1:00 PM with the ADM (who is the abuse coordinator), when asked why CNA A was allowed to finish her shift, he stated that at that point in time and after getting [CNA A's] statement it was unclear whether [the alleged abuse] was incidental or intentional, he had no concern about other residents being harmed at that time. CNA A had spoken with the charge nurse and there was no concern. CNA A was moved out of the MC unit and allowed to finish the remainder of her shift working another hall of the facility. CNA A was terminated the next day. Review of the facility's Abuse, Neglect and Exploitation policy dated last revised 01/08/2023 reflected the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Investigation of Alleged Abuse, Neglect and Exploitation 12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. The IDON, ADON, and ADM were notified on 01/22/2025 at 5:43 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 01/23/2025 at 5:15 PM: PLAN OF REMOVAL Name of facility: [name of facility] Date: 1/22/25 F 600 - Problem: The facility failed to keep the residents free from abuse. Resident #1 Was immediately assessed by the nurse without noted injuries and remains in the facility in stable condition. Immediate action: 1. On 1/22/25 The facility IDON/ADON/Designee immediately initiated skin assessments to ensure no s/s of physical injuries were present in all residents currently residing at the facility- no issues noted. Completed 1/23/25 2. On 1/22/25 The facility Adm/IDON/Designee initiated Life safety rounds with interviewable residents, interviews revealed no negative outcomes. Non-interviewable residents' responsible parties will also be interviewed. Any issues identified will be addressed immediately. Completed 1/23/25 3. On 1/22/25 The VPO conducted a 1:1 in-service with the facility administrator on the company abuse and neglect policy focusing on immediately suspending employees pending allegations of abuse and neglect. This included returned verbalized understanding of the process. This was documented on a signed in-service sheet. Any reportable incidents will also be reported to the corporate VP of Operation and or VP of Clinical to ensure an appropriate investigation, interventions and follow-up takes place. Any issues identified with this process will be addressed through further education and or disciplinary action. Interventions 4. On 1/22/25 The Adm initiated an in-service with the facility management staff on expectations to assure residents safety, abuse and neglect policy and reporting incidents immediately, this includes removing/suspending any staff members involved with any allegations or suspicion of abuse. Comprehension was verified by successfully completing a questionnaire on the subject, Completed 1/23/25 5. On 1/22/25 The facility Adm/IDON/Designee initiated an in-service with the staff on the corporate compliance hot line to report unusual events. Comprehension was verified by successfully completing a questionnaire on the subject, Completed 1/23/25 On 1/22/25 The facility Adm/DON/Designee initiated in-service with the facility staff on Abuse and Neglect focusing on ensuring residents safety and immediately reporting suspected abuse or neglect to the abuse prevention coordinator and or the corporate compliance hot line. The Abuse prevention coordinator contact information is posted throughout the facility. The abuse prevention coordinator will suspend, investigate, rule out, or report any allegation of abuse and neglect within the allotted time frame. Completed 1/23/25. Ongoing Projected completion 1/23/25. Any staff member not present during initial in-servicing/training will not be allowed to assume their duties until in-service. Ongoing In-service will be completed by IDON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, PRN, and agency staff in completed. Monitoring 1. The facility IDT conduct residents Angel Rounds at least 5xweek to ensure residents do not have unknown safety concerns. Any concerns will be documented on the rounding sheet then turned to the administrator/Designee for immediately follow up. VP of Ops and/or Regional Nurse will provide additional oversight to ensure steps are completed. On going 1/22/25. 2. On 1/22/23 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 1/23/25. 3. On 1/22/25 An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on 1/22/25. 4. Any reportable incidents will also be reported to the corporate VP of Operation and or VP of Clinical to ensure an appropriate investigation, interventions and follow-up takes place. Any issues identified with this process will be addressed through further education and or disciplinary action 1/22/25. The surveyor monitored the POR on 01/23/2025 as followed: During interviews on 01/23/2025 from 4:30pm -5:20pm 3 CNA's, 1 LVN, and 1 MA (from all 3 shifts) all stated they were in-serviced before starting their shift on 01/23/2025 and then given questionnaires to complete to verify their knowledge. All were able to state that their abuse coordinator was the ADM, if he were not available, they were to notify the ADON, IDON, or charge nurse. They were all able to give examples of physical, verbal, and emotional abuse. All expressed the importance of reporting abuse the first time they see or hear it. All know where the corporate compliance hotline number is posted and know when to contact if needed. During interviews on 01/23/2025 from 3:55pm-4:20pm with 3 alert and oriented residents revealed they had recently had communication with management regarding their satisfaction with living at the facility and that they have no concerns about their safety, the staff that provide their daily care, or the management at the facility. Interview with the ADM on 1/23/2025 at 5:10pm, he stated he was in-serviced one-on-one with the VPO regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he was to notify the VPO anytime an allegation was made of ANE. The ADM stated that all employees will be in-serviced before the start of their next shift. The ADM also stated that CNA A was terminated on 1/6/2025. Review of skin assessments dated 1/22/2025-1/23/2025 of all residents revealed no new skin issues/concerns. Review of one-on-one in-service dated 1/22/2025 titled Health and Human Services Reportable Guidelines presented by the VPO to the ADM revealed he went over review of the facility abuse, neglect, and exploitation policy. Included a review of policy section III. Prevention of abuse, neglect, and exploitation, and section VI. Investigation of alleged abuse, neglect and exploitation and section VII. Protection of resident. Review of in-service dated 1/22/2025 titled 'Abuse and Neglect policy: prevention and reporting' was provided by the ADM to department managers. Review of in-service dated 1/22/2025 titled 'Abuse and Neglect policy: It is our policy to ensure resident safety and immediately report suspected abuse or neglect to the abuse coordinator', and listed the ADM's telephone number, was provided to direct care staff. Review of in-service dated 1/22/2025 titled 'Company Compliance Program' revealed information on the company's compliance hotline for employees to contact and was provided to direct care staff. Review of in-service titled 'Angel/Ambassador Rounds Policy' with the policy attached was provided to Angel Round staff members. Review of 'Responsible Party Contact Log' dated week of 1/20/2025 revealed 48 residents' responsible parties were contacted and notes were written regarding complaints/praises/remarks. No notes made regarding suspected abuse/neglect. Review of Safe Surveys dated week of 1/20/2025-1/24/2025 revealed no residents expressing concerns regarding their safety or abusive staff. Review of multiple employee Abuse/Neglect and Compliance Questionnaire's dated between 1/22/2025-1/23/2025 revealed staff answered questions based on the in-services provided. Review of QAPI meeting notes dated 1/22/2025 revealed an email from the MD stating his agreement to their path moving forward. The ADM was informed the IJ was removed on 01/23/2025 at 5:15 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to implement their written policies and procedures regarding investigating abuse for one (Resident #1) of five residents reviewed for abuse and neglect. The facility failed to ensure CNA A was suspended/terminated or removed from working with all residents after she slapped a resident in the memory care unit, potentially causing additional abuse and/or emotional distress. An Immediate Jeopardy (IJ) was identified on 01/22/2025. The IJ template was provided to the facility on [DATE] at 5:43 PM. While the IJ was removed on 01/23/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse/neglect. This failure placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: Review of Resident #1's Quarterly MDS dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including traumatic bran dysfunction (an injury to the brain caused by external mechanical force), dementia (a group of symptoms affecting memory, thinking, and social abilities), senile degeneration of brain (progressive deterioration of brain tissue and function that occurs beyond what's considered normal aging), and age-related physical debility. Review of Resident #1's care plan, dated last reviewed 01/12/2025, reflected she had impaired cognitive function and impaired thought processes with interventions to cue, reorient, and supervise as needed, and to not correct her if she gets confused to reality. Review of a witness statement, dated 1/5/2025 and documented by CNA B, reflected the following: I witnessed [Resident #1] coming up to [CNA A] and hit her in the face [CNA A] slapped [Resident #1] on the left cheek and [Resident #1] sat by her afterwards. I went to the restroom afterwards came back got the administrators number called then went to inform the nurse. I did ask 2 coworkers on what to do I've never experienced situation before. Review of written statement dated 1/5/25 and documented by CNA A, reflected the following: I was sitting on the brown table when [Resident #1] walked up to me and started talking to me from there she slapped me in my face from there I did reach and pushed her back with my hand in her face. Just to make myself clear I did not slap the resident on the face I put my heel of my hand on her left cheek and pushed her back. When I realized I may contact with her I apologized to the resident. Review of video footage provided by the facility with a date/time stamp of 01/05/2025 11:51 am reflected CNA A seated on a bench/table with Resident #1 to her right-side adjusting items on the bench/table. Resident #1 then walked to the front of CNA A and the two appeared to be in conversation. Resident #1 could be seen moving both of her arms while talking and then raised her right arm and slapped CNA A across the right side of her face. CNA A is then seen raising her right arm all the way up and slapping Resident #1 back across the left side of her face and Resident #1 can be seen being turned about 45-degrees due to the slap. After that, Resident #1 and CNA A can be seen in conversation again, and Resident #1 turns to walk to her left when CNA A grabbed the back of Resident #1's shirt and pulled toward her, making Resident #1 fall into a seated position to the right side of CNA A on the bench/table. Review of CNA A's time stamp card dated 01/05 revealed she clocked in at 06:02 AM and clocked out at 10:04 PM, working a total of 16.03 hours. During a phone interview on 01/22/2025 at 12:37 PM with RN A she stated that she was the charge nurse during the morning of 01/05/2025 and that CNA A did not tell her that she had slapped Resident #1 back. It was not until after CNA B contacted the ADM and then went to speak with RN A that she was notified that CNA A had slapped the resident. She stated that after she was informed by CNA B, she immediately went to go assess Resident #1. During a phone interview on 01/22/2025 at 12:47 PM with CNA B, she revealed from her phone log that she called the ADM on 01/05/2025 at 2:17 PM to notify him of the alleged abuse of Resident #1 by CNA A that happened earlier that day at 11:51 AM. CNA B was instructed by the ADM to then go and write a statement of the events that occurred as well as to inform the charge nurse. During a phone interview on 01/22/2024 at 1:00 PM with the ADM, when asked why CNA A was allowed to finish her shift, he stated that at that point in time and after getting [CNA A's] statement it was unclear whether [the alleged abuse] was incidental or intentional, he had no concern about other residents being harmed at that time. CNA A had spoken with the charge nurse and there was no concern. CNA A was moved out of the MC unit and allowed to finish the remainder of her shift working another hall of the facility. CNA A was terminated the next day. During a phone interview on 01/22/2025 at 1:41 PM with the NP she stated that she expected facilities to immediately suspend an employee who had abused a resident and report it to HHSC. She stated that you can never tell if it could happen again. If the perpetrator were to stay working with the resident it could get worse for the resident. Review of the facility's Abuse, Neglect and Exploitation policy dated last revised 01/08/2023 reflected the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Investigation of Alleged Abuse, Neglect and Exploitation 12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. The IDON, ADON, and ADM were notified on 01/22/2025 at 5:43 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 01/23/2025 at 5:15 PM: PLAN OF REMOVAL Name of facility: [name of facility] Date: 1/22/25 F 607 -Problem: The facility failed to implement written policies and procedures to investigate allegations of abuse Resident #1 Was immediately assessed by the nurse without noted injuries. Remains in the facility in stable condition. Immediate action: 1. On 1/22/25 The facility IDON/ADON/Designee immediately initiated skin assessments to ensure no s/s of physical injuries were present in all residents currently residing at the facility- no issues noted. Completed 1/23/25 2. On 1/22/25 The facility Adm/IDON/Designee initiated Life safety rounds with interviewable residents, Interviews revealed no new negative events. Completed 1/23/25. 