**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for one of three incidents (Resident #1) reviewed for reporting according to facility policy. CNA A failed to follow the facility's policy to report allegations of neglect when she failed to report Resident #1 fell over hitting her shoulder/neck on the bedrail when she reached for the wheelchair during attempted transfer, in which she did not use a gait belt, on 06/12/25. This failure could place the residents in the facility at risk of neglect and lack of timely reporting of incidents. Findings included: Review of Resident #1's face sheet dated 06/14/25 revealed Resident #1 was [AGE] year-old female, admitted to the facility on [DATE]. Review of Resident #1's MDS dated [DATE] revealed Resident #1 had a BIMS score of 00, indicating Resident #1 was not able to complete. Resident #1 utilized a wheelchair, Resident #1 required partial/moderate assistance with lying to sitting on side of bed and chair/bed to chair transfer. The resident's active diagnoses included Non-Alzheimer's Dementia (loss of memory and other intellectual functions), Malnutrition (deficiency of essential nutrients), Anxiety Disorder (intense, excessive and persistent worry and fear about everyday situations), Depression (mood disorder causing persistent feeling of sadness and loss of interest), and Bipolar Disorder (extreme mood swings that include emotional highs). Review of Resident #1's undated care plan reflected Resident #1's activities of daily living functions required extensive assist by 1 staff and gait belt with transfers, locomotion, toileting/hygiene, dressing, and bathing. Limited assist by 1 staff with eating-responsible party request resident in dining room for meals and bed mobility. Goal: Resident #1 will maintain a sense of dignity by being clean, dry, order free, and well groomed. Interventions included Encourage independence, praise when attempts are made. Assist with activities of daily living as needed. Offer tray set-up, assist with verbal cueing/feeding as needed. Review of Resident #1's progress notes written by LVN B reflected: 06/13/25 5:30 PM - Note Text: Resident's Family Member reported to this Nurse that he saw through surveillance camera that Aide who worked 2-10 Pm shift on previous day (6/12/2025) at around 6:11 PM, Aide dropped resident to bed and was stopped by bed rail, resident Family Member suspected that resident might have sustained injuries to right shoulder and right side of neck. Aide did not report to this Nurse about it. This Nurse notified facility DON and Physician; received and carried out STAT X-Ray orders for Right shoulder and Right side of neck. 06/13/25 8:35 PM - Note Text: Local Lab Technician in facility, STAT X-Ray done to Right shoulder and Right side of neck, resident tolerated well, results pending. Family notified via phone call. 06/14/25 6:38 AM - Note Text: Xray resulted: labs sent to MD AWAITING RESPONSE. Review of the facility's grievance report with a date range of March 2025 - June 2025 revealed no grievances regarding Resident #1. Review of the facility's Incident and Accident reports with a date range of March 2025-June 2025 revealed no incidents or accident involving Resident #1. Review of a video footage dated 06/12/25 6:01 PM revealed an aide (later identified as CNA A) assisting Resident #1 with getting dressed with the lights off. Resident #1 was lying flat in bed. CNA lifted Resident #1 up placing her left hand underneath the right back side of her neck, and Resident #1 could be heard saying why are you hurting me old women. Resident #1 was then positioned to be sitting up on the side of the bed while being held by CNA A's left hand to the right side of Resident #1's head. Resident #1's pants were pulled to her hips as she sat on the side of the bed. CNA A then stepped to the Resident's left side to grab the wheelchair that was out of reach. CNA A stepped back placing both hands on Resident #1's shoulder saying, Mama, we are going to dinner. CNA A then tried to pull Resident #1's pants up. Resident #1 then leaned to the right hitting her shoulder/neck on the bedrail.CNA A was observed trying to place her body in position to keep Resident #1 from falling off the bed. CNA A was not using a gait belt during the attempted transfer. Review of Resident #1's Radiology report dated 06/13/26 9:36 PM for Shoulder complete minimum 2 view/Cervical Spine 2 or 3 views. Examination date:06/13/25 6:51 PM Reported Date: 06/13/25 9:36 PM Procedure: Shoulder complete minimum 2 views Interpretation: Reason for Study: Pain in Right shoulder Findings: The right shoulder, clavicle, and scapula demonstrate no acute fracture. No dislocation. Conclusion:1. Mild-moderate right shoulder arthritis. No obvious or acutely displaced fracture on todays provided shoulder views. Interview and observation on 06/14/25 at 9:25 AM Resident #1 was sitting in the television room, yelling out for help, when approached by surveyor Resident #1 started to cry. Resident #1 expressed I can't help it; this is just what happens. Resident #1 revealed she was ok; she was missing family members. Resident #1 revealed she did not recall falling over and hitting the bedrail. Resident #1 was observed with no bruising or skin tears to her right shoulder and neck area. Interview on 06/14/25 at 12:18 PM with LVN B revealed CNA A was working with Resident #1 on 06/12/25 during the second shift. According to LVN B, after asking CNA A to prepare Resident #1 for dinner, she reported to him that Resident #1 was refusing to go to the dining room. LVN B stated he entered the room to assist with encouraging her out of the bed. LVN B stated he was never notified by CNA A that Resident #1 fell over on her right side hitting the bedrail while being dressed and prepared for dinner. LVN B stated on 06/13/25 around 4:00 PM he received a call from Family Member asking why the facility had not followed up about Resident #1 falling onto the bedrail. LVN B stated he replied that he was not notified about a possible injury, and at that point, Family Member requested an x-ray. LVN B stated he reported the information to the DON, the DON stated, he was aware of the situation and to go ahead and call the physician for an order to x-ray. LVN B stated he completed an assessment and notified the doctor, requested an x-ray. LVN B reiterated that he was never notified by CNA A that Resident #1 hit her shoulder or neck on the bedrail. LVN B stated he expected aides to report incidents to him immediately so that he could assess the situation and resident for injuries. LVN B stated he was responsible to report those incidents to the DON, not doing so placed residents at risk of neglect. Interview on 06/14/25 at 12:46 PM with DON revealed he was not aware of the incident until he received messages from Family Member on 06/12/25 at 10:00 PM requesting that an aide be removed from working with Resident #1. The DON stated the Family Member complained that the aide almost dropped Resident #1. After confirming that CNA A was the aide working with Resident #1, the DON stated CNA A reported Resident #1 was not almost dropped. Resident #1 was sitting at the edge of the bed when I reached for the wheelchair. According to the DON, he had not been alerted by staff that Resident #1 had almost been dropped, refused care or that there was an incident involving Resident #1. The DON revealed he had not done anything further concerning this incident after speaking with CNA A. Interview by phone on 06/14/25 at 1:13 PM with CNA A revealed she was asked by LVN B to get Resident #1 out of bed and dressed for dinner. CNA A reported she did not almost drop Resident #1 while preparing her for dinner. CNA A stated she went to prepare Resident #1 for dinner by getting her dressed while she was in bed. CNA A stated, I sat Resident #1 up on the side of the bed, supporting Resident #1 with my body, the wheelchair was not in reach, so I had to reach for it. At that time, she did not want to transfer so I laid her back down on the bed. CNA stated she went to alert LVN B, and they returned to the room together to encourage her to get up for dinner. According to CNA A, she had not had any training from the facility on appropriate way to transfer/assist residents when transferring. During observation and interview with CNA on 06/14/25 at 2:30 PM, video footage of Resident #1 was reviewed. CNA A confirmed she was in the video providing care to Resident #1. CNA A stated, I'm not going to lie. I did not inform the nurse of the incident. I laid her [Resident #1] back down. CNA A stated she was supposed to report this incident to the nurse; however, she did not. CNA A stated she was not aware Resident #1 hit her head on the bedrail; however, she heard the resident say she did not want to eat, so she laid Resident #1 in bed and went to inform the nurse that Resident #1 refused to eat. According to CNA A, not reporting incidents placed residents at risk of not getting the care they required. She stated it was her responsibility to report everything to the nurse. During observation and interview with the DON on 06/14/25 at 2:39 PM, video footage of Resident #1 was reviewed. The DON revealed Resident #1 was sat up on the side of the bed by CNA A, who supported Resident #1's head with her left hand. When CNA A went to reach for the wheelchair without a gait belt, Resident #1 fell over unto the rail. The DON stated all aides were expected to use a gait belt when transferring residents. The DON stated he expected the aide to have reported the incident to the nurse, and the nurse to have notified him. The DON stated he would have completed an in-service with staff. During observation and interview with the Administrator on 06/14/25 at 3:20 PM, video footage of Resident #1 was reviewed. The Administrator revealed she was not aware of the incident or video. The Administrator stated observation of the video revealed CNA A was getting Resident #1 up in the wheelchair, and Resident #1 slumped over and hit her neck area on the side rail. The Administrator stated she expected the aide to have reported this incident to the nurse, the nurse should then investigate and complete incident report, pain assessment, x-ray if needed and complete neuro checks or at least follow up on her. The Administrator stated not reporting the incident placed residents at risk of injuries and neglect. Review of the facility's Accidents and Incidents-Investing and Reporting policy, dated July 2017, reflected: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . Review of the facility's Abuse Prohibition Protocol policy, dated August 2024, reflected: . The Patient has the right to be free from abuse, neglect, misreatmentof resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required in treatin the Patient's symtoms. . Our Facility will not condone Patient abuse or neglect by anyone, including staff members . . the Executive Director, or in his/her absence, the Director of Nursing, will perform the duties of the Abuse Prevention Coordinator. . The