3. On 1/22/25 The VPO conducted a 1:1 in-service with the facility administrator on the company abuse and neglect policy focusing on immediately suspending employees pending allegations of abuse and neglect. This included returned verbalized understanding of the process. This was documented on a signed in-service sheet. Any reportable incidents will also be reported to the corporate VP of Operation and or VP of Clinical to ensure an appropriate investigation, interventions and follow-up takes place. Any issues identified with this process will be addressed through further education and or disciplinary action. Interventions On 1/22/25 The Adm initiated an in-service with the facility management staff on expectations to assure residents safety, abuse and neglect policy and reporting incidents immediately, this includes removing/suspending any staff members involved with any allegations or suspicion of abuse. Any staff member not present during initial in-servicing/training will not be allowed to assume their duties until in-service. Ongoing In-service will be completed by IDON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Comprehension was verified by successfully completing a questionnaire on the subject. Completed 1/23/25 4. On 1/22/25 The facility Adm/IDON/Designee initiated an in-service with the staff on the corporate compliance hot line to report unusual events. Comprehension was verified by successfully completing a questionnaire on the subject. Completed 1/23/25 5. On 1/22/25 The facility Adm/DON/Designee initiated in-service with the facility staff on Abuse and Neglect focusing on ensuring residents safety and immediately reporting suspected abuse or neglect to the abuse prevention coordinator and or the corporate compliance hot line. The Abuse prevention coordinator contact information is posted throughout the facility. The abuse prevention coordinator will suspend, investigate, rule out, or report any allegation of abuse and neglect within the allotted time frame. Comprehension was verified by successfully completing a questionnaire on the subject, Completed 1/23/25. Ongoing Projected completion 1/23/25. Any staff member not present during initial in-servicing/training will not be allowed to assume their duties until in-service. Ongoing In-service will be completed by IDON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring 1. The facility IDT conduct residents Angel Rounds at least 5xweek to ensure residents do not have unknown safety concerns. Any concerns will be reported to the Adm/Designee immediately for proper follow up. VP of Ops and/or Regional Nurse will provide additional oversight to ensure steps are completed. On going 1/22/25. 2. On 1/22/23 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 1/23/25. 3. On 1/22/25 An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on 1/22/25. The surveyor monitored the POR on 01/23/2025 as followed: During interviews on 01/23/2025 from 3:55pm-4:20pm with 3 alert and oriented residents revealed they had recently had communication with management regarding their satisfaction with living at the facility and that they have no concerns about their safety, the staff that provide their daily care, or the management at the facility. During interviews on 01/23/2025 from 4:30pm -5:20pm 3 CNA's, 1 LVN, and 1 CMA (from all 3 shifts) all stated they were in-serviced before starting their shift on 01/23/2025 and then given questionnaires to complete to verify their knowledge. All were able to state that their abuse coordinator was the ADM, if he were not available, they were to notify the ADON, IDON, or charge nurse. They were all able to give examples of physical, verbal, and emotional abuse. All expressed the importance of reporting abuse the first time they see or hear it. All know where the corporate compliance hotline number is posted and know when to contact if needed. Interview with the ADM on 1/23/2025 at 5:10pm, he stated he was in-serviced one-on-one with the VPO regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he is to notify the VPO anytime an allegation is made of ANE. The ADM stated that all employees will be in-serviced before the start of their next shift. The ADM also stated that CNA A was terminated on 1/6/2025. Review of skin assessments dated 1/22/2025-1/23/2025 of all residents revealed no new skin issues/concerns. Review of one-on-one in-service dated 1/22/2025 titled Health and Human Services Reportable Guidelines presented by the VPO to the ADM revealed he went over review of the facility abuse, neglect, and exploitation policy. Included a review of policy section III. Prevention of abuse, neglect, and exploitation, and section VI. Investigation of alleged abuse, neglect and exploitation and section VII. Protection of resident. Review of in-service dated 1/22/2025 titled 'Abuse and Neglect policy: prevention and reporting' was provided by the ADM to department managers. Review of in-service dated 1/22/2025 titled 'Abuse and Neglect policy: It is our policy to ensure resident safety and immediately report suspected abuse or neglect to the abuse coordinator', and listed the ADM's telephone number, was provided to direct care staff. Review of in-service dated 1/22/2025 titled 'Company Compliance Program' revealed information on the company's compliance hotline for employees to contact and was provided to direct care staff. Review of in-service titled 'Angel/Ambassador Rounds Policy' with the policy attached was provided to Angel Round staff members. Review of 'Responsible Party Contact Log' dated week of 1/20/2025 revealed 48 residents' responsible parties were contacted and notes were written regarding complaints/praises/remarks. No notes made regarding suspected abuse/neglect. Review of Safe Surveys dated week of 1/20/2025-1/24/2025 revealed no residents expressing concerns regarding their safety or abusive staff. Review of multiple employee Abuse/Neglect and Compliance Questionnaire's dated between 1/22/2025-1/23/2025 revealed staff answered questions based on the in-services provided. Review of QAPI meeting notes dated 1/22/2025 revealed an email from the MD stating his agreement to their path moving forward. The ADM was informed the IJ was removed on 01/23/2025 at 5:15 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to, in response to allegations of abuse, prevent further potential abuse for one (Resident #1) of five residents reviewed for abuse and neglect while the investigation of alleged abuse was in progress. The facility failed to ensure CNA A was suspended/terminated or removed from working with all residents while the investigation of alleged abuse was ongoing. CNA A was moved to another wing to continue the remainder of her shift working with other residents for approximately 10 additional hours on the day she slapped a resident in the memory care unit. An Immediate Jeopardy (IJ) was identified on 01/22/2025. The IJ template was provided to the facility on [DATE] at 5:43 PM. While the IJ was removed on 01/23/2025, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on abuse/neglect. This failure placed residents at risk of abuse, trauma, and/or psychosocial harm. Findings included: Review of Resident #1's Quarterly MDS dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including traumatic bran dysfunction (an injury to the brain caused by external mechanical force), dementia (a group of symptoms affecting memory, thinking, and social abilities), senile degeneration of brain (progressive deterioration of brain tissue and function that occurs beyond what's considered normal aging), and age-related physical debility. Resident #1 had a BIMS score of 00 indicating severe cognitive impairment. Review of Resident #1's care plan, dated last reviewed 01/12/2025, reflected she had impaired cognitive function and impaired thought processes with interventions to cue, reorient, and supervise as needed, and to not correct her if she gets confused to reality. Review of a witness statement, dated 1/5/2025 and documented by CNA B, reflected the following: I witnessed [Resident #1] coming up to [CNA A] and hit her in the face [CNA A] slapped [Resident #1] on the left cheek and [Resident #1] sat by her afterwards. I went to the restroom afterwards came back got the administrators number called then went to inform the nurse. I did ask 2 coworkers on what to do I've never experienced situation before. Review of written statement dated 1/5/25 and documented by CNA A, reflected the following: I was sitting on the brown table when [Resident #1] walked up to me and started talking to me from there she slapped me in my face from there I did reach and pushed her back with my hand in her face. Just to make myself clear I did not slap the resident on the face I put my heel of my hand on her left cheek and pushed her back. When I realized I may contact with her I apologized to the resident. Review of video footage provided by the facility with a date/time stamp of 01/05/2025 11:51 am reflected CNA A seated on a bench/table with Resident #1 to her right-side adjusting items on the bench/table. Resident #1 then walked to the front of CNA A and the two appeared to be in conversation. Resident #1 could be seen moving both of her arms while talking and then raised her right arm and slapped CNA A across the right side of her face. CNA A is then seen raising her right hand all the way up and slapping Resident #1 back across the left side of her face and Resident #1 can be seen being turned about 45-degrees due to the slap. After that Resident #1 and CNA A can be seen in conversation again, and Resident #1 turns to walk to her left when CNA A grabbed the back of Resident #1's shirt and pulled toward her, making Resident #1 fall into a seated position to the right side of CNA A on the bench/table. Review of CNA A's time stamp card dated 01/05 revealed she clocked in at 06:02 AM and clocked out at 10:04 PM, working a total of 16.03 hours. During a phone interview on 01/22/2025 at 12:37 PM with RN A she stated that she was the charge nurse during the morning of 01/05/2025 and that CNA A did not tell her that she had slapped Resident #1 back. It was not until after CNA B contacted the ADM and then went to speak with RN A that she was notified that CNA A had slapped the resident. She stated that after she was informed by CNA B she immediately went to go assess Resident #1. During a phone interview on 01/22/2025 at 12:47 PM with CNA B, she revealed from her phone log that she called the ADM on 01/05/2025 at 2:17 PM to notify him of the alleged abuse of Resident #1 by CNA A that happened earlier that day at 11:51 AM. CNA B was instructed by the ADM to then go and write a statement of the events that occurred as well as to inform the charge nurse. During a phone interview on 01/22/2025 at 1:00 PM with the ADM, when asked why CNA A was allowed to finish her shift he stated that at that point in time and after getting [CNA A's] statement it was unclear whether [the alleged abuse] was incidental or intentional, he had no concern about other residents being harmed at that time. CNA A had spoken with the charge nurse and there was no concern. CNA A was moved out of the MC unit and allowed to finish the remainder of her shift working another hall of the facility. CNA A was terminated the next day. During a phone interview on 01/22/2025 at 1:41 PM with the NP she stated that she expected facilities to immediately suspend an employee who had abused a resident and report it to HHSC. She stated that you can never tell if it could happen again. If the perpetrator were to stay working with the resident it could get worse for the resident. Review of the facility's Abuse, Neglect and Exploitation policy dated last revised 01/08/2023 reflected the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Investigation of Alleged Abuse, Neglect and Exploitation 12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. The DON, ADON, and ADM were notified on 01/22/2025 at 5:43 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 01/23/2025 at 5:15 PM: PLAN OF REMOVAL Name of facility: [name of facility] Date: 1/22/25 F 610 -Problem: The facility failed to prevent further potential abuse while the investigation was in progress. Resident #1 Was immediately assessed by the nurse without noted injuries Remains in the facility in stable condition. Immediate action: 1. On 1/22/25 The facility IDON/ADON/Designee immediately initiated skin assessments to ensure no s/s of physical injuries were present in all residents currently residing at the facility- no issues noted. Completed 1/23/25 2. On 1/22/25 The facility Adm/IDON/Designee initiated Life safety rounds with interviewable residents, Interviews revealed no new negative events. Completed 1/23/25. 3. On 1/22/25 The VPO conducted a 1:1 in-service with the facility administrator on the company abuse and neglect policy focusing on immediately suspending employees pending allegations of abuse and neglect. This included returned verbalized understanding of the process. This was documented on a signed in-service sheet. Any reportable incidents will also be reported to the corporate VP of Operation and or VP of Clinical to ensure an appropriate investigation, interventions and follow-up takes place. Any issues identified with this process will be addressed through further education and or disciplinary action. Interventions 4. On 1/22/25 The Adm initiated an in-service with the facility management staff on expectations to assure residents safety, abuse and neglect policy and reporting incidents immediately, this includes removing/suspending any staff members involved with any allegations or suspicion of abuse. Comprehension was verified by successfully completing a questionnaire on the subject Completed 1/23/25 5. On 1/22/25 The facility Adm/IDON/Designee initiated an in-service with the staff on the corporate compliance hot line to report unusual events. Comprehension was verified by successfully completing a questionnaire on the subject Completed 1/23/25. 6. On 1/22/25 The facility Adm/DON/Designee initiated in-service with the facility staff on Abuse and Neglect focusing on ensuring residents safety and immediately reporting suspected abuse or neglect to the abuse prevention coordinator and or the corporate compliance hot line. The Abuse prevention coordinator contact information is posted throughout the facility. The abuse prevention coordinator will suspend, investigate, rule out, or report any allegation of abuse and neglect within the allotted time frame. Comprehension was verified by successfully completing a questionnaire on the subject Completed 1/23/25. Ongoing Projected completion 1/23/25. Any staff member not present during initial in-servicing/training will not be allowed to assume their duties until in-service. Ongoing In-service will be completed by IDON/ADON/WC NURSE/or weekend nurse supervisor, until all staff, weekend, prn, and agency staff in completed. Monitoring 1. The facility IDT conduct residents Angel Rounds at least 5xweek to ensure residents do not have unknown safety concerns. Any concerns will be reported to the Adm/Designee immediately for proper follow up. VP of Ops and/or Regional Nurse will provide additional oversight to ensure steps are completed On going 1/22/25. 2. On 1/22/23 The DON/designee began a questionnaire to validate the effectiveness of the training. The questionnaire is conducted with facility staff. Immediate re-education will be completed by the DNS/designee if any staff is unable to answer appropriately to the questions on the questionnaire. Staff will not be allowed to work until after completion of the questionnaire. Projected completion 1/23/25. 3. On 1/22/25 An impromptu QAPI meeting was conducted with the facility's Medical Director to notify of the potential for non-compliance and the action plan implemented for approval. Plan approved on 1/22/25. The surveyor monitored the POR on 01/23/2025 as followed: During interviews on 01/23/2025 from 4:30pm -5:20pm 3 CNA's, 1 LVN, and 1 CMA (from all 3 shifts) all stated they were in-serviced before starting their shift on 01/23/2025 and then given questionnaire's to complete to verify their knowledge. All were able to state that their abuse coordinator was the ADM, if he were not available, they were to notify the ADON, IDON, or charge nurse. They were all able to give examples of physical, verbal, and emotional abuse. All expressed the importance of reporting abuse the first time they see or hear it. All know where the corporate compliance hotline number is posted and know when to contact if needed. During interviews on 01/23/2024 from 3:55pm-4:20pm with 3 alert and oriented residents revealed they had recently had communication with management regarding their satisfaction with living at the facility and that they have no concerns about their safety, the staff that provide their daily care, or the management at the facility. During interviews on 01/23/2025 from 4:30pm -5:20pm 3 CNA's, 1 LVN, and 1 CMA (from all 3 shifts) all stated they were in-serviced before starting their shift on 01/23/2025 and then given questionnaires to complete to verify their knowledge. All were able to state that their abuse coordinator was the ADM, if he were not available, they were to notify the ADON, IDON, or charge nurse. They were all able to give examples of physical, verbal, and emotional abuse. All expressed the importance of reporting abuse the first time they see or hear it. All know where the corporate compliance hotline number is posted and know when to contact if needed. Interview with the ADM on 1/23/2025 at 5:10pm, he stated he was in-serviced one-on-one with the VPO regarding the timeliness of reporting alleged abuse to HHSC (within 2 hours of the alleged abuse), keeping residents safe, prevention of abuse, and that he is to notify the VPO anytime an allegation is made of ANE. The ADM stated that all employees will be in-serviced before the start of their next shift. Review of skin assessments dated 1/22/2025-1/23/2025 of all residents revealed no new skin issues/concerns. Review of one-on-one in-service dated 1/22/2025 titled Health and Human Services Reportable Guidelines presented by the VPO to the ADM revealed he went over review of the facility abuse, neglect, and exploitation policy. Included a review of policy section III. Prevention of abuse, neglect, and exploitation, and section VI. Investigation of alleged abuse, neglect and exploitation and section VII. Protection of resident. Review of in-service dated 1/22/2025 titled 'Abuse and Neglect policy: prevention and reporting' was provided by the ADM to department managers. Review of in-service dated 1/22/2025 titled 'Abuse and Neglect policy: It is our policy to ensure resident safety and immediately report suspected abuse or neglect to the abuse coordinator', and listed the ADM's telephone number, was provided to direct care staff. Review of in-service dated 1/22/2025 titled 'Company Compliance Program' revealed information on the company's compliance hotline for employees to contact and was provided to direct care staff. Review of in-service titled 'Angel/Ambassador Rounds Policy' with the policy attached was provided to Angel Round staff members. Review of 'Responsible Party Contact Log' dated week of 1/20/2025 revealed 48 residents' responsible parties were contacted and notes were written regarding complaints/praises/remarks. No notes made regarding suspected abuse/neglect. Review of multiple employee Abuse/Neglect and Compliance Questionnaire's dated between 1/22/2025-1/23/2025 revealed staff answered questions based on the in-services provided. Review of QAPI meeting notes dated 1/22/2025 revealed an email from the MD stating his agreement to their path moving forward. The ADM was informed the IJ was removed on 01/23/2025 at 5:15 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported immediately, but not later than 2 hours after the allegation was made for one (Resident #1) of five residents reviewed for abuse and neglect. The facility failed to report alleged violations related to abuse within prescribed timeframes when CNA A witnessed abuse at 11:51 AM on 1/5/2025, did not report it to the ADM until 2:17 PM on 1/5/2025, and the ADM did not report to HHSC until 1/6/2025 at 8:43 PM. This failure placed residents at risk of abuse, trauma, and/or psychosocial harm. Findings included: Review of Resident #1's Quarterly MDS dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including traumatic bran dysfunction (an injury to the brain caused by external mechanical force), dementia (a group of symptoms affecting memory, thinking, and social abilities), senile degeneration of brain (progressive deterioration of brain tissue and function that occurs beyond what's considered normal aging), and age-related physical debility. Resident #1 had a BIMS score of 00 indicating severe cognitive impairment. Review of Resident #1's care plan, dated last reviewed 01/12/2025, reflected she had impaired cognitive function and impaired thought processes with interventions to cue, reorient, and supervise as needed, and to not correct her if she gets confused to reality. Review of Provider Investigation Report Form 3613-A revealed the date reported to HHSC as 1.6.25 and time 8:43 PM, with the date of incident being 1.5.25 and the time of incident as 2:30 PM. Review of video footage provided by the facility with a date/time stamp of 01/05/2025 11:51 am reflected CNA A seated on a bench/table with Resident #1 to her right-side adjusting items on the bench/table. Resident #1 then walked to the front of CNA A and the two appeared to be in conversation. Resident #1 could be seen moving both of her arms while talking and then raised her right arm and slapped CNA A across the right side of her face. CNA A is then seen raising her right arm all the way up and slapping Resident #1 back across the left side of her face and Resident #1 can be seen being turned about 45-degrees due to the slap. After that, Resident #1 and CNA A can be seen in conversation again, and Resident #1 turns to walk to her left when CNA A grabbed the back of Resident #1's shirt and pulled toward her, making Resident #1 fall into a seated position to the right side of CNA A on the bench/table. During a phone interview on 01/22/2025 at 12:47 PM with CNA B, she revealed from her phone log that she called the ADM on 01/05/2025 at 2:17 PM to notify him of the alleged abuse of Resident #1 by CNA A that happened earlier that day at 11:51 AM. CNA B was instructed by the ADM to then go and write a statement of the events that occurred as well as to inform the charge nurse. CNA A stated she had to ask 2 coworkers what she needed to do in this situation because she had never experienced something like that before. During a phone interview on 01/22/2024 at 1:00 PM with the ADM, when asked why CNA A was allowed to finish her shift, he stated that at that point in time and after getting [CNA A's] statement it was unclear whether [the alleged abuse] was incidental or intentional, he had no concern about other residents being harmed at that time. CNA A had spoken with the charge nurse and there was no concern. CNA A was moved out of the MC unit and allowed to finish the remainder of her shift working another hall of the facility. CNA A was terminated the next day. Review of the facility's Abuse, Neglect and Exploitation policy dated last revised 01/08/2023 reflected the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Reporting 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .

Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 4 of 5 residents (Residents #1, #2, #3, & #4) reviewed for resident rights. The facility failed to ensure Residents #1, #2, #3, and #4's call light was within reach on 12/28/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #1's admission record dated 12/28/24 documented a [AGE] year-old female admitted on [DATE]. Resident #1 had diagnoses which included: need for assistance with personal care, major depressive disorder (loss of interest in activities), and essential primary hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause). Record review of Resident #1's Quarterly MDS assessment, dated 10/18/24, revealed the resident had a BIMS score of 03 indicating the resident had severe cognitive impairment. The MDS also revealed Resident #1 required substantial/maximal assistance in the areas of toileting hygiene, lower body dressing, upper body dressing, and putting on /taking off footwear. Record review of Resident #1's care plan, dated 12/28/24, revealed Resident #1 was care planned for ADL self-care performance deficit r/t activity intolerance, impaired balance, limited mobility, and limited ROM. Observation on 12/28/24 at 11:30 a.m., revealed Resident #1's call light was lying on the floor, right side of the bed, and out of her reach. During an interview on 12/28/24 at 11:30 a.m., Resident #1 stated she had wanted her blanket and a Dr. Pepper but was not able to get anyone to assist her because the call light was on the floor. Resident # 1 was not able to state how long the call light had been on the floor or when the last time staff had come in to assist her. Record review of Resident #2's admission record dated 12/28/24 documented an [AGE] year-old female admitted on [DATE]. Resident #2 had diagnoses which included: anemia (blood does not have enough healthy red blood cells and hemoglobin), acute kidney failure (kidneys suddenly can't filter waste from blood), and unspecified dementia (loss of memory can't be categorized as a specific type). Record review of Resident #2's Quarterly MDS assessment, dated 10/14/24, revealed the resident had a BIMS score of 03 indicating the resident had severe cognitive impairment. The MDS also revealed Resident #1 required partial/moderate assistance in the areas of toileting hygiene, lower body dressing, upper body dressing, and putting on /taking off footwear. Record review of Resident #2's care plan, dated 12/28/24, revealed Resident #1 was care planned for assistance with ADL's r/t impaired mobility and dementia. Resident #2's goal was to receive assistance as needed with ADL's daily and ongoing. Observation on 12/28/24 at 11:34 a.m., revealed Resident #2's call light was wrapped around her headboard, behind her head, not within reach under the pillow. During an interview on 12/28/24 at 11:34 a.m., Resident #2 did not respond when asked where her call light was. Resident # 2 closed her eyes and appeared to be sleeping. Resident #2 was not able to be asked how long her call light was not in reach. Record review of Resident #3's admission record dated 12/28/24 documented a [AGE] year-old male admitted on [DATE]. Resident #3 had diagnoses which included: type 2 diabetes (body has trouble controlling blood sugar and using it for energy), acute kidney failure (kidneys suddenly can't filter waste from the blood), and essential primary hypertension (high blood pressure with no identifiable cause). Record review of Resident #3's Admission MDS assessment, dated 12/16/24, revealed the resident had a BIMS score of 15 indicating the resident was cognitively intact. The MDS also revealed Resident #3 was dependent in the area of shower/bathe self. Resident #3 required partial/moderate assistance in the areas of toileting hygiene, personal hygiene, upper body dressing, and putting on/taking of footwear. Record review of Resident #3's care plan, dated 12/28/24, revealed Resident #3 was care planned requiring assistance to perform functional abilities in self-care and mobility r/t other orthopedic conditions-bilateral knee contractures. Observation on 12/28/24 at 11:38 a.m., revealed Resident #3's call light on the floor, on the left side of the bed, and out of his reach. During an interview on 12/28/24 at 11:38 a.m., Resident #3 stated that he had been looking for his call light to get care staff to empty the bedside urinal. Resident # 3 stated he did not know where his call light was and could not recall how long it was missing. Resident # 3 was not able to provide how long it had been since staff came in to assist him. Or he had to holler out for staff. Record review of Resident #4's admission record dated 12/28/24 documented an [AGE] year-old female admitted on [DATE]. Resident #4 had diagnoses which included: essential primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), chronic kidney disease (waste built up in kidneys), and pulmonary hypertension (affects arteries in the lungs and the right side of the heart). Record review of Resident #4's Quarterly MDS assessment, dated 10/14/24, revealed the resident had a BIMS score of 12 indicating the resident had moderate cognitive impairment. The MDS also revealed Resident #4 required substantial/maximal assistance in the areas of toileting hygiene, shower/bathe self, lower body dressing, upper body dressing, personal hygiene, and putting on /taking off footwear. Record review of Resident #4's care plan, dated 12/28/24, revealed Resident #4 was care planned for assistance with all ADL's r/t weakness, impaired mobility, and dementia. Resident #4's goal was to receive assistance as needed with ADL's daily and ongoing. Observation on 12/28/24 at 11:40 a.m., revealed Resident #4''s call light was behind her, at the middle of her back, unable to be reached. During an interview on 12/28/24 at 11:40 a.m., Resident #4 stated she could not reach her call light because it was under her towards her back. Resident #4 stated she did not know the last time staff had come in or how long the call light was under her. During an interview on 12/28/24 at 1:15 p.m., CNA A stated CNAs should make rounds at least every two hours or as needed. CNA A stated that CNAs should be looking to see if a resident needed assistance, ensured call lights were within reach, and made sure all residents were comfortable. CNA A stated if a resident's call light was not within reach, then the resident's needs would not be met. During an interview on 12/28/24 at 1:29 p.m., the ADON stated that all staff that entered the resident's room was responsible for ensuring the call light was within reach. The ADON stated it was expected for all staff that entered a resident's room to make sure the call light was in reach so residents could notify staff that they needed assistance. The ADON stated if a resident's call light was not in reach, then the resident's needs would not have been met. An interview on 12/28/24 at 4:00 p.m., the ADM stated it was everyone's responsibility to ensure call lights were always within reach of the resident. The ADM stated that if a call light was not within reach, then a resident's needs would not be met. The ADM stated that it was expected for call lights to be always within reach of the residents. Review of the facility's Call Lights: Accessibility and Timely Response policy, revised 02/23, reflected, The purpose of this this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to staff member or centralized location to ensure appropriate response.

Based on interview and record review, the facility failed to provide a reasonable cost-based fee for the provision of medical records for 1 of 2 residents (Resident #1) who were reviewed for access to medical records. The facility failed to charge the RP, for Resident #1, reasonable prices for medical records cost determined in the Texas Health and Safety Code, Title 4. Health Facilities; Subtitle B. Licensing of Health Facilities; Chapter 241. Hospitals; Subchapter A. General Provisions; Section 241.154 (THSC 241.154.) This failure placed residents, or their RP, at risk for complications with continuity of care and financial hardship. Findings included: Record review of Resident #1's Discharge MDS, dated [DATE], reflected the Resident was a [AGE] year-old female who admitted to the facility on [DATE]. She was diagnosed with peripheral vascular disease (which was slow and progressive circulation disorder caused by narrowing of the blood vessels.) Section C., Cognitive Patterns: Indicated Resident #1's short-term memory was appropriate; independent decisions were consistent and reasonable. Staff assessed BIMS. Record review of a release of information request, dated 2/12/2024, reflected RP #2's request for Resident #1's medical records from the facility. Record review of an invoice, dated 3/8/2024, reflected a cost breakdown for the medical records requested on 2/12/2024. The total cost was $274.28 for 216 pages. The invoice was sent by MRC A to RP #2. The cost breakdown reflected: 1. Pages 1-10 = $52.12 (search fee); 10 pages; Cost equaled $52.12 2. Pages 11-60 = $1.76 (per page); 50 pages; Cost equaled $88.00 3. Pages 61-400 = .86 (per page); 156 pages; Cost equaled $134.16 Invoice to RP #2, dated 3/8/2024, reflected $52.12 + $88.00 + $134.16= $274.28 Record review on 7/17/2024 of Texas Health and Safety Code, Title 4. Health Facilities; Subtitle B. Licensing of THSC 241.154, effective date 5/27/2023, reflected: (1) a basic retrieval or processing fee, which must include the fee for providing the first 10 pages of the copies and which may not exceed $30; and (A) a charge for each page of: (i) $1 for the 11th through the 60th page of the provided copies; (ii) .50 cents for the 61st through the 400th page of the provided copies. Having used a calculator on a state issued iPhone on 7/17/2024: Calculations for the 216 pages of Resident #1's medical record copies, based on THSC 241.154 reflected: 1. Pages 1-10 = $30.00 (basic retrieval and processing fee); 10 pages; Cost equaled $30.00 2. Pages 11-60 = $1.00 (per Page); 50 pages; Cost equaled $50.00 3. Pages 61-400 = .50 (per page; 156 pages; Cost equaled $78.00 Calculations with THSC 241.154 reflected $30.00 + $50.00 + $78.00= $158.00 Having used a calculator on a state issued iPhone on 7/17/2024: $274.28 - $158.00 = $116.28 of an inflated cost. Interview on 7/17/2024 at 9:45 AM with MRC B revealed the invoice for Resident #1's medical record copies was created on 3/8/2024, and sent to RP #2, by MRC A, who no longer worked at the facility. MRC B stated the CCO, from the corporate offices was the person who calculated the prices for medical records and calculated the amount of $274.28 for Resident #1's medical record copies. Interview on 7/17/2024 at 10:15 AM with RP #2 revealed the facility was unjust in asking for $274.28 for copies of Resident #1's medical records. Upon his own research with RP #3, he stated the cost was supposed to had been much lower. He had hoped the matter could be resolved so he could have attained the medical records at a reasonable cost. Interview on 7/17/2024 at 10:25 AM with RP #3 revealed the facility had charged inflated rates for Resident #1's medical record copies. RP #3 stated she researched Texas law and determined the rates for medical records were supposed to be a basic retrieval or processing fee, which must include the fee for providing the first 10 pages of the copies and which may not exceed $30; and a charge of $1.00 for the 11th through the 60th page; and .50 cents for the 61st through the 400th page. RP #3 wanted the discrepancy addressed and the facility to follow the guidance she discovered through her own research of Texas law. Interview on 7/17/2024 at 11:13 AM with the CCO revealed she was the Chief Compliance Officer for the facility's corporate offices. She stated the corporate offices followed the guidelines in THSC 241.154 when having determined reasonable cost for medical record copies; however, the invoice of cost provided to RP #2, dated 3/8/2024, for Resident #1's medical record copies was not correct. The CCO stated THSC 241.154 was utilized for the reasonable cost of medical records in the facility's Release of Medical Records Policy, dated January 2023. The THSC 241.154 was updated, on 5/27/2023, to reflect a reduction of reasonable cost, but the facility's Release of Medical Records Policy, dated January 2023, was not updated to reflect the new reasonable cost. Resident #1's medical record copies invoice, dated 3/8/2024, utilized calculations with the outdated version of THSC 241.154. The CCO stated the cost for Resident #1's medical record copies, calculated on the invoice on 3/8/2024, was based on an outdated THSC 241.154, prior to the 5/27/2023 update, and on the facility's Release of Medical Records Policy dated January 2023, which she should have reflected the update. She stated she discovered the discrepancy in April 2024 and updated the facility's Release of Medical Records Policy on 4/29/2024 to reflect the new THSC 241.154 guidelines for reasonable cost for medical records, effective 5/27/2023. The CCO stated the corporate offices did not reach out to RPs, who had requested copies of medical records between 05/27/2023 and 4/29/2024, to inform them they had been charged inflated prices. Interview on 7/17/2024 at 1:25 PM with MRC B revealed she took the position over as medical records coordinator about a month ago with a Release of Medical Records Policy, dated 4/29/2024. MRC B stated RP #2 or RP #3 had not contacted the facility to address the cost provided in the invoice, dated 3/8/2024, for Resident #1's medical record copies. MRC B stated she had no knowledge that the prices in the invoice, dated 3/8/2024, were calculated with prices from an outdated version of THSC 241.154, prior to 5/27/2023, or a non-updated facility policy, dated January 2023. MRC B stated the failure to have updated prices and an updated policy, at the time the medical records were requested on 2/12/2024, fell upon communication, not checking the policy, or verifying the prices. MRC B stated access to medical record was important for residents who needed to continue care elsewhere. As well, the inflated cost $116.28 was a lot of money and could have gone elsewhere for better use. Interview on 7/17/2024 at 1:37 PM with the CCO stated the costs associated with copies of medical records came from the corporate offices. The failure for the facility to have the correct information fell at the corporate level. There was a leadership change, and the failure was human error on behave of corporate. Safeguards in place to avoid this type of this failure were policy reviews and meetings with the compliance teams. The CCO stated the addition expenses for the medical records copies placed the requestor at risk for financial hardship. Interview on 7/17/2024 at 2:20 PM with the ADM revealed medical record release, and reasonable medical record release cost, were important for continued care. She expressed dissatisfaction the facility was being held responsible for a failure at the corporate level. Record review of the facility's Release of Medical Records Policy, dated January 2023, reflected basic retrieval and processing fee not to exceed $52.12 for the first 10 pages. $1.76 per page for pages 11-60.86 cents per page for pages 61-400.47 cents per page for any remaining. Record review of the facility's Release of Medical Records Policy, dated April 29, 2024, reflected basic retrieval and processing fee not to exceed $30.00 for the first 10 pages. $1.00 per page for pages 11-60.50 cents per page for pages 61-400.25 cents per page for any remaining.