Abuse Prevention Coordinator will assure that all Facility staff is in-serviced on recognizing abuse, abuse prevention and abuse reporting upon employment, and as necessary to maintain an abuse free environment . .The Charge Nurse will immediately examine the Patient and notify the Abuse Prevention Coordinator upon receiving reports of mental, physical or sexual abuse. Findings of the examination will be recorded in the Patient's medical record. (Protection) .The Abuse Prevention Coordinator will: Immediately (within 2 hours) report to the State agency and other appropriate authorities incidents of Patient Abuse as required under applicable regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to The State agency and other appropriate authorities as required under applicable regulations and regulatory guidance. Immediately (within 24 hours) suspend the employee for an abuse allegation until an investigation is completed. Conduct and document on a Patient Abuse Investigation (see Form 3-5) a thorough investigation of each incident of Patient Abuse, neglect, exploitation or mistreatment to include: observations, interviews and reviews of all Patient's involved interviews of all witnesses, including Patients, staff and family members notifying physicians notifying families and responsible parties of the involved Patient's recording all relevant physical findings. Complete an appropriate assessment of all Patient's involved Take all steps necessary to protect the Facility's Patients from further incidents of Patient Abuse, neglect, exploitation or mistreatment while the investigation is in progress. Be responsible for carrying out any interventions or follow-up steps subsequent to the investigation of any abuse or alleged abuse, neglect, exploitation or mistreatment. (Investigation) .The Facility will provide orientation and regular in-services to employees on abuse prevention practices

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator of the facility for 1 of 3 residents (Resident #1) reviewed for reporting abuse and neglect. The facility failed to report an incident to HHSC involving CNA A failing to perform a safe, proper transfer using a gait-belt for Resident #1 which resulted in the resident bumping against the siderail. The failure placed residents at risk of injuries and neglect of care. Findings included: Review of Resident #1's face sheet dated 06/14/25 revealed Resident #1 was [AGE] year-old female, admitted to the facility on [DATE]. Review of Resident #1's MDS dated [DATE] revealed Resident #1 had a BIMS score of 00, indicating Resident #1 was not able to complete. Resident #1 utilized a wheelchair, Resident #1 required partial/moderate assistance with lying to sitting on side of bed and chair/bed to chair transfer. The resident's active diagnoses included Non-Alzheimer's Dementia (loss of memory and other intellectual functions), Malnutrition (deficiency of essential nutrients), Anxiety Disorder (intense, excessive and persistent worry and fear about everyday situations), Depression (mood disorder causing persistent feeling of sadness and loss of interest), and Bipolar Disorder (extreme mood swings that include emotional highs). Review of Resident #1's undated care plan reflected Resident #1's activities of daily living functions required extensive assist by 1 staff and gait belt with transfers, locomotion, toileting/hygiene, dressing, and bathing. Limited assist by 1 staff with eating-responsible party request resident in dining room for meals and bed mobility. Goal: Resident #1 will maintain a sense of dignity by being clean, dry, order free, and well groomed. Interventions included Encourage independence, praise when attempts are made. Assist with activities of daily living as needed. Offer tray set-up, assist with verbal cueing/feeding as needed. Review of Resident #1's progress notes written by LVN B reflected: 06/13/25 5:30 PM - Note Text: Resident's Family Member reported to this Nurse that he saw through surveillance camera that Aide who worked 2-10 Pm shift on previous day (6/12/2025) at around 6:11 PM, Aide dropped resident to bed and was stopped by bed rail, resident Family Member suspected that resident might have sustained injuries to right shoulder and right side of neck. Aide did not report to this Nurse about it. This Nurse notified facility DON and Physician; received and carried out STAT X-Ray orders for Right shoulder and Right side of neck. 06/13/25 8:35 PM - Note Text: Local Lab Technician in facility, STAT X-Ray done to Right shoulder and Right side of neck, resident tolerated well, results pending. Family notified via phone call. 06/14/25 6:38 AM - Note Text: Xray resulted: labs sent to MD AWAITING RESPONSE. Review of the facility's grievance report with a date range of March 2025 - June 2025 revealed no grievances regarding Resident #1. Review of the facility's Incident and Accident reports with a date range of March 2025-June 2025 revealed no incidents or accident involving Resident #1. Review of a video footage dated 06/12/25 6:01 PM revealed an aide (later identified as CNA A) assisting Resident #1 with getting dressed with the lights off. Resident #1 was lying flat in bed. CNA lifted Resident #1 up placing her left hand underneath the right back side of her neck, and Resident #1 could be heard saying why are you hurting me old women. Resident #1 was then positioned to be sitting up on the side of the bed while being held by CNA A's left hand to the right side of Resident #1's head. Resident #1's pants were pulled to her hips as she sat on the side of the bed. CNA A then stepped to the Resident's left side to grab the wheelchair that was out of reach. CNA A stepped back placing both hands on Resident #1's shoulder saying, Mama, we are going to dinner. CNA A then tried to pull Resident #1's pants up. Resident #1 then leaned to the right hitting her shoulder/neck on the bedrail. CNA A was observed trying to place her body in position to keep Resident #1 from falling off the bed. CNA A was not using a gait belt during the attempted transfer. Review of Resident #1's Radiology report dated 06/13/26 9:36 PM for Shoulder complete minimum 2 view/Cervical Spine 2 or 3 views. Examination date:06/13/25 6:51 PM Reported Date: 06/13/25 9:36 PM Procedure: Shoulder complete minimum 2 views Interpretation: Reason for Study: Pain in Right shoulder Findings: The right shoulder, clavicle, and scapula demonstrate no acute fracture. No dislocation. Conclusion:1. Mild-moderate right shoulder arthritis. No obvious or acutely displaced fracture on todays provided shoulder views. Interview and observation on 06/14/25 at 9:25 AM Resident #1 was sitting in the television room, yelling out for help, when approached by surveyor Resident #1 started to cry. Resident #1 expressed I can't help it; this is just what happens. Resident #1 revealed she was ok; she was missing family members. Resident #1 revealed she did not recall falling over and hitting the bedrail. Resident #1 was observed with no bruising or skin tears to her right shoulder and neck area. Interview on 06/14/25 at 12:18 PM with LVN B revealed CNA A was working with Resident #1 on 06/12/25 during the second shift. According to LVN B, after asking CNA A to prepare Resident #1 for dinner, she reported to him that Resident #1 was refusing to go to the dining room. LVN B stated he entered the room to assist with encouraging her out of the bed. LVN B stated he was never notified by CNA A that Resident #1 fell over on her right side hitting the bedrail while being dressed and prepared for dinner. LVN B stated on 06/13/25 around 4:00 PM he received a call from Family Member asking why the facility had not followed up about Resident #1 falling onto the bedrail. LVN B stated he replied that he was not notified about a possible injury, and at that point, Family Member requested an x-ray. LVN B stated he reported the information to the DON, the DON stated, he was aware of the situation and to go ahead and call the physician for an order to x-ray. LVN B stated he completed an assessment and notified the doctor, requested an x-ray. LVN B reiterated that he was never notified by CNA A that Resident #1 hit her shoulder or neck on the bedrail. LVN B stated he expected aides to report incidents to him immediately so that he could assess the situation and resident for injuries. LVN B stated he was responsible to report those incidents to the DON, not doing so placed residents at risk of neglect. Interview on 06/14/25 at 12:46 PM with DON revealed he was not aware of the incident until he received messages from Family Member on 06/12/25 at 10:00 PM requesting that an aide be removed from working with Resident #1. The DON stated the Family Member complained that the aide almost dropped Resident #1. After confirming that CNA A was the aide working with Resident #1, the DON stated CNA A reported Resident #1 was not almost dropped. Resident #1 was sitting at the edge of the bed when I reached for the wheelchair. According to the DON, he had not been alerted by staff that Resident #1 had almost been dropped, refused care or that there was an incident involving Resident #1. The DON revealed he had not done anything further concerning this incident after speaking with CNA A. Interview by phone on 06/14/25 at 1:13 PM with CNA A revealed she was asked by LVN B to get Resident #1 out of bed and dressed for dinner. CNA A reported she did not almost drop Resident #1 while preparing her for dinner. CNA A stated she went to prepare Resident #1 for dinner by getting her dressed while she was in bed. CNA A stated, I sat Resident #1 up on the side of the bed, supporting Resident #1 with my body, the wheelchair was not in reach, so I had to reach for it. At that time, she did not want to transfer so I laid her back down on the bed. CNA stated she went to alert LVN B, and they returned to the room together to encourage her to get up for dinner. According to CNA A, she had not had any training from the facility on appropriate way to transfer/assist residents when transferring. During observation and interview with CNA on 06/14/25 at 2:30 PM, video footage of Resident #1 was reviewed. CNA A confirmed she was in the video providing care to Resident #1. CNA A stated, I'm not going to lie. I did not inform the nurse of the incident. I laid her [Resident #1] back down. CNA A stated she was supposed to report this incident to the nurse; however, she did not. CNA A stated she was not aware Resident #1 hit her head on the bedrail; however, she heard the resident say she did not want to eat, so she laid Resident #1 in bed and went to inform the nurse that Resident #1 refused to eat. According to CNA A, not reporting incidents placed residents at risk of not getting the care they required. She stated it was her responsibility to report everything to the nurse. During observation and interview with the DON on 06/14/25 at 2:39 PM, video footage of Resident #1 was reviewed. The DON revealed Resident #1 was sat up on the side of the bed by CNA A, who