Based on observations, interviews, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area for 1 of 12 residents (Residents #5) reviewed for call lights. The facility failed to place Resident #5's call light within reach to call staff for assistance. This failure placed residents at risk for having their needs go unmet. Findings included: Record review of Resident #5's undated face sheet revealed an [AGE] year-old woman who admitted to the facility on [DATE]. She was diagnosed with Unspecified Dementia (which was a disease that affected memory, thought, and interfered with daily life;) Syncope and Collapse (which was also known as fainting;) and, Dyspnea (which was a condition that causes shortness of breath.) Record review of Resident #5's Quarterly MDS, dated [DATE], reflected Section C., Cognitive Patterns; Resident #5 had a BIMS Score of 00. A BIMS Score of 00 indicated Resident #5 had severe cognitive impairment. Section GG., Functional Abilities and (Range of Motion;) Resident had no impairment in either upper extremity (shoulder, elbow, wrist, and hand.) Resident had impairment on both sides of lower extremities (hip, knee, ankle, and foot.) Resident #5 utilized a wheelchair for mobility. Section GG., Functional Abilities and Goals (Self Care;) Resident #5 was dependent upon staff for toileting hygiene, shower/bathe self, and personal hygiene. Dependent meant the helper did all the effort. Section H., Bladder and Bowel (Bladder) indicated Resident #5 was always incontinent; (Bowl) indicated Resident #5 was always incontinent. Interview and observation on 4/23/2024 at 12:29 PM with Resident #5 revealed resident resting in her bed. Resident #5 did not respond to verbal introductions. Resident #5's bed was at a lower level of height; the back rest was slightly elevated. The call button clip, the call button, and the call button cord were on the floor to the resident's right side of body. The resident did not have access to the call light button because the call light button was further than arms reach. Observations on 4/25/2024 at 2:46 PM with Resident #5 revealed resident sleeping in her bed. The call button clip, the call button, and the call button cord were on the floor to the resident's right side of body. The resident did not have access to the call light button because the call light button was further than arms reach. Interview on 4/25/2024 at 2:49 PM with CNA A revealed she was a new employee and had been working at the facility for about 2-3 weeks. CNA A was trained to make sure the resident's call light was placed within arms reach after each resident contact. For example, the correct location of the cord would be with the resident in a chair or a bed. The location of the resident did not matter. CNA A performed room checks every 2 hours and to look for the call light's location and correct if needed. A resident's diagnosis, willingness to use the call light, or understanding the purpose for the call light did not negate the need for the call light to be within reach of the resident. Interview and observation on 4/25/2023 at 3:04 PM revealed CNA B exiting from Resident #5's room. CNA B stated he just performed his rounds for Resident #5. While performing rounds in Resident #5's room at 3:04 PM, he stated Resident #5's call light was located on the floor, out of reach of Resident #5, and that he placed the call light button in the correct location, within reach of Resident #5. He stated the call light was not in the correct position when he entered the room, a few moments ago. Interview on 4/25/2024 at 4:15 PM with the DON revealed staff was trained to place the resident's call light button within reach of each resident. If a staff member entered the room and noticed the call light out of reach of the resident, the call light button was supposed to be moved to the correct location, within arm's reach. Safeguards in place to make sure residents had access to their call light buttons was the use of angel rounds, which were daily room checks by administrative staff. Risks posed to a resident without access to their call button were falls, delayed assessments, and psychosocial harm. Interview on 4/25/2025 at 4:50 PM with the ADM revealed the facility had a policy for Answering the Call Ligh t and the policy stipulated the call light was supposed to be within reach of the resident. She expected her staff to follow the policy. There were no specific circumstances that would negate any resident from having or needing access to their call light button. Safeguards in place to ensure residents had access to their call lights were the policy and angel rounds. A resident without access to their call light button risked falls, lack of access to assistance, and frustration. Record review of the facility's [Answering the Call Light] policy, revised September 2003, reflected; (5) when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interview and record review, facility staff failed to ensure 2 of 3 residents (Resident #'s 1 and 2) reviewed for accuracy of medication administration were free of significant medication errors on 400 Hall. Medication Aide A administered fourteen (14) of Resident #2's morning medications to Resident #1. Medications administered included opiates (narcotic) pain medications, anticonvulsant medications, antipsychotic medication, a blood pressure medication, a medication to treat heart arthymias, a diuretic medication, and various other medications. This resulted in hospitalization of Resident #1, who had no physician orders for the above medications. This failure was identified as an Immediate Jeopardy (IJ) on 12/15/15. While the IJ was lowered on 12/16/15, the facility remained out of compliance at a level of actual harm at a scope of isolated, that is not an IJ, because the facility administrator and staff needed time to monitor their plan of removal for effectiveness. This deficient practice placed 37 residents on the 400 Hall who receive medications from facility staff at risk for receiving incorrect medications which has the potential to cause serious harm or death. Findings include: Review of Resident #1's Face Sheet dated 03/19/15 revealed an [AGE] year old female admitted on [DATE]. Review of Resident #1's Physician Orders dated 12/01/15 revealed the following Diagnoses: [REDACTED].>History of falling, Dislocation of MCP joint of finger, Muscle wasting and atrophy, Unspecified lack of coordination, Age-related [MEDICAL CONDITION], Obstructive sleep apnea, [MEDICAL CONDITION], Gastro-[MEDICAL CONDITION] reflux, [MEDICAL CONDITION], Anorexia, Anxiety disorders, Parkinson ' s disease, Hypertension, Other recurrent [MEDICAL CONDITION], Other [MEDICAL CONDITION], Adult failure to thrive, Ataxic gait, Dehydration, Cachexia, Other secondary Parkinsonism, [DIAGNOSES REDACTED] in conditions classified elsewhere with cataplexy and Arthropathy. Further review of Resident #1's Physician Orders revealed the following medication orders: [MEDICATION NAME] DR 40 mg (milligram) Capsule 1 cap PO (by mouth) Q (every) Day [MEDICATION NAME]-Levo (medication to treat Parkinson ' s disease) 25-100 mg 1 tablet PO BID (twice a day) [MEDICATION NAME]-600 with Vit D tab 1 tab PO BID Advanced Stress Formula plus zinc 1 tab Po BID Aspirin 81 mg chewable tablet 1 tab PO Q-HS (hour of sleep) [MEDICATION NAME] (medication to treat [DIAGNOSES REDACTED]) 200 mg 1 PO Daily [MEDICATION NAME] (antibiotic used to treat Urinary Infections) 100 mg capsule 1 cap PO QD [MEDICATION NAME] (antidepressant medication) 10 mg tablet 1 tab PO Q-HS [MEDICATION NAME] 15 mg tablet 1 tab PO Q-HS [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]) 50 mg tablet 1 tablet PO Q-HS Review of Nurses Notes dated 12/14/15 at 7:45 AM revealed that Medication Aide (MA) A reported to Registered Nurse (RN) B that a medication error had been made and when questioned on what medication, the Med aide replied that the resident had gotten another resident ' s medications prior to going into the dining room. Upon reading the medications that were administered, narcotics and heart medications such as [MEDICATION NAME], and [MEDICATION NAME] were given, I immediately assessed the resident's HR (heart rate), with had a rate of 70, B/P (blood pressure) 90/58, RR (respiration rate) 18, even and unlabored. O2 sats (Oxygen saturation) 96% on RA (room air). Patient hard to wake, sternal rub woke patient up, the patient would return back to sleep and snore. Review of Nurses Notes dated 12/14/15 at 8:00 AM revealed EMS (Emergency Medical Services) here to take resident to assigned hospital, Face Sheet, MD orders, along with a copy of meds administered were sent with EMS, Upon leaving the facility, the resident was awake, stable, B/P 88/56. Review of a transfer form dated 12/14/15 at 2:25AM, reflected Resident #1's [DIAGNOSES REDACTED]. Record review of Emergency Department (ED) documents dated 12/14/15 revealed the following: HPI Comments: Per EMS the patient was essentially unresponsive with a low blood pressure but normal heart rate. They were unable to obtain O2 (oxygen) saturation in route. Vitals: B/P 80/59; Heart Rate 56, Respirations 18. Physical Exam: Patient is essentially unresponsive to all stimuli. Patient was treated with [MEDICATION NAME] (opioid antagonist indicated for the emergency treatment of [REDACTED]. Her blood pressure was marginal in the ER (emergency room ) but seemed to respond to [MEDICATION NAME] and fluids. Review of the Hospitalist Report dated 12/14/15 revealed the following: Resident #1 was an [AGE] year old female that was sent to the ER for altered mental status and had been administered another person's medications. She had was completely unresponsvie and hypercapnic. The medications incuded [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME], Klonopin, [MEDICATION NAME] ([MEDICATION NAME]), [MEDICATION NAME] ([MEDICATION NAME] ([MEDICATION NAME]) and other medications. [MEDICATION NAME] (medication given for opioid overdose) had some response and Hypercapnia showed some improvement. She remained hyperstensive with a systolic blood pressure below 90. She had na elevated latic acid and urinary tract infection. She had been initiated [MEDICAL CONDITION] protocol. She was admitted to the ICU (Intensive Care Unit). Review of a reference at the website www.merckmanuels.com for Hypercapnia. The reference states that Hypercapnia is a rise in Pa co 2 (Partial pressure of carbon [MEDICATION NAME] in the arterial blood). The most common causes are acute exacerbations of asthma and [MEDICAL CONDITION], overdoses of drugs that suppress ventilatory drive, and conditions that cause respiratory muscle weakness. Death can result Further review of the Hospitalist Report dated 12/14/15 revealed the following: Principle Problem: Sepsis due to urinary tract infection Active Problems: ARF (acute [MEDICAL CONDITION]) Acute [MEDICAL CONDITION] with Hypercapnia Medication overdose, accidental or unintentional, initial encounter During an interview on 12/15/15 at 10:00 AM, RN D (Director of Case Management at a local hospital) stated that Resident #1 had been admitted to the ICU in the hospital on [DATE] after a stay in the emergency room . She stated the ED report shows that Resident #1 was administered [MEDICATION NAME] for a possible