supported Resident #1's head with her left hand. When CNA A went to reach for the wheelchair without a gait belt, Resident #1 fell over unto the rail. The DON stated all aides were expected to use a gait belt when transferring residents. The DON stated he expected the aide to have reported the incident to the nurse, and the nurse to have notified him. The DON stated he would have completed an in-service with staff. During observation and interview with the Administrator on 06/14/25 at 3:20 PM, video footage of Resident #1 was reviewed. The Administrator revealed she was not aware of the incident or video. The Administrator stated observation of the video revealed CNA A was getting Resident #1 up in the wheelchair, and Resident #1 slumped over and hit her neck area on the side rail. The Administrator stated she expected the aide to have reported this incident to the nurse, the nurse should then investigate and complete incident report, pain assessment, x-ray if needed and complete neuro checks or at least follow up on her. The Administrator stated not reporting the incident placed residents at risk of injuries and neglect. Review of the facility's Accidents and Incidents-Investing and Reporting policy, dated July 2017, reflected: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . Review of the facility's Abuse Prohibition Protocol policy, dated August 2024, reflected: . The Patient has the right to be free from abuse, neglect, misreatmentof resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required in treatin the Patient's symtoms. . Our Facility will not condone Patient abuse or neglect by anyone, including staff members . . the Executive Director, or in his/her absence, the Director of Nursing, will perform the duties of the Abuse Prevention Coordinator. . The Abuse Prevention Coordinator will assure that all Facility staff is in-serviced on recognizing abuse, abuse prevention and abuse reporting upon employment, and as necessary to maintain an abuse free environment . .The Charge Nurse will immediately examine the Patient and notify the Abuse Prevention Coordinator upon receiving reports of mental, physical or sexual abuse. Findings of the examination will be recorded in the Patient's medical record. (Protection) .The Abuse Prevention Coordinator will: Immediately (within 2 hours) report to the State agency and other appropriate authorities incidents of Patient Abuse as required under applicable regulations and regulatory guidance. Report events that cause reasonable suspicion of serious bodily injury immediately (within 2 hours) after forming the suspicion to The State agency and other appropriate authorities as required under applicable regulations and regulatory guidance. Immediately (within 24 hours) suspend the employee for an abuse allegation until an investigation is completed. Conduct and document on a Patient Abuse Investigation (see Form 3-5) a thorough investigation of each incident of Patient Abuse, neglect, exploitation or mistreatment to include: observations, interviews and reviews of all Patient's involved interviews of all witnesses, including Patients, staff and family members notifying physicians notifying families and responsible parties of the involved Patient's recording all relevant physical findings. Complete an appropriate assessment of all Patient's involved Take all steps necessary to protect the Facility's Patients from further incidents of Patient Abuse, neglect, exploitation or mistreatment while the investigation is in progress. Be responsible for carrying out any interventions or follow-up steps subsequent to the investigation of any abuse or alleged abuse, neglect, exploitation or mistreatment. (Investigation) .The Facility will provide orientation and regular in-services to employees on abuse prevention practices

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 resident (Resident #1) reviewed for supervision. CNA A failed to safely transfer Resident #1 from her bed to the wheelchair, which resulted in her losing her grasp of the resident and the resident bumping against the siderail. The failure placed residents at risk of injury. Findings included: Review of Resident #1's face sheet dated 06/14/25 revealed Resident #1 was [AGE] year-old female, admitted to the facility on [DATE]. Review of Resident #1's MDS dated [DATE] revealed Resident #1 had a BIMS score of 00, indicating Resident #1 was not able to complete. Resident #1 utilized a wheelchair, Resident #1 required partial/moderate assistance with lying to sitting on side of bed and chair/bed to chair transfer. The resident's active diagnoses included Non-Alzheimer's Dementia (loss of memory and other intellectual functions), Malnutrition (deficiency of essential nutrients), anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), Depression (mood disorder causing persistent feeling of sadness and loss of interest), and bipolar disorder (extreme mood swings that include emotional highs). Review of Resident #1's undated care plan reflected Resident #1's activities of daily living functions required extensive assist by 1 staff and gait belt with transfers, locomotion, toileting/hygiene, dressing, and bathing. Limited assist by 1 staff with eating-responsible party request resident in dining room for meals and bed mobility. Goal: Resident #1 will maintain a sense of dignity by being clean, dry, order free, and well groomed. Interventions included Encourage independence, praise when attempts are made. Assist with activities of daily living as needed. Offer tray set-up, assist with verbal cueing/feeding as needed. Review of Resident #1's progress notes written by LVN B revealed: 06/13/25 5:30 PM - Note Text: Resident's Family Member reported to this Nurse that he saw through surveillance camera that Aide who worked 2-10 Pm shift on previous day (6/12/2025) at around 6:11 PM, Aide dropped resident to bed and was stopped by bed rail, resident Family Member suspected that resident might have sustained injuries to right shoulder and right side of neck. Aide did not report to this Nurse about it. This Nurse notified facility DON and the Physician. Received and carried out STAT X-Ray orders for Right shoulder and Right side of neck. 06/13/25 8:35 PM - Note Text: Local Lab Technician in facility, STAT X-Ray done to Right shoulder and Right side of neck, resident tolerated well, results pending. Family notified via phone call. 06/14/25 6:38 AM - Note Text: Xray resulted: labs sent to MD AWAITING RESPONSE. Review of the facility's Incident and Accident reports with a date range of March 2025-June 2025revealed no incidents or accident involving Resident #1. Review of a video footage dated 06/12/25 6:01 PM revealed aide (later identified as CNA A) assisting Resident #1 with getting dressed, while laying flat in bed, with the lights off. CNA A lifted Resident #1 to sitting position on the side of the bed Resident #1 could be heard saying why are you hurting me old women. Resident #1 was being supported by CNA's left hand to the right side of Resident #1's head. Resident #1's pants were pulled to her hips as she sat on the side of the bed, CNA then steps to the Resident's left side to grab the wheelchair that was out of reach. CNA A stepped back placing both hands on Resident #1's shoulder (which appears that it was attempting to get her attention/or wake her) saying, Mama, we are going to dinner. CNA A then tried to reach behind Resident #1 to pull Resident #1's pants up. Resident #1 then leaned to the right hitting her should/neck on the bedrail. CNA A was observed trying to place her body in position to keep Resident #1 from falling off the bed. CNA A was not using a gait belt during the attempted transfer. Review of Resident #1's Radiology report dated 06/13/26 9:36 PM for Shoulder complete minimum 2 view/Cervical Spine 2 or 3 views. Examination date:06/13/25 6:51 PM Reported Date: 06/13/25 9:36 PM Procedure: Shoulder complete minimum 2 views Interpretation: Reason for Study: Pain in Right shoulder Findings: The right shoulder, clavicle, and scapula demonstrate no acute fracture. No dislocation. Conclusion:1. Mild-moderate right shoulder arthritis. No obvious or acutely displaced fracture on todays provided shoulder views. Interview and observation on 06/14/25 at 9:25 AM Resident #1 was sitting in the television room, yelling out for help, when approached by surveyor Resident #1 started to cry. Resident #1 revealed she did not recall falling over and hitting the bedrail. Resident #1 was observed with no bruising or skin tears to her right shoulder and neck area. Interview on 06/14/25 at 10:12 AM with Family Member revealed Resident #1 has electronic monitoring in her room, and upon reviewing the footage it was observed aide (CNA A) was unprepared and unknowledgeable to work with residents in a nursing facility. According to the Family Member, CNA A was getting Resident #1 dressed for dinner, at such a late time in the day, I feel like they forgot to get her up and was rushing to get her to the dining room. The aide sat Resident #1 up on the side of the bed, without ensuring she was stable, holding Resident #1 by her head while reaching for the wheelchair that was not within reach. Resident #1 fell out of her hands hitting the bedrail. The bed rail was her saving grace. The aide pushed her knee forward to keep her from falling and placed her back in bed, covered her up and left the room. I had not received a call or plan of action from the facility concerning this incident so around 10:00 PM I contacted the DON by text to inform him of the incident and that I did not want this aide to work with Resident #1 anymore. On 06/13/25 around 4:00 PM, I contacted LVN B and asked him about the incident to see if they ordered x-ray, and why have not anyone contacted me, which I was then told he was not aware anything had happened. At this point I requested an x-ray. Review and observation of the message sent to the DON revealed: A video attached to a message that read Hey DON. I do not want this Aide dealing with Resident #1 ever again. She is rough and abrasive, and she appears to have no idea of how to handle an elderly fragile person. She almost dropped Resident #1 because she was holding her by her head and not prepared the chair or herself to transport or move. Another video in the message read I do not know what time dinner was served, but it was 6:11 PM before Resident #1 was gotten out of bed to go to the dining facility. And Resident #1's head and face hit the bed rail in that video. Instead of getting Resident #1 out of the bed, she laid back into the bed. At 6:15 PM, another aide and nurse came to get Resident #1 out of bed. Response from DON revealed: Yes, Sir I will address this. Interview on 06/14/25 at 12:18 PM with LVN B revealed CNA A was working with Resident #1 on 06/12/25 during the second shift. According to LVN B, after asking CNA A to prepare Resident #1 for dinner, she reported to him that Resident #1 was refusing to go to the dining room. LVN B stated he entered the room to assist