drug overdose and will be moved to a regular floor room this afternoon, because she is more alert. She stated Resident #1 is also being treated for [REDACTED]. Review of Resident #2's MAR (Medication Administration Report) for the month of December 2015 revealed the following medications were administered on 12/14/15: [MEDICATION NAME] (opiate) HCL 10 mg, [MEDICATION NAME] (opiate) 10/325 mg, [MEDICATION NAME] (anticonvulsant) 1200 mg, [MEDICATION NAME] (antipsychotic) 0.25 mg, Klonopin (anticonvulsant) 0.5 mg, [MEDICATION NAME] HCL (antidepressant) 100 mg, [MEDICATION NAME] (heart arrhythmia medication), [MEDICATION NAME] (antihypertensive) Succ ER (Extended Release) 25 mg, [MEDICATION NAME] (diuretic) 40 mg, Aspirin 81 mg, [MEDICATION NAME] (antiplatelet to prevent blood clots) 75mg, and [MEDICATION NAME] ([MEDICATION NAME]) 25 mg, Cranberry Tablet 450 mg, and Artificial Tears 2 drops in both eyes. Review of fourteen (14) facility Medication Error Reports dated 12/14/15 revealed Resident #1 was given Resident #2's medications in error during the morning medication pass by MA A. The Medication Error Reports revealed that the medications were not prescribed for Resident #1, but she was given another resident's medications. The Report revealed Resident #1 was sent to the emergency room . During an interview on 12/15/15 at 9:30 AM, the Administrator stated that they were still working on the investigation into the medication errors. She stated that MA A had given Resident #2's medications to Resident #1. The Administrator stated that Resident #1 had been sent to the hospital on [DATE] as soon as the Charge Nurse was made aware of the error. During an interview on 12/15/15 at 9:30 AM, the Director of Nurses (DON) stated that MA A was passing medications yesterday (12/14/15) morning and gave medications ordered for Resident #2 to Resident #1. The DON stated that when Resident #2 came to the medication cart and stated to MA A that she needed her medications she realized what she did and she went to the charge nurse, RN B and told her. The DON stated that Resident #1 was assessed and EMS was called and she was sent to the hospital.The DON stated that the MA had been working at the facility for approximately one and half months. She stated that she immediately started an investigation and MA A was removed from the floor. She stated that in-services on resident identifaction had been started with staff. She did not indicate at that time that the MAR had been updated with new pictures or that the PRN (as needed/part time staff) would be in-serviced before they were allowed to pass medications. During an interview on 12/15/15 at 9:50 AM, RN B stated that on 12/14/15 at 7:45 AM MA A reported that she had made a medication error. RN B stated that when she asked which medication the MA told her all of them. RN B stated that MA A stated that when Resident #2 came up to the medication carts to ask about her medication she realized she had given Resident #1 the wrong medications. RN B stated she assessed Resident #1 and her B/P was 80/58 and she called EMS and sent her to the emergency room . RN B stated that she notified the DON and that she pointed out to the DON and the Administrator that both residents had the same first names, the same middle initial and their last names were similar in that they started with the same letter. RN B stated that Resident #1 had been lethargic since Friday and they had obtained a urinary analysis with a culture and sensitivity. She stated that Resident #1 was on a maintenance dose of antibiotic for chronic Urinary Tract Infections. She stated that Resident #1's Primary Physician office nurse called the facility as she was getting ready to report the medication error to them. RN B stated that the physician's office was calling to give them an order for [REDACTED]. RN B stated she was not familiar with all the residents so she was unable to identify Resident #1 when she was asked by MA A to identify the resident. During an interview on 12/15/15 at 1:28 PM, MA A stated that she was passing medications yesterday (12/14/15) morning. She stated that she was still learning the resident's names. A resident came to her medication cart and she did not recognize her and the resident spoke very softly and was unable to clearly say her name. MA A stated that she asked the Charge Nurse (RN B) to identify the resident and RN B told her she didn't know the identity of the resident. She then asked CNA C who the resident was using first name and last name of Resident #2. CNA C stated that yes it was Resident #2. MA A stated she checked the MAR for Resident #2 and there was no picture of the resident. She stated she administered the medications to Resident #1 thinking the CNA had correctly identified the resident. MA A stated that a few minutes later Resident #2 came to the medication cart and asked about her medications and identified herself by name (Resident #2). She stated she immediately went through the MAR and looked at several different residents' pictures until she saw Resident #1's picture. MA A stated, I knew I had given the wrong medications to a resident and I went to the Charge Nurse and reported it immediately. MA A stated that some of the MARs have pictures of residents but a few do not. When asked what she had been taught about identifying a resident before giving medications she stated I was told to look at their picture in the MAR and ask the resident their name and, if they could not tell me, to ask the charge nurse or another staff member to identify them. During an interview on 12/15/15 at 2:15 AM, the DON stated that Resident #2 did not miss any of her medication dosages. Review of the facility PassPort Transaction Log for dispensing medications revealed that the individual dosages for the medications that were given in error were dispensed between 7:03 AM and 7:04 AM. Duplicate dosages for these medications were dispensed between 7:54 AM and 8:08 AM and were administered to Resident #2. During an interview on 12/15/15 at 8:25 AM, CNA C stated that she did tell MA A that Resident #1 was the wrong Resident (Resident #2). I now realize, if I wasn't absolutely positive I should have said I don't know. She stated that the two residents' first names are the same. She stated, I guess I was so busy helping a resident to the dining room I didn't really hear the last name very clearly. CNA C stated, I'm so sorry this happened. Review of Nursing 2016 Drug Handbook revealed the following: A. [MEDICATION NAME]: Therapeutic class: Opioid [MEDICATION NAME] Adverse Reactions: CV (Cardiovascular): arrhythmias, [MEDICAL CONDITIONS], shock, heart failure; Respiratory: respiratory arrest, respiratory depression, [MEDICAL CONDITIONS]. B. [MEDICATION NAME] bitrate-[MEDICATION NAME] ([MEDICATION NAME]) Pharmacologic class: Opioid [MEDICATION NAME] Adverse Reactions: CV: [MEDICAL CONDITIONS], circulatory collapse, Respiratory: respiratory depression, acute airway obstruction. C. [MEDICATION NAME]: Therapeutic class: Antihypertensives Adverse Reactions: CV: [MEDICAL CONDITIONS], heart failure, [MEDICAL CONDITION], palpitations. Review of a current facility policy revised April 2010 Administering Medications reflected the following elements: 5. The individual administering medications must verify the resident ' s identity before giving the resident his/her medications. Methods of identifying the residents include: a. Checking identification band; b. Checking photograph attached to medical record; c. Calling resident by name; and d. If necessary, verifying resident identification with other facility personnel. The facility Administrator and DON were notified on 12/15/15 at 2:25 PM that an Immediate Jeopardy (IJ) had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 12/15/15 at 4:50 PM. The final Plan of Removal was accepted by the surveyor/investigator on 12/15/15 at 5:10 PM. The plan of removal included the following: In-service with Staff on the 6 resident rights on medication pass, i.e. right resident, right medication, etc. started Monday, 12/14/14 to be completed by 12/21/15. In-service given by the In-service Nurse. In serviced staff on checking picture ID on the MAR by the In-service Nurse Monday, 12/14/15 to be completed by 12/21/15. All medication aides and nurses will not be allowed to administer medication until after their in-service. Medication Aide was removed off medication cart on Monday, 12/14/15 pending investigation and scheduled for extensive retraining on Thursday, 12/17/15. Audits were performed by ADONs (Assistant Director of Nurses) on Monday, December 14, 2015 to ensure proper identification and that processes (checking identification band, checking photograph attached to medical record, calling resident by name and if necessary, verifying resident identification with other facility personnel) were in place. This to include all charts and MARS books. Audit started and completed on Monday, December 14, 2015. Residents being reviewed by DON for possible name similarities/location on Tuesday, December 15, 2015. This is to be completed no later than Friday, December 18, 2015. Residents found with name similarities, their charts, MARS and TARS will be flagged. In-service with All departments by the In-service Nurse on Patient Identification started Monday, December 14, 2015 to be completed by 12/21/15. In-servicing Admission Department by DON on taking pictures of new residents and giving to nurse for placement in MARS, TARS and chart to be completed by Wednesday, December 16, 2015. Resident #1 is to move to 100 hall with son ' s permission due to name similarities on 400 hall upon resident's return from hospital. Admissions and Social Service in serviced by DON on room assignments for name similarities, Tuesday, December 15, 2015. Director of Nursing or designee to monitor all above processes once a week for three months and quarterly thereafter. Administrator to provide oversight to Director of Nursing or designee monthly and will report any and all findings to monthly QAA. Next QAA meeting is to be held Thursday, December 17, 2015. The surveyor monitored the current plan of removal as follows: During an interview on 12/15/15 at 2:35 PM, RN K (Inservice Nurse) stated that she written the inservice on the 6 rights and had started inservices on 12/14/15. During interviews on 12/15/15 between 2:40 PM, MA D, MA E, MA F stated they had been in-serviced on the importance of identifying residents correctly yesterday (12/14/15). During an interview on 12/16/15 at 8:25 AM, the DON stated that all staff had been inserviced per the Plan of Removal. She stated that all audits had been completed. Record reviews of facility MARS revealed each resident had a picture in the MARS to help with identification. During interviews on 12/16/15 between 8:50 AM and 9:10 AM, RN B, MA A, CNA C, MA G, MA H, MA I, CNA J, SW (Social Worker), Housekeeper, and Medical Records Supervisor stated they had been in-serviced on the importance of identifying residents correctly. On 12/16/15 at 9:15 AM, the Administrator and DON were informed the IJ was lowered. However, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. The Resident Roster identified 37 residents on the 400 Hall who receive medications from facility staff.