with encouraging her out of the bed. LVN B stated he was never notified by CNA A that Resident #1 fell over on her right side hitting the bedrail while being dressed and prepared for dinner. LVN B stated on 06/13/25 around 4:00 PM he received a call from Family Member asking why the facility had not followed up about Resident #1 falling onto the bedrail. LVN B stated he replied that he was not notified about a possible injury, and at that point, Family Member requested an x-ray. LVN B stated he reported the information to the DON, the DON stated, he was aware of the situation and to go ahead and call the physician for an order to x-ray. LVN B stated he completed an assessment and notified the doctor, requested an x-ray. LVN B stated again that he was never notified by CNA A that Resident #1 hit her shoulder or neck on the bedrail. LVN B stated he expected aides to report incidents to him immediately so that he could assess the situation and resident for injuries. LVN B stated he was responsible to report those incidents to the DON, not doing so placed residents at risk of neglect and unknown injury. Interview on 06/14/25 at 12:46 PM with DON revealed he was not aware of the incident until he received messages from Family Member on 06/12/25 at 10:00 PM requesting that an aide be removed from working with Resident #1. The DON stated the Family Member complained that the aide almost dropped Resident #1. After confirming that CNA A was the aide working with Resident #1, DON stated she reported Resident #1 was not almost dropped, she was sitting at the edge of the bed when I reached for the wheelchair but decided to place her back in bed. According to the DON he had not been alerted by CNA A or LVN B that Resident #1 had almost been dropped, refused care or that there was an incident involving Resident #1. Interview by phone on 06/14/25 at 1:13 PM with CNA A revealed she was asked by LVN B to get Resident #1 out of bed and dressed for dinner. CNA A reported that she did not almost drop Resident #1 while preparing her for dinner. CNA A stated she went to prepare Resident #1 for dinner by getting her dressed while she was in bed. CNA A stated I sat Resident #1 up on the side of the bed, supporting Resident #1 with my body, the wheelchair was not in reach, so I had to reach for it. At that time, she did not want to transfer so I laid her back down on the bed. CNA A stated she went to alert LVN B, and they returned to the room together to encourage her to get up for dinner. According to CNA A she had not had any training from the facility on resident transfers. During observation and interview with CNA A on 06/14/25 at 2:30 PM, video footage of Resident #1 being assisted in bed was viewed. CNA A confirmed it was her in the video assisting Resident #1. CNA A stated, I'm not going to lie. I did not inform the nurse of the incident. I laid her back down. CNA A stated, I was supposed to report this incident to the nurse, however I did not. CNA A then stated she was not aware that Resident #1 hit her head on the bedrail but heard Resident #1 say I don't want to eat so she then laid her down in bed and went to inform LVN B that Resident #1 refused to eat. During observation and interview with the DON on 06/14/25 at 2:39 PM, video footage of Resident #1 being assisted in bed by CNA A was viewed. The DON revealed Resident #1 was sat up on the side of the bed by CNA A, supporting Resident #1's head with her left hand, when CNA A went to reach for the wheelchair without a gait belt, Resident #1 fell over unto the rail. The DON stated all aides were expected to use a gait belt when transferring residents. During observation and interview with the Administrator on 06/14/25 at 3:20 PM, video footage of Resident #1 being assisted in bed by CNA A was viewed. The Administrator revealed she was not aware of the incident or video. The Administrator stated observation of the video revealed CNA A was getting Resident #1 up in the wheelchair, and Resident #1 slumped over and hit her neck area on the side rail. The Administrator stated she expected the aide to have used a gait belt during the transfer. Review of the facility's TRANSFERS: Method, Equipment and Preparation policy, reflected: .Firm, stable surfaces for patients to move to and from are required for all transfers. Most transfers are made towards the normal or stronger side of the patient, regardless of the cause of the disability. Know the patient's weight bearing status. Give assistance to the patient's weaker side. Use gait belt on all assisted transfers. Patient's shoulder or arms are not appropriate to pull, push or lift upon. Cup your hand under the gait belt for greater control. Plan maneuver before lifting. Keep patient in good alignment. Support the arm or leg as needed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #52) of four residents reviewed for medication errors. The facility failed to ensure potassium (a mineral supplement used to treat or prevent low potassium levels in the blood) was administered to Resident #52 as ordered from 4/10/2025 until 4/23/2025 (13 days). This failure could place residents at risk for not receiving medications as ordered by their physician and not receiving the intended therapeutic benefit of the medications. Findings included: Record review of Resident #52's Quarterly MDS assessment dated [DATE] revealed Resident #52 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), respiratory failure, and vitamin deficiency. Section N of the MDS assessment revealed Resident #52 was taking a diuretic (medication that reduces fluid build up in the body). Section C of the MDS assessment revealed Resident #52 had a BIMs score of 07 (suggested severe cognitive impairment). Record review of Resident #52's care plan revised on 4/10/2025 revealed Resident #52 had health problems and medications should have been administered as ordered. Record review of Resident #52's physician order summary on 4/23/2025, revealed an order was entered on 4/10/2025 to administer two tablets of Potassium Chloride ER 20 mEq one time only then to administer one tablet of Potassium Chloride ER 20 mEq twice a day for low potassium levels. Record review of Resident #52's April 2025 MAR revealed Potassium Chloride ER 20 mEq was signed as administered each day from 4/10/2025 until 4/23/2025 (13 days). In an observation on 4/22/2025 at 9:05 a.m., MA A mixed two packets of Potassium 20 mEq powder with water for a total of 40 mEq of Potassium. MA A ensured Resident #52 drank the entire cup of medicine and left the room. In an interview and observation on 4/23/2025 at 10:23 a.m., MA A stated she had followed the directions on Resident #52's MAR, and it had stated to administer two packets of Potassium 20 mEq powder. MA A looked at Resident #52's MAR on her computer screen and pointed to the medication on the screen. The directions under the medication (Potassium 20 mEq) read Potassium Chloride 20 mEq Packet: Mix 2 packets as directed .more. When MA A was asked to click the more link at the end of the directions, additional directions opened up on the computer screen. The additional directions that opened revealed Potassium Chloride 20 mEq Packet: Mix 2 packets as directed; Take by mouth daily for 1 day then 1 packet twice a day. MA A stated she did not realize that there were additional instructions and that the order changed to one packet of Potassium. MA A stated the order was very confusing, and she had given Resident #52 two packets of Potassium 20 mEq (total of 40 mEq) at the same time every day since 4/10/2025. In an interview and observation on 4/23/2025 at 10:53 a.m., the DON looked at Resident #52's MAR on his computer. The DON stated he did not know why the MAR was showing to administer packets of potassium when tablets were ordered. The DON looked at Resident #52's medication history, and stated she was taking packets of potassium previously. The DON confirmed the entire directions for the Potassium did not show unless the more option was clicked. The DON reported the nurse managers were responsible for monitoring the medication orders and ensuring the medication orders matched the residents' MARs. The DON stated they changed from one computer charting system to a new system in February and were still learning the new system. The DON stated the expectation was that nursing staff would administer medications correctly. The DON reported the risk to the resident was that if the wrong dose of potassium was given was that they could have developed hyperkalemia (high potassium levels). The DON did not state how high potassium levels could affect the resident. In an interview on 4/23/2025 at 12:23 p.m., the MD reported a stat potassium level (immediate lab) was ordered due to the wrong dose of potassium that was given. The MD stated the risks to the resident from receiving the wrong dose of potassium was that the potassium level could be too high. The MD stated he expected staff to administer medications as ordered and follow the directions. Record review of Resident #52's lab results dated 4/23/2025 revealed Resident #52's potassium level was 3.9 and normal range was from 3.5 to 5.1. Record review of facility policy titled Administering Medications, with a revision date of April 2019, revealed Medications are administered in accordance with prescriber orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for one (the only medication room) of one medication rooms reviewed for pharmacy services. The facility failed to ensure expired medication administration supplies were removed from the only facility medication room. These failures could place residents at risk for infection and having possible adverse effects. Findings included: In an interview and observation on [DATE] at 11:23 a.m., expired supplies found stored in the medication room included: 1 - box of 100 count insulin syringes that expired on [DATE] 5 - boxes of 100 count tuberculin syringes that expired on [DATE] The DON was present and stated Central Supply is responsible for monitoring the expiration dates of supplies in the medication room. The DON reported he thought the central supply person checked the dates monthly. The DON stated he expected there not to be any expired supplies in the medication room and was not sure what the risks to the residents would be. In an interview on [DATE] at 9:43 a.m., the DON reported Central Supply was providing transportation to residents and was not available for an interview at this time. The DON reported all expired supplies were removed from the medication room. Record review of facility policy titled Medication Labeling and Storage, with a revision date of February 2023, revealed 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety in the facility's kitchen, reviewed for food safety. 1. The facility failed to correctly label and date 4 storage bags of cheese. 2. The facility failed to correctly label a cart of water and juice stored in the refrigerator. 3. The facility failed to label and date packages of opened bread. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observation of the dry storage room in the kitchen on 04/22/2025 at 9:40 a.m. revealed a tray with 3 open packages of bread. There were no dates on the open packages. Observation of the walk in refrigerator on 04/22/2025 at 9:46 a.m. revealed a cart with prepared water and juice with no creation or discard dates on the tray or containers. Observation of a the walk in refrigerator on 04/23/23/2025 at 11:25 Am revealed several packages of cheese were observed to be open with only the received date on the packaging. In an interveiw with the [NAME] on 04/22/2025 at 9:46 a.m. she stated that someone put the beverage cart in the refrigerator before she got a chance to put a label on the trays. She stated they all watch for expiration dates and labels. She stated that she tries to make sure everything has a date on it. She stated that she doesnt want any of teh residents to get from anyting coming from the kitchen. In an interview with the DM on 04/22/2025 at 10:15 a.m., he revealed that the bread vendor left the tray of expired bread in the storage room. He took the bread and yelled out the back door for someone to stop the bread man. He stated they usually go by the dates on the packages to determine when to discard out of date bread. He stated that his staff member forgot to put the date on the tray when they poured the water and juice cups. He stated that they were corrected as soon as I left the refrigerator. In an interview and observation with the DM on 04/24/2025 at 11:30 a.m.he stated they usually go by the dates on the packages to know when to discard items. He stated they normally don't last that long. He stated he has a chart in his office with dates detailing how long items should be kept. When looking across the dry storage area packages and boxes of food showed a received date. The DM stated he referred to the chart in his office to know how long each item is kept once its opned. There were 2 packages of opened bread that had no dates on them other than the manufacturers best by date. He stated they were just delivered, but no other dates were included. There were two packages of cheese observed that had been opened and used and they only had the received date on the packages. The DM stated he understood residents could sick from expired food. Record Review of the facility policy Nutrition Services Policy & Proceedurees Food Production & Food Safety Cantex March 2009, Rev 03/2019 revealed 4. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must legible and accurately labeled, including the date the package was opened .13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2-3 days or discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for two (Resident #1 and Resident #2) of four reviewed for resident call system, in that. 1.Resident #1 and Resident #2's call lights were on the floor and not within reach on 10/10/2024. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: Record review of Resident #1's electronic face sheet, printed on 10/10/2024, revealed a [AGE] year-old female who was admitted to the facility 04/24/2024 with diagnoses that included but not limited to dementia (loss of cognitive function), glaucoma (a condition that damages the optic nerve, often due to increased eye pressure, leading to vision loss or blindness), high blood pressure. Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 03, indicating the was severely cognitively impaired. Review of Section GG functional abilities and goals revealed substantial/ maximal assistance needed with eating, oral hygiene, toileting hygiene, shower, dressing, putting on/ taking off footwear and personal hygiene. Record review of Resident #1 s care plan, dated 05/03/2024, reflected, problems that included skin concerns, pain interference with day-to-day activities, communication issues, resident is able to understand others and able to communicate. Record review of Resident #2's electronic face sheet, printed on 10/11/2024, revealed a [AGE] year-old female who was admitted to the facility 01/03/2024 with diagnoses that included but not limited to dementia (loss of cognitive function), chronic kidney disease(involves gradual loss of kidney function), cellulitis of the lower limbs( bacterial skin infection), major depressive disorder(disorder that causes a persistent feeling of sadness and loss of interest) Record review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS score of 03, indicating the was severely cognitively impaired. Review of the MDS revealed section GG functional abilities and goals was not completed. Record review of Resident #2 s care plan, dated 04/26/2024, reflected, problems that included falls related to self-ambulating while unsteady with intervention to include place call light within reach. Observation on 10/10/2024 at 1:15PM revealed Resident #1 and Resident #2's call lights were out of reach. Resident #1's call light was behind the headboard and out of reach. Resident #2's call light was behind the headboard and not within reach. LVN A came inside the room to pass medication however the nurse did not ensure Resident #1 and Resident #2's call lights were within reach before leaving the room. Interview and observation on 10/10/2024 at 1:30PM revealed Resident #1 was observed lying in bed. She stated she was not sure how she would reach staff if she needed them. The call light was handed to Resident #1 and was observed to be working. Observation on 10/10/2024 at 1:35 PM revealed Resident #2 was lying in bed. Attempted interview revealed Resident #2 did not answer any questions and closed her eyes when questions were asked. Interview on 10/10/2024 at 2:25 PM with the Interim Administrator and the DON revealed staff should have been ensuring call lights were within reach each time they went to a resident room. The DON stated the ADON had been in the room during the morning and had ensured the call lights were within reach. The DON stated the family may have moved the call lights since they were at bedside however LVN A should have ensured the call lights were within reach despite the family being in the room. The Interim Administrator revealed the risk of not having call lights withing reach would be that residents may not have been able to alert staff of their needs. Interview on 10/10/2024 at 3:12PM with the ADON revealed she was in Resident #1 and Resident #2's room during the morning and had made sure the call lights were in reach. She stated she helped Resident #2 into her wheelchair and the call light could have fallen behind the bed when she left. The ADON stated staff should have ensured call lights were within reach each time they entered a resident room. The policy regarding call lights was requested from the Interim Administrator on 10/10/2024 at 2:25PM however she stated the facility did not have a policy regarding the call light being within reach.

Based on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments for one (400 hall cart) of four medication carts. The facility failed to lock the 400-hall cart leaving all medications on the carts accessible. These failures could affect all resident by placing them at risk for possible drug diversions. Findings included: Observation on 10/10/2024 at 12:50 PM revealed the 400 hall cart was left unattended and unlocked for approximately one minute. There were no residents observed on the hall. The drawers of the cart were able to be pulled open and all routine medications were accessible. Interview on 10/10/2024 at 12:53 PM LVN A stated she left the cart unlocked due to being called into a resident's room for assistance. LVN A stated she would typically always lock the cart when it was not within eyesight, but she forgot. LVN A stated the 400-hall cart contained all routine medication for the 400 hall. LVN A stated the risk of leaving the medication cart unlocked would be others would have access to the medication. Interview on 10/10/2024 at 2:25 PM with the Interim Administrator and DON revealed the medication carts should have been locked when staff were not within eyesight of the cart. They stated the risk staff not locking the cart would be others could access the medication. The Interim Administrator stated LVN A was still fairly new and she would in- service her regarding medication storage. Review of the facility policy Storage of Medication dated revised April 2007 Compartments (including but not limited to drawers, cabinets, rooms ,refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use and trays or carts used to transport such items may not be left unattended if open or otherwise potentially available to others.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all alleged violations involving abuse, and neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency in accordance with State law through established procedures for one (Resident #1) of three incidents reviewed for reporting. The facility failed to report within 2 hours to the State Survey Agency when Resident #1 had an altercation with LVN A which resulted in Resident#1 falling face first. Resident#1 was transported to the hospital with a major head injury which supports serious bodily injury. These failures could affect place residents by resulting in at risk of a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment. Findings included: Record review of Resident 1's face sheet dated 08/31/24 reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included unspecified Dementia (a group of symptoms affecting memory, thinking and social abilities), Epilepsy (Brain condition that causes recurring seizures), Congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to meet your body's needs) and muscle spasm. Record review of Resident#1's discharged MDS dated [DATE] reflected Resident #1 had a BIMS of 07, which indicated his cognition was severely impaired, and used a manual wheelchair. Record review of Resident #1's care plan dated 09/05/23 reflected problems: walk in corridor [Resident#1] required supervision. Goals: [Resident #1] walk in corridor with supervision and/or cueing as required. Interventions: instruct [Resident#1] to use hand rails and ambulatory assist devices to maintain balance . [Resident#1 call for assistance before walking in the corridor. Record review of Resident #1's incident report dated 07/30/24 at 4:53 AM completed by LVN A reflected: This nurse went into residents' room around ( 0245)to obtain UA prior to lab arrival for pick up. When resident asked for a UA sample resident stated that he was unable to provide a sample. This nurse responded by telling the resident that I could assist him with obtaining the sample. Resident stated no he and set up in the bed and swung his hand at me. This nurse stated to resident that he was confused and that he possibly has a UTI and that w why I was asking for a sample. resident then setup more in the bed where he then punched this nurse in the mouth. This nurse states to the patient that hitting me was unacceptable and that I was not okay to hit the staff. Resident stated that he wanted to do a lot more to me and kicked at me. I stepped back and told resident that he did not have to be physical with me and that I was leaving the room. He shouted I better get out before he did more. As resident jumped out of bed i walked out of the room and closed the door. While walking down the hallway resident opens the door and says there you are and began running towards me. This nurse yelled for assistance stating [Resident#1] was being combative and that he had punched me in the mouth. As resident begin running towards me, he swung and lost his balance and fell face forward to the floor where he hit his head and face . Detail location of injury. Resident has skin abrasions to face, bilateral wrist skin tears. blood from lip and nose Treatment provided by the facility reflected first aid in facility and referred to ER B. Charge nurse interventions post incident:1. Head to toe assessment.2. Administered first aid to assist in stopping the bleeding.3. Resident stabilized and 911 called for assistance.4. Resident transported to the ER for further evaluation. Record review of LVN B witness statement dated 07/30/24 reflected: she heard the nurse yelling for help. Upon getting to the hallway, she saw the resident chasing the nurse down the hallway. Per the employee, the resident noted to have fallen face forward before getting to the nurse. Nurse went to assess the resident and called 911. 