Based on interview and record review, facility staff failed to ensure 2 of 3 residents (Resident #'s 1 and 2) reviewed for accuracy of medication administration were free of significant medication errors on Hall 400. Medication Aide A administered fourteen (14) of Resident #2's morning medications to Resident #1. Medications administered included opiates (narcotic) pain medications, anticonvulsant medications, antipsychotic medication, a blood pressure medication, a medication to treat heart arthymias, a diuretic medication, and various other medications. This resulted in hospitalization of Resident #1, who had no physician orders for the above medications. This failure was identified as an Immediate Jeopardy (IJ) on 12/15/15. While the IJ was lowered on 12/16/15, the facility remained out of compliance at a level of actual harm at a scope of isolated, that is not an IJ, because the facility administrator and staff needed time to monitor their plan of removal for effectiveness. This deficient practice placed 37 residents on the 400 Hall who receive medications from facility staff at risk for receiving incorrect medications which has the potential to cause serious harm or death. Findings include: Review of Resident #1's Face Sheet dated 03/19/15 revealed an [AGE] year old female admitted on [DATE]. Review of Resident #1's Physician Orders dated 12/01/15 revealed the following Diagnoses: [REDACTED].>History of falling, Dislocation of MCP joint of finger, Muscle wasting and atrophy, Unspecified lack of coordination, Age-related osteoporosis, Obstructive sleep apnea, [DIAGNOSES REDACTED], Gastro-esophageal reflux, Insomnia, Anorexia, Anxiety disorders, Parkinson ' s disease, Hypertension, Other recurrent depressive disorders, Other [DIAGNOSES REDACTED], Adult failure to thrive, Ataxic gait, Dehydration, Cachexia, Other secondary Parkinsonism, [DIAGNOSES REDACTED] in conditions classified elsewhere with cataplexy and Arthropathy. Further review of Resident #1's Physician Orders revealed the following medication orders: Prilosec DR 40 mg (milligram) Capsule 1 cap PO (by mouth) Q (every) Day Carbidopa-Levo (medication to treat Parkinson ' s disease) 25-100 mg 1 tablet PO BID (twice a day) Caltrate-600 with Vit D tab 1 tab PO BID Advanced Stress Formula plus zinc 1 tab Po BID Aspirin 81 mg chewable tablet 1 tab PO Q-HS (hour of sleep) Provigil (medication to treat [DIAGNOSES REDACTED]) 200 mg 1 PO Daily Macrodantin (antibiotic used to treat Urinary Infections) 100 mg capsule 1 cap PO QD Lexapro (antidepressant medication) 10 mg tablet 1 tab PO Q-HS Remeron 15 mg tablet 1 tab PO Q-HS Trazodone (medication used to treat Insomnia) 50 mg tablet 1 tablet PO Q-HS Review of Nurses Notes dated 12/14/15 at 7:45 AM revealed that Medication Aide (MA) A reported to Registered Nurse (RN) B that a medication error had been made and when questioned on what medication, the Med aide replied that the resident had gotten another resident's medications prior to going into the dining room. Upon reading the medications that were administered, narcotics and heart medications such as digoxin, and Metoprolol were given, I immediately assessed the resident's HR (heart rate), with had a rate of 70, B/P (blood pressure) 90/58, RR (respiration rate) 18, even and unlabored. O2 sats (Oxygen saturation) 96% on RA (room air). Patient hard to wake, sternal rub woke patient up, the patient would return back to sleep and snore. Review of Nurses Notes dated 12/14/15 at 8:00 AM revealed EMS (Emergency Medical Services) here to take resident to assigned hospital, Face Sheet, MD orders, along with a copy of meds administered were sent with EMS, Upon leaving the facility, the resident was awake, stable, B/P 88/56. Review of a transfer form dated 12/14/15 at 2:25AM, reflected Resident #1's [DIAGNOSES REDACTED]. Record review of Emergency Department (ED) documents dated 12/14/15 revealed the following: HPI Comments: Per EMS the patient was essentially unresponsive with a low blood pressure but normal heart rate. They were unable to obtain O2 (oxygen) saturation in route. Vitals: B/P 80/59; Heart Rate 56, Respirations 18. Physical Exam: Patient is essentially unresponsive to all stimuli. Patient was treated with Narcan (opioid antagonist indicated for the emergency treatment of [REDACTED]. Her blood pressure was marginal in the ER (emergency room ) but seemed to respond to Narcan and fluids. Review of the Hospitalist Report dated 12/14/15 revealed the following: Resident #1 was an [AGE] year old female that was sent to the ER for altered mental status and had been administered another person's medications. She had was completely unresponsvie and hypercapnic. The medications incuded Methadone, Hydrocodone (Norco), Meclizine, Klonopin, Gabapentin (Neurontin), Furosemide (Lasix, Digoxin (Lanoxine) and other medications. Narcan (medication given for opioid overdose) had some response and Hypercapnia showed some improvement. She remained hyperstensive with a systolic blood pressure below 90. She had na elevated latic acid and urinary tract infection. She had been initiated on sepsis protocol. She was admitted to the ICU (Intensive Care Unit). Review of a reference at the website www.merckmanuels.com for Hypercapnia. The reference states that Hypercapnia is a rise in Pa co 2 (Partial pressure of carbon dioxide in the arterial blood). The most common causes are acute exacerbations of asthma and COPD, overdoses of drugs that suppress ventilatory drive, and conditions that cause respiratory muscle weakness. Death can result Further review of the Hospitalist Report dated 12/14/15 revealed the following: Principle Problem: Sepsis due to urinary tract infection Active Problems: ARF (acute renal failure) Acute respiratory failure with Hypercapnia Medication overdose, accidental or unintentional, initial encounter During an interview on 12/15/15 at 10:00 AM, RN D (Director of Case Management at a local hospital) stated that Resident #1 had been admitted to the ICU in the hospital on [DATE] after a stay in the emergency room . She stated the ED report shows that Resident #1 was administered Narcan for a possible drug overdose and will be moved to a regular floor room this afternoon, because she is more alert. She stated Resident #1 is also being treated for [REDACTED]. Review of Resident #2's MAR (Medication Administration Report) for the month of December 2015 revealed the following medications were administered on 12/14/15: Methadone (opiate) HCL 10 mg, Norco (opiate) 10/325 mg, Neurontin (anticonvulsant) 1200 mg, Risperdal (antipsychotic) 0.25 mg, Klonopin (anticonvulsant) 0.5 mg, Sertraline HCL (antidepressant) 100 mg, Lanoxin (heart arrhythmia medication), Metoprolol (antihypertensive) Succ ER (Extended Release) 25 mg, Lasix (diuretic) 40 mg, Aspirin 81 mg, Clopidogrel (antiplatelet to prevent blood clots) 75mg, and Meclizine (antihistamine) 25 mg, Cranberry Tablet 450 mg, and Artificial Tears 2 drops in both eyes. Review of fourteen (14) facility Medication Error Reports dated 12/14/15 revealed Resident #1 was given Resident #2's medications in error during the morning medication pass by MA A. The Medication Error Reports revealed that the medications were not prescribed for Resident #1, but she was given another resident's medications. The Report revealed Resident #1 was sent to the emergency room . During an interview on 12/15/15 at 9:30 AM, the Administrator stated that they were still working on the investigation into the medication errors. She stated that MA A had given Resident #2's medications to Resident #1. The Administrator stated that Resident #1 had been sent to the hospital on [DATE] as soon as the Charge Nurse was made aware of the error. During an interview on 12/15/15 at 9:30 AM, the Director of Nurses (DON) stated that MA A was passing medications yesterday (12/14/15) morning and gave medications ordered for Resident #2 to Resident #1. The DON stated that when Resident #2 came to the medication cart and stated to MA A that she needed her medications she realized what she did and she went to the charge nurse, RN B and told her. The DON stated that Resident #1 was assessed and EMS was called and she was sent to the hospital.The DON stated that the MA had been working at the facility for approximately one and half months. She stated that she immediately started an investigation and MA A was removed from the floor. She stated that in-services on resident identifaction had been started with staff. She did not indicate at that time that the MAR had been updated with new pictures or that the PRN (as needed/part time staff) would be in-serviced before they were allowed to pass medications. During an interview on 12/15/15 at 9:50 AM, RN B stated that on 12/14/15 at 7:45 AM MA A reported that she had made a medication error. RN B stated that when she asked which medication the MA told her all of them. RN B stated that MA A stated that when Resident #2 came up to the medication carts to ask about her medication she realized she had given Resident #1 the wrong medications. RN B stated she assessed Resident #1 and her B/P was 80/58 and she called EMS and sent her to the emergency room . RN B stated that she notified the DON and that she pointed out to the DON and the Administrator that both residents had the same first names, the same middle initial and their last names were similar in that they started with the same letter. RN B stated that Resident #1 had been lethargic since Friday and they had obtained a urinary analysis with a culture and sensitivity. She stated that Resident #1 was on a maintenance dose of antibiotic for chronic Urinary Tract Infections. She stated that Resident #1's Primary Physician office nurse called the facility as she was getting ready to report the medication error to them. RN B stated that the physician's office was calling to give them an order for [REDACTED]. RN B stated she was not familiar with all the residents so she was unable to identify Resident #1 when she was asked by MA A to identify the resident. During an interview on 12/15/15 at 1:28 PM, MA A stated that she was passing medications yesterday (12/14/15) morning. She stated that she was still learning the resident's names. A resident came to her medication cart and she did not recognize her and the resident spoke very softly and was unable to clearly say her name. MA A stated that she asked the Charge Nurse (RN B) to identify the resident and RN B told her she didn't know the identity of the resident. She then asked CNA C who the resident was using first name and last name of Resident #2. CNA C stated that yes it was Resident #2. MA A stated she checked the MAR for Resident #2 and there was no picture of the resident. She stated she administered the medications to Resident #1 thinking the CNA had correctly identified the resident. MA A stated that a few minutes later Resident #2 came to the medication cart and asked about her medications and identified herself by name (Resident #2). She stated she immediately went through the MAR and looked at several different residents' pictures until she saw Resident #1's picture. MA A stated, I knew I had given the wrong medications to a resident and I went to the Charge Nurse and reported it immediately. MA A stated that some of the MARs have pictures of residents but a few do not. When asked what she had been taught about identifying a resident before giving medications she stated I was told to look at their picture in the MAR and ask the resident their name and, if they could not tell me, to ask the charge nurse or another staff member to identify them. During an interview on 12/15/15 at 2:15 AM, the DON stated that Resident #2 did not miss any of her medication dosages. Review of the facility PassPort Transaction Log for dispensing medications revealed that the individual dosages for the medications that were given in error were dispensed between 7:03 AM and 7:04 AM. Duplicate dosages for these medications were dispensed between 7:54 AM and 8:08 AM and were administered to Resident #2. During an interview on 12/15/15 at 8:25 AM, CNA C stated that she did tell MA A that Resident #1 was the wrong Resident (Resident #2). I now realize, if I wasn't absolutely positive I should have said I don't know. She stated that the two residents' first names are the same. She stated, I guess I was so busy helping a resident to the dining room I didn't really hear the last name very clearly. CNA C stated, I'm so sorry this happened. Review of Nursing 2016 Drug Handbook revealed the following: A. Methadone Hydrochloride: Therapeutic class: Opioid analgesics Adverse Reactions: CV (Cardiovascular): arrhythmias, bradycardia, cardiac arrest, shock, heart failure; Respiratory: respiratory arrest, respiratory depression, pulmonary edema. B. Hydrocodone bitrate-acetaminophen (Norco) Pharmacologic class: Opioid analgesics Adverse Reactions: CV: bradycardia, cardiac arrest, circulatory collapse, Respiratory: respiratory depression, acute airway obstruction. C. Metoprolol: Therapeutic class: Antihypertensives Adverse Reactions: CV: hypotension, bradycardia, heart failure, edema, palpitations. Review of a current facility policy revised April 2010 Administering Medications reflected the following elements: 5. The individual administering medications must verify the resident ' s identity before giving the resident his/her medications. Methods of identifying the residents include: a. Checking identification band; b. Checking photograph attached to medical record; c. Calling resident by name; and d. If necessary, verifying resident identification with other facility personnel. The facility Administrator and DON were notified on 12/15/15 at 2:25 PM that an Immediate Jeopardy (IJ) had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 12/15/15 at 4:50 PM. The final Plan of Removal was accepted by the surveyor/investigator on 12/15/15 at 5:10 PM. The plan of removal included the following: In-service with Staff on the 6 resident rights on medication pass, i.e. right resident, right medication, etc. started Monday, 12/14/14 to be completed by 12/21/15. In-service given by the In-service Nurse. In serviced staff on checking picture ID on the MAR by the In-service Nurse Monday, 12/14/15 to be completed by 12/21/15. All medication aides and nurses will not be allowed to administer medication until after their in-service. Medication Aide was removed off medication cart on Monday, 12/14/15 pending investigation and scheduled for extensive retraining on Thursday, 12/17/15. Audits were performed by ADONs (Assistant Director of Nurses) on Monday, December 14, 2015 to ensure proper identification and that processes (checking identification band, checking photograph attached to medical record, calling resident by name and if necessary, verifying resident identification with other facility personnel) were in place. This to include all charts and MARS books. Audit started and completed on Monday, December 14, 2015. Residents being reviewed by DON for possible name similarities/location on Tuesday, December 15, 2015. This is to be completed no later than Friday, December 18, 2015. Residents found with name similarities, their charts, MARS and TARS will be flagged. In-service with All departments by the In-service Nurse on Patient Identification started Monday, December 14, 2015 to be completed by 12/21/15. In-servicing Admission Department by DON on taking pictures of new residents and giving to nurse for placement in MARS, TARS and chart to be completed by Wednesday, December 16, 2015. Resident #1 is to move to 100 hall with son ' s permission due to name similarities on 400 hall upon resident ' s return from hospital. Admissions and Social Service in serviced by DON on room assignments for name similarities, Tuesday, December 15, 2015. Director of Nursing or designee to monitor all above processes once a week for three months and quarterly thereafter. Administrator to provide oversight to Director of Nursing or designee monthly and will report any and all findings to monthly QAA. Next QAA meeting is to be held Thursday, December 17, 2015. The surveyor monitored the current plan of removal as follows: During an interview on 12/15/15 at 2:35 PM, RN K (Inservice Nurse) stated that she written the inservice on the 6 rights and had started inservices on 12/14/15. During interviews on 12/15/15 between 2:40 PM, MA D, MA E, MA F stated they had been in-serviced on the importance of identifying residents correctly yesterday (12/14/15). During an interview on 12/16/15 at 8:25 AM, the DON stated that all staff had been inserviced per the Plan of Removal. She stated that all audits had been completed. Record reviews of facility MARS revealed each resident had a picture in the MARS to help with identification. During interviews on 12/16/15 between 8:50 AM and 9:10 AM, RN B, MA A, CNA C, MA G, MA H, MA I, CNA J, SW (Social Worker), Housekeeper, and Medical Records Supervisor stated they had been in-serviced on the importance of identifying residents correctly. On 12/16/15 at 9:15 AM, the Administrator and DON were informed the IJ was lowered. However, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated due to the facility administration and staff requiring time to train all staff and monitor their plan of removal. The Resident Roster identified 37 residents on the 400 Hall who receive medications from facility staff.

Based on observation, interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of thirteen (13) residents reviewed for abuse/neglect. (Resident #1) Resident #1 experienced a [MEDICAL CONDITION] and first complained of leg pain at 4:50 AM on 7/9/14. The facility did not thoroughly assess pain or administer pain medication until 8:00 AM on 7/9/14. This deficient practice affected Resident #1, and placed 52 residents identified on a pain management program at risk for unrelieved pain. Findings include: Review of Resident #1's Face Sheet revealed a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set Assessment ((MDS) dated [DATE] revealed that she required extensive physical assistance of one person for bed mobility, transfers and toileting, and her balance was only steady with physical assist by staff to stabilize. Review of an x-ray report obtained of Resident #1's left hip revealed the following: Date of Service: 7/9/14 Exam Reason: Acute Pain Findings: Diffuse osteopenia is noted. An acute superiorly displaced subcapital [MEDICAL CONDITION] femoral neck (broken hip bone) is noted with no other fractures or subluxations identified. Impression: Acute subcapital [MEDICAL CONDITION] femoral neck. Reported at 10:59 AM. Observation on 7/21/14 at 9:30 AM revealed Resident #1 resting in bed with an abductor pillow ( a medical recovery device most commonly used to keep the legs stable after hip surgery) secured to her legs. Resident #1 reported to the surveyor that she had fallen, and had a lot of pain to her leg. She could not recall when or where she had fallen. Review of the facility 24 hour report/change of condition report dated 7/9/14 revealed the following entries for Resident #1: Remarks (night) 10 PM to 6 AM: Complained of leg pain 5:30 AM. Remarks (day) 6 AM to 2 PM: Sent to local hospital emergency room at 11:45 AM due to possible fall. Fractured left hip and acute pain. Review of Nurse's Notes dated 7/9/14 on Resident #1's chart revealed the following: 8:00 AM Resident complained of pain to general body and back, legs, knees. Instructed Certified Nurse Aide (CNA) to leave resting in bed for now and medicated times one for pain. Will continue to monitor. 9:00 AM Resident continues to complain of pain, grimaces and screams with touch to back, legs and to knees. Resident noted grabbing at left hip and knee. Doctor called, made aware of assessment findings. New order for stat x-ray of left hip and knee. Review of a Pain Management Flowsheet for Resident #1 dated July, 2014 revealed the following: 7/9/14 at 8:00 AM Pain rating at an 8 (on 1-10 scale). Medicated with two 325mg Tylenol tablets. Resident behaviors: Moaning and yelling. 9:00 AM Pain rating after intervention: at a 7 (on 1-10 scale). Comments: Resident still hurting. Review of a facility investigation report dated 7/10/14 revealed the following written statements: CNA E: I worked 7/8/14 on the 10 PM to 6 AM shift. I put Resident #1 to bed. After my break at 3:30 AM, I did a walk through and everyone was in bed. I started last rounds at 4:50 AM. When I got to Resident #1, she was in bed saying she was hurting. Licensed Vocational Nurse (LVN) B was walking by, so I stopped her and told her. She said she would check and see what Resident #1 had for pain. So I did not take Resident #1 to the toilet. I just changed her in bed instead. I did report to the nurse. LVN B: At 5:30 AM while making rounds, I found Resident #1 lying on her left side with her legs, below the knee, dangling over the right side of her bed. She looked uncomfortable and so I lifted her legs up to the bed. She complained of leg pain at this time, which I attributed to the position she'd been lying in. I believed that in a position with her legs now up on the bed, that she would begin to feel better. I checked her meds (medication orders) and noted that she had an as needed Tylenol, which I felt would not be effective enough, so I wrote down her complaints of leg pain on the 24 hour report in order that if she continued to complain, the 6-2 (day shift) could acquire a doctor's order for a stronger pain med for her. During a telephone interview on 7/23/14 at 11:10 AM, Resident #1's primary care physician stated, "With Resident #1's advanced [MEDICAL CONDITION], she could have sustained a fracture simply by standing up. Makes me wonder if the resident was minimizing her pain, or if staff asessed her fully; they should have assessed her more fully between the first complaints of pain and subsequent complaints. I would not want to wait 3 hours to get something for pain if I was hurting." During a telephone interview on 7/22/14 at 1:20 PM, CNA E stated that she put Resident #1 to bed about midnight on 7/9/14. She did routine checks during the night and Resident #1 was in her bed sleeping. About 4:50 AM, she was getting Resident #1 up to go the the bathroom. As she got Resident #1 into a standing (weight bearing) position; she cried out, 'Oh, oh, I'm hurting.' CNA E said she had never heard the resident cry out like that before. So she provided incontinent care in the bed. Resident #1 was hollering out in pain, when she rolled her side to side to clean her up. CNA E told her charge nurse (LVN B) that something was wrong. Resident #1 was hollering, and shouting that she was hurting and bending over. I told LVN B I had never seen her do that, and saying she was hurting. The nurse said she was going to see what she had for pain. It really scared me, that Resident #1 started yelling and saying she hurt so bad. I stood there at the nurse's station until LVN B checked and said Resident #1 had an order for [REDACTED]. During a telephone interview on 7/22/14 at 2:40 PM, LVN B stated that Resident #1 was up later that night (7/9/14) as her spouse (who was also her roommate) was in the hospital. The CNA did routine incontinent care for her and did not report anything unusual. At about 5:30 AM during rounds, I saw Resident #1 in bed, with her legs dangling off from the knee down. She said her legs hurt. I thought the pain was due to her legs dangling, and began putting her legs back on the bed by myself. She moaned and groaned, but did not scream. I thought the pain was from the poor positioning. I know if my legs had been dangling like that, I would have hurt. CNA E was walking by and came in to help me. Resident #1 said she was hurting, but I didn't think it was a high degree of pain. I went to check to see what she had for pain meds. I saw she had Tylenol, but didn't think the Tylenol would be the best pain medication for muscle pain from her legs dangling. I had no inkling she might have fallen; there was no reason for me to think she had a fracture. I told the oncoming day shift RN (at 6:00 AM) that I found her with her legs dangling off the bed, and she might need to get her something for pain. I didn't have time to do a better assessment. During an interview on 7/23/14 at 9:00 AM, CNA F stated that she came in to work about 6:15 AM on 7/9/14, and heard Resident #1 screaming. When I went into her room, Resident #1 told me she was in pain. I did not get her up because if I just touched her, she started screaming. I told the nurse then that something was wrong, and I told her she was in pain a few times and again at about 7:00 AM. After breakfast, about 8:30 AM, I called CNA G into Resident #1's room to help me get her up. When I tried to get her up she was screaming. I told CNA G to get the nurse. During an interview on 7/21/14 at 11:30 AM, Registered Nurse (RN) C stated that she can't remember for sure if, during change of shift at 6:00 AM on 7/9/14, LVN B reported that Resident #1 complained of leg pain on the night shift. She did go back and check the 24 hour report and noted LVN B had recorded the complaint of leg pain at 5:30 AM. Then she remembers that about "sevenish" (7:00 AM on 7/9/14) an aide came and said Resident #1 was yelling out. I told the aide to re-direct her. Her husband (roommate) was in the hospital and I thought Resident #1 was acting out. She wasn't saying she was hurting, she was just yelling out. At about 8:30 AM, they (aides) said she was yelling out, and I went in. She said she was hurting all over, and she was touching her back and knee. She was yelling 'Help me'. That's when I gave her Tylenol. I checked her out. When asked by the surveyor on 7/23/14 at 11:35 AM, how she checked out Resident #1, RN C stated that Resident #1's legs looked the same and her arms were exposed, and they had the same bruising she always had, but RN C did not remove her clothing, nor did she remove her linens to look at her skin or lower extremities. When asked, RN C said she did not palpate (examine a part of the body by feeling with the hands and fingers, especially to distinguish swelling of body parts or pain with touch). I went back about an hour later to check on her and she went to sleep. When she woke up, she was yelling out, and localizing the pain (holding) to her left knee. I called the doctor, and got an order for [REDACTED]. I called the doctor and her family, who wanted her sent to the emergency room . During an interview on 7/22/14 at 8:30 AM, CNA D stated, "I wasn't working with Resident #1 on 7/9/14, but when I walked down the hallway I heard her yelling out. That's not like her. I went in to check on her, and she told me she was in pain. I went and told the nurse that she was in pain. Resident #1 is a quiet woman; she never yelled out like that." During an interview on 7/22/14 at 10:10 AM, the Assistant Director of Nurses ADON) stated that staff reported to her that Resident #1 did not want to go to bed on 7/8/14. Her spouse (roommate) had been sent out to the hospital, so staff were checking on her more frequently. Staff reported they laid her down at 11:30 PM, and she was in the bed through the night. Then about 5:30 AM, she told the nurse she was complaining of leg pain. The nurse repositioned her. Resident #1 is usually quiet, it is not normal for her to yell out. She usually had no behaviors. On 7/23/14 at 11:00 AM, the ADON stated that if staff feel there is a change in condition, she would expect them to do a head to toe assessment checking their skin for color and warmth and their extremities looking for any disalignments. If they have pain, staff should check to see what pain med is available, notify the doctor and if they have pain that is not controlled, get an order to send them out to the hospital. Review of Resident #1's care plan revealed it was updated on 7/9/14 to reflect the following: Resident has [DIAGNOSES REDACTED]. Review of Resident #1's care plan revealed it was updated on 7/12/14 to reflect the following: Resident currently receiving Physical and Occupational Therapy related to [MEDICAL CONDITION] with (surgical) Repair. Review of a facility policy dated 2005 (Revised 2007) titled 'Pain - Clinical Protocol' reflected the following elements: Assessments and Recognition: The physician and staff will identify individuals who have pain or who are at risk for having pain. a. This includes a review of known [DIAGNOSES REDACTED]. c. Such assessments should occur on admission to the facility, at each quarterly review, whenever there is a significant change in condition and at any time pain is suspected. The staff and physician will identify the nature and severity of pain including characteristics (location, intensity, frequency, duration, etc.) The staff and physician will evaluate nonverbal individuals for nonspecific signs and symptoms that could reflect pain; for example, grimacing while being repositioned. Review of a facility completed CMS 672 Form identified 52 residents on a pain management program.