911 took the resident to the hospital. Record review of DON statement dated 07/30/24 reflected: At approximately 3:00 AM., I received a call from the charge Nurse [LVN A], in regard to an incident with [Resident#1]. Per [LVN A] she went into the resident's room at 2:45 AM to obtain a urinalysis from the resident due to lab being present to pick it up. Upon entering the room, the nurse asked the resident for a UA sample. The resident voiced to the nurse that he was unable to provide one. Per [LVN A], she advised him that she could assist with obtaining a sample. The resident then sat up in the bed and swung at the nurse. The nurse explained to the resident why she needed to obtain the UA from him. The resident then struck the nurse in the mouth. The nurse expressed to the resident that it was unacceptable. The resident became more upset and told the nurse that he wanted to do more to the resident and started to kick at her. The nurse began leaving the room. He jumped out the bed and came out into the hallway behind the nurse. Nurse states that the resident started running towards her and missed causing him to lose his balance and falling to the floor. The CNA was at the nurse station and saw the resident running towards the nurse. Per [LVN A] the resident did not connect with the nurse and lost his balance and fell face forward to the floor. At that time 911 was called to come and assess the resident as he had some abrasions to his face and arms. 911 came into the facility, assessed, and transported the resident to the ER. [NAME] and ED reviewed the incident, questioned staff as to what was witnessed and what they saw. Witness did not note any physical aggression from the nurse ti the resident as the nurse retreated trying to get away from the resident. The DON and ED reviewed incident/accident as well as the Abuse/Neglect Policy and determined the incident not to be reportable. Outcomes of the investigation determined staff did not abuse the resident and did not meet the criteria for neglect. Record review of hospital records dated 09/03/24 reflected Resident#1 was admitted on [DATE] and was discharged on 08/03/24. Resident#1 impressions reflected: evidence of closes head injury with subarachnoid hemorrhage probably manifested from white matter injury in the periventricular regions. Narrative: CT Trauma head W/O contrast. Findings: Evidence of acute intracranial injury with intraventricular hemorrhage [serious medical condition where bleeding occurs within the brain's ventricular system] probably from shear strain injury [distort and rupture axons, blood vessels and major fibre tacts] the periventricular white matter [white matter that is immediately to the side if the two lateral ventricles of the brain.]regions including a focus of blood along the right lateral ventricle and atrium independently in the right occipital horn. Narrative: CT facial bones w/o contrast Findings: No evidence of facial fracture with significant left supraorbital soft tissue swelling [swelling above the left eye .common causes trauma .] Record review of ED provider notes dated 07/30/24 reflected: Subarachnoid hemorrhage [Bleeding within the subarachnoid, which is the area between the brain and the tissue covering the brain] following injury, no loss of consciousness, initial encounter. Interview on 09/03/24 at 5:35 AM with LVN A who stated she went to Resident#1 room to collect a urine sample from him and stated he could not and punched her in the mouth. LVN A stated that Resident#1 was usually not confrontational, and they suspected he had a UTI. LVN A stated she told the resident that was not appropriate and closed the resident's door and walked out to the nursing station. LVN A stated Resident#1 came out of his room yelling there you are and ran down the hallway. LVN A stated she yelled for help. LVN A stated Resident#1 tried to hit her again and he fell hitting his head and face. LVN A stated the CNA B witness everything and cleaned the blood from Resident#1 face. LVN A stated she did not remember the CNA's name that assisted her. LVN A stated she completed head to toe assessment, called DON, family and doctor. LVN A called 911 to have resident transported to hospital. LVN A stated she reported the incident to the DON and followed the facility fall policy. Interview on 09/03/24 at 7:17 AM with the Regional Director of Operations stated Resident#1 had a fall at the facility because the resident had a change of condition. The Regional Director stated the facility followed the fall and reporting policy correctly. Interview over the phone on 09/03/24 at 7:21 AM with Regional Director of Clinical Services stated that she was responsible for logging the falls and the facility completes the internal investigation. The regional Director of clinical Services stated the DON reported the incident to her and from there they have a meeting and discussed the findings. The regional Director of Clinical services stated they did not feel the incident was related to abuse and did not report it to state. The regional Director of Clinical Services stated they monitor the hospital transfers and based reporting off what is reported. The regional Director of clinical Services stated if an incident accorded that had allegations of abuse it would need to be reported to prevent abuse from happening. Interview over the phone on 09/03/24 at 10:05 AM with the Director of Rehabilitation stated Resident#1 used a walker and would often leave it often. The Director of Rehabilitation stated Resident#1 had a physical and cognitive decline when he came back from the hospital on [DATE]. The Director of Rehabilitation stated she was not sure if Resident#1 could run. Interview on 09/30/24 at 1:30 PM with DON stated Resident#1 had a skin tear to his face and arms and staff called 911 because he had a fall and fell face first. The DON stated they did not know that Resident#1 had a head injury. The DON stated he completed a call with the ED and regional to determine if the incident was reportable and the determination was no. The DON stated if an event was reportable to state, and it does not get report the resident could be at risk for abuse and neglect. Interview over the phone on 09/03/24 at 4:00 PM with CNA B stated that she did remember Resident#1. CNA B stated that she heard about the incident with Resident#1 but was not directly involved. Record review of the facility policy dated titles Reportable incident Protocol External Reportable Incidents: In reporting accidents/incidents, the following protocol must be observed: External Reportable Incidents: In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 1. Ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of patient property, are reported immediately, but no later than 2 hours after allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Executive Director of the facility to other officials (including State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. 4. Report the results of all investigations to the ED or his or her designee and to other officials in accordance with the state law, including the State Survey Agency within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin were reported immediately to the State agency for one (Resident #6) of six residents reviewed for injuries of unknown origin. The facility failed to report to the State Survey Agency on 03/08/24, when Resident #6 was noted with an injury of unknown origin. This failure could place residents at risk for unreported abuse and/or neglect. Findings included: Review of Resident #6's dated 03/11/24 admission Record revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE]. Review of Resident #6's quarterly MDS assessment, dated 05/17/24, revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses including: atrial fibrillation, (irregular pulse), coronary artery disease (clogged up arteries), heart failure (heart not pumping like it should), hypertension (high blood pressure), end stage renal disease (kidneys not working), dialysis (machine assisting to purify the blood and urine), diabetes (increased blood sugar), anxiety disorder (anxious), disorder of bone density (bones not strong), osteoarthritis (bone disease), and osteoporosis (bone disease). The MDS indicated the resident's cognition was severely impaired and unable to make decisions for herself. The resident required the extensive assistance of two staff for activities of daily living. Review of Resident #6's comprehensive care plan, updated 03/11/24, revealed the resident had a care plan goals for osteoarthritis, osteoporosis, and a care plan for risk of injury due to these diagnoses. Further review reflected goals and approaches related to the finger fracture. Review of the nursing progress notes dated 03/08/24 at 2:59 p.m. reflected the family approached LVN A concerning Resident #6's left hand and her finger was swollen, and she was compling of pain. Further review of the nursing progress notes, reflected LVN A assessed the left hand or Resident #6, the fourth digit distal finger of the left hand was swollen and administered pain medication for the pain Resident #6 expressed. LVN A documented she called the physician and got x-ray ordered. It was documented by LVN A the x-rya results for the left hand were positive fracture to the left proximal phalanx of the left finger, the physician assistant and physician were informed, and splint was ordered to apply to the finger. In an interview on 03/20/24 at 3:00 p.m. with LVN A revealed she had been the nurse in charge when Resident #6's family approached her about the swelling in her hand. LVN A stated that she and treatment nurse assessed the finger, there was a small amount of swelling, with no bruising noted on the back side of the ring finger and the resident was expressing pain. I called the physician assistant and the physician, an x-ray was ordered the results came back showing a fracture of her ring finger, I called the physician and the Physician assistant. A splint was ordered, and we taped the two fingers together, while waiting on the splint. I informed the DON that the finger was broken on the same day. Review of an accident/incident report dated 03/08/24 revealed Resident #6's family reported a swollen left ring finger with complaints of pain. This nurse (LVN A) assessed the residents' left hand and noticed swelling at the fourth distal finger. The resident stated she felt pain. Pain medication was administered. Resident stated that she hit her finger while studying by the window. The family stated Resident #6 complained of pain while she was washing her hands. Contacted physician, new orders for x-ray results Findings AP (anterior and posterior) and lateral views of the left hand demonstrate a diffuse osteoporosis (bone disease). The fourth proximal phalangeal (top of fourth finger) oblique (top) fracture is visualized. The pisiform (wrist bone) is laterally subluxed (partial dislocated). The scapholunate (torn ligament) joint is widened. No bony erosion of destruction is present. The soft tissues are unremarkable. There is no radiopaque foreign body (any object that enters the body, that can be seen by x-ray). RP aware. Observation and interview on 03/19/24 at 9:15 a.m. Resident #6 sitting in a wheelchair at the nurse's station, her hand was in a pink cast. Attempts to interview the resident revealed that she thought she had caught her hand in something but could not recall what. The resident smiled and stated but it is doing better now. Review of the Providers Investigation Report dated 03/11/2024 reflected incident category: of an unknown fracture made by the family on 03/11/24. Description of the allegation: reflected that the nurse noticed swelling on the resident's finger. After getting x-rays the finger came back fractured. The next day the family states they watched video and saw a CNA being rough. They denied abuse but she was rough. The family refused to show the video to the facility. (There was no other dates provided in this section) Assessment description: Assessed hand on 03/08/24 after an allegation of rough body assessment on 03/10/24. Provider Action taken post investigation was signed by the Administrator and dated 03/12/24. In an interview on 03/21/24 at 7:45 a.m. with the Administrator revealed she was the facility's abuse prohibition coordinator and responsible for conducting facility investigations. When asked about an investigation of Resident #6's left hand and the broken finger, she stated she had been made aware of the broken finger, it was on a Friday, the eighth of March. The Administrator stated that she had not reported the broken finger separately because then the family had come back on 03/09/24 and stated there was a CNA that was rough with Resident #6 but would not provide the video to me. I guess I got confused and just combined them all because it was the weekend, and I did not call the reports in separately. The Administrator stated she would take that because she understood that the two should have been reported separately, the allegation of injury of unknown origin and the other, allegation of abuse. Review of the facility's abuse prohibition policy/procedure dated April 2019 was provided by the Administrator on 03/19/24 and identified as current, reflected . 6. Accidents and Incidents internally and externally must be reported and investigate in accordance with the Reportable Incident Protocol .The policy/procedure reflected events of injuries of unknown origin would be identified and thoroughly investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for one (Resident #6) of six residents reviewed for injury of unknown origin. The Administrator failed to start thoroughly investigating an injury of unknown origin when Resident #6 was discovered with fracture of proximal phalanx of left ring finger on 03/08/2024. Failure to timely investigate injuries of unknown origin placed residents at risk for unidentified abuse or neglect. Findings included: Review of Resident #6's dated 03/11/24 admission Record revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE]. Review of Resident #6's quarterly MDS assessment, dated 05/17/24, revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses including: atrial fibrillation, (irregular pulse), coronary artery disease (clogged up arteries), heart failure (heart not pumping like it should), hypertension (high blood pressure), end stage renal disease (kidneys not working), dialysis (machine assisting to purify the blood and urine), diabetes (increased blood sugar), anxiety disorder (anxious), disorder of bone density (bones not strong), osteoarthritis (bone disease), and osteoporosis (bone disease). The MDS indicated the resident's cognition was severely impaired and unable to make decisions for herself. The resident required the extensive assistance of two staff for activities of daily living. Review of Resident #6's comprehensive care plan, updated 03/11/24, revealed the resident had a care plan goals for osteoarthritis, osteoporosis and a care plan for risk of injury due to these diagnoses. Further review reflected goals and approaches related to the finger fracture. Review of the nursing progress notes dated 03/08/24 at 2:59 p.m. reflected the family approached LVN A concerning Resident #6's left hand and her finger was swollen, and she was compling of pain. Further review of the nursing progress notes, reflected LVN A assessed the left hand or Resident #6, the fourth digit distal finger of the left hand was swollen and administered pain medication for the pain Resident #6 expressed. LVN A documented she called the physician and got x-ray ordered. It was documented by LVN A the x-rya results for the left hand were positive fracture to the left proximal phalanx (fourth finger, ring finger)of the left hand , the physician assistant and physician were informed, and splint was ordered to apply to the finger. In an interview on 03/20/24 at 3:00 p.m. with LVN A revealed she had been the nurse in charge when Resident #6's family approached her about the swelling in her hand. LVN A stated that she and treatment nurse assessed the finger, there was a small amount of swelling, with no bruising noted on the back side of the ring finger and the resident was expressing pain. I called the physician assistant and the physician, an x-ray was ordered the results came back showing a fracture of her ring finger, I called the physician and the Physician assistant. A splint was ordered, and we taped the two fingers together, while waiting on the splint. I informed the DON that the finger was broken on the same day. Review of an accident/incident report dated 03/08/24 revealed Resident #6's family reported a swollen left ring finger with complaints of pain. This nurse (LVN A) assessed the residents' left hand and noticed swelling at the fourth distal finger. The resident stated she felt pain. Pain medication was administered. Resident stated that she hit her finger while studying by the window. The family stated Resident #6 complained of pain while she was washing her hands. Contacted physician new orders for x-ray results Findings AP (anterior and posterior) and lateral views of the left hand demonstrate a diffuse osteoporosis(bone disease) . The fourth proximal phalangeal (fourth finger,ring finger) oblique fracture is visualized. The pisiform (wrist bone) is laterally subluxed (partially dislocated). The scapholunate (torn ligament) joint is widened. No bony erosion of destruction is present. The soft tissues are unremarkable. There is no radiopaque foreign body (an object that has entered the body that can be visualized by x-ray). RP aware. Observation and interview on 03/19/24 at 9:15 a.m. Resident #6 sitting in a wheelchair at the nurse's station, her hand was in a pink cast. Attempts to interview the resident revealed that she thought she had caught her hand in something but could not recall what. The resident smiled and stated but it is doing better now. Review of the Providers Investigation Report dated 03/11/2024 reflected incident category: of an unknown fracture made by the family on 03/11/24. Description of the allegation: reflected that the nurse noticed swelling on the resident's finger. After getting x-rays the finger came back fractured. The next day the family states they watched video and saw a CNA being rough. They denied abuse but she was rough. The family refused to show the video to the facility. (There were no other dates provided in this section) Assessment description: Assessed hand on 03/08/24 after a allegation of rough body assessment on 03/10/24. Provider Action taken post investigation was signed by the Administrator and dated 03/12/24. In an interview on 03/21/24 at 7:45 a.m. with the Administrator revealed she was the facility's abuse prohibition coordinator and responsible for conducting facility investigations. When queried about an investigation of Resident #6's left hand and the broken finger, she stated she had been made aware of the broken finger, it was on a Friday, the eighth of March. The Administrator stated that she had not reported the broken finger separately because then the family had come back on 03/09/24 and stated there was a CNA that was rough with Resident #6but would not provide the video to me. I guess I got confused and just combined them all because it was the weekend, and I did not call the reports in separately. The Administrator stated she would take that because she understood that the two should have been reported separately, the allegation of injury of unknown origin and the other, allegation of abuse. Review of the facility's abuse prohibition policy/procedure dated April 2019 was provided by the Administrator on 03/19/24 and identified as current, reflected . 6. Accidents and Incidents internally and externally must be reported and investigate in accordance with the Reportable Incident Protocol .The policy/procedure reflected events of injuries of unknown origin would be identified and thoroughly investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #76) of six residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan on 03/04/2024 to address Resident #76's need for assistance with Activities of daily living needs due to fracture. This failure could place residents at risk for not receiving the necessary care or receiving inappropriate care for their condition and diagnosis. Findings included: Review of Resident #76's MDS assessment dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fracture of the upper and lower end of right tibia and fibula. Review of Resident #76's Baseline Care Plan dated 02/05/24, reflected the resident had a fall related to fracture. Interventions included low bed, one person assist and therapy three days a week. An observation and interview on 03/19/24 at 11:02 AM revealed Resident d#76 sitting in wheelchair, watching tv and writing in a composition notebook. Bed was low. The resident was alert and able to answer questions. An interview on 03/21/24 at 12:45 AM with LVN C revealed Resident #76 received therapy for her right leg. Only one person assist for transfer, but able to do daily living activities on her own. Interview on 03/20/24 at 2:00 pm with MDS Coordinator B revealed she was responsible for doing the comprehensive care plans. She stated all the care plans are in the electronic medical recor d and if they were not there then they were not trigger. She tried to pulled Resident #76 care plan up on the system and stated it was not there and that she would trigger it manually and bring me a copy. She stated there should be a care plan for all medical diagnosis and specialized medications so that the residents can be properly monitored and to ensure that the care plans were person centered. She stated if there were missing care plans that the potential harm to the residents could be missing interventions to protect the residents. She was unsure why Resident #76 care plan did not trigger. Interview on 10/12/23 at 04:13 pm with the Administrator revealed the care plan had not been triggered had been brought to her attention today, the MDS nurse will verify no other care plan was needed to be manually triggered. She stated her expectation was that the care plans are completed on time and accurately. Record review of facilities policy titled Care Plans, Comprehensive Person-Centered revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to within 14 days after a facility completed a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS system for two (Residents #24 and #48) of eight residents reviewed for resident assessments. The facility failed to ensure Residents #24 and #48's Admission, Quarterly and Annual MDS assessments was transmitted within 14 days after their MDS Assessments were completed. The MDS Assessments were not completed and submitted timely and accurately on 07/16/23, 10/17/23, 11/01/23, 11/16/23, 02/16/24 and 03/15/24. This failure could place residents at risk of not getting appropriate care and services at the facility if CMS was unable to track the location and condition of the residents, which could cause a loss of their healthcare benefits and lead to increased room and board fees and discharge notices, resulting in distress and decline in their psycho-social well-being. The findings included: A) Record review of Resident #24's Quarterly MDS assessment dated [DATE] by MDS Coordinators B and D revealed a [AGE] year-old female who admitted [DATE] with a BIMS Score of 01 (Severe cognitive impairment). She used a wheelchair, substantial assistance needed with Shower/bathe, upper and lower body dressing and putting taking off foot ware. She needed partial/moderate assist to sit/stand and chair/bed transfer, toilet transfer, tub/shower transfer and always incontinent of bowel and bladder. She had medically complex conditions. Record review of Resident #24 's CMS Submission Report/MDS 3.0 NH Final Validation (Simple LTC) report revealed an ARD target date of 03/15/24 accepted with a Warning: completed late: and OBRA assess (comprehensive or quarterly) is due every quarter unless the resident is no longer in the facility. A prior record with no ARD (2300) within 92 days of the submitted record could not be found. Record review of Resident #24 's CMS Submission Report/MDS 3.0 NH Final Validation (Simple LTC) Report revealed an ARD target date of 11/01/23 accepted with a Warnings: Assessment completed late .Resident information mismatched .Payment reduction warning .incorrect RUG/PDPM version .care plan completed late. B) Record review of Resident #48's Quarterly MDS assessment dated [DATE] by MDS Coordinators B and D revealed a [AGE] year-old male who admitted [DATE] with a BIMS Score of 12 (No cognitive impairment). He used a wheelchair, needed partial/moderate assistance with shower/bathe and upper body dressing and substantial/maximal assistance with sit to stand and tub/shower transfers. He had medically complex conditions. Record Review of Resident #48 's CMS Submission Report/MDS 3.0 NH Final Validation (Simple LTC) Report revealed an ARD target date 02/16/24 was accepted with Warnings: Records submitted late .Resident information mismatch .Assessment completed late. Record Review of Resident #48 's CMS Submission Report/MDS 3.0 NH Final Validation (Simple LTC) Report revealed an ARD target date 11/16/23 was accepted with Warnings: Incorrect RUG/PDPM value .incorrect RUG/PDPM version .assessment completed late. Record Review of Resident #48 's CMS Submission Report/MDS 3.0 NH Final Validation (Simple LTC) Report an ARD target date 10/17/23 was accepted with warnings: Invalid ICD (international classification of diseases) Code .Resident information mismatch .Assessment completed late. Record Review of Resident #48 's CMS Submission Report/MDS 3.0 NH Final Validation (Simple LTC) Report an ARD target date 07/16/23 was accepted with a Warning: Assessment completed late: An OBRA comprehensive assessment with the care area assessment is due every year unless the resident is no longer in the facility. A prior record with an ARD within 366 days of the submitted record could not be found. Interview on 03/20/24 at 11:44 am, MDS Coordinator D stated there were no issues with submitting the MDS Assessments in a timely manner. She stated MDS Assessments were due every 90 days and when residents had a hospital visit and when they returned. She stated Residents #24 and #48's MDS Assessments were all submitted within 14 days. She stated in the Medicaid Simple LTC portal was where they found out if an MDS Assessment was rejected or had warnings and to her knowledge their MDS Assessment had no issues. She stated since the new MDS forms came out in October 2023 they have had a lot of changes and they were not able to get the errors resolved for some of the residents. She stated she would get with her Regional Corporate RN to help her figure out why Resident #24 and #48 MDS Assessments did not transmit right, or they would just have to redo them. Interview on 03/20/24 at 12:02 pm, MDS Coordinator B stated Residents #24 and #48 had no late MDS Assessments, rejections, or warnings of which she was aware. Interview on 03/21/24 at 1:44 pm, MDS Coordinator D stated after reviewing the Medicaid Simple LTC portal, Residents #24 and #48's MDS Assessments had a lot of transmission issues, but it was hard to tell which residents had issues. She stated she was not able to track transmission errors but once she checked Medicaid Simple LTC she was able to get the validation results of the transmissions. She stated Residents #24 and #48's MDS Assessments just got lost in the mix and added she needed to check and re-check the validation results to make sure the transmissions went through. She stated Corporate RN planned to do the monitoring of their submissions and transmissions daily and they were currently doing audits of other resident's MDS Assessments and would continue to do to prevent this from happening again. She stated the resident's payments may be affected if MDS Assessments were not submitted on time or with errors. She stated she was responsible for ensuring the MDS Assessments were submitted timely and accurately. Interview on 03/21/24 at 1:55 pm, MDS Coordinator B stated, after review of the Medicaid Simple LTC portal she saw where they had a lot of warnings in 10/2023 because of MDS updates. She stated when she saw validation issues, she informed RN Corporate MDS so that the MDS could be opened and re-submitted. She stated she submitted MDS Assessments mostly in the evening and the next morning checked the transmittal status of them. She stated she did not know the MDS Assessment were transmitted late but said going forward she would do the Medicare Resident Assessments and Corporate RN would do the MDS transmissions. She stated she, MDS Coordinator D and RN Corporate MDS were responsible for ensuring the MDS Assessments were submitted timely and accurately. Interview on 03/21/24 at 6:11 pm, the Administrator stated they had problems submitting the MDS Assessments last year and by looking in Medicaid Simple LTC (long-term care) for gaps in payments, and validation reports. She stated not being aware of the coding errors of their MDS Assessments. She stated she, MDS and RN Corporate were responsible for ensuring the MDS Assessments were competed on time. She stated MDS coding errors typically affected the resident's payments. She stated she thought the transmission issues had been resolved and today 03/21/24 she requested an audit to be completed for all residents because of the warning errors and late submissions of Residents #24 and #48's MDS Assessments. Record Review of the Facility's MDS Error Correction policy revised September 2010 revealed, Policy Statement: The assessment coordinator and/or interdisciplinary assessment team will follow the established processes for making correction to the MDS. Policy interpretation and implementation: 4. If an error is discovered after the encoding and editing period and the record in error is an entry, discharge, or PPS assessment, then correct the record an submit to the QIES ASAP system. 6. If an error is discovered in the record that has already been accepted by QIES ASAP system, implement procedures for either modification or inactivation of the information in the system within 14 days of the discovery of the error .7. Modification requests are used when information in the record contains clinical or demographic errors Record review of the Facility's MDS Assessment Coordinator job description revised November 2019 revealed, Policy Statement: a registered nurse (RN) shall be responsible for conducting and coordinating the development and completion of the resident assessment (MDS). Policy interpretation and implementation: 1. A Registered nurse (RN) shall be designated the responsibility of conducting each resident's assessment (MDS). 2. The resident assessment coordinator must date and sign each assessment (MDS) to certify that the assessment is completed. 3. Each individual who completes a portion of the assessment (MDS) must certify the accuracy of that portion of the assessment by: a. dating and signing the assessment (MDS); and b. identifying each section completed . Record review of CMS Minimum Data Set Error message Reference Guide dated January 3, 2024, revealed, 4. File processing error messages for MDS Data: The MDS 3.0 Final Validation Report is automatically generated within 24 hours of successful submission of a file. A file may include one or more records. The report details the errors, if any, in the submitted records within the file. Go to the Reports section in iQUIES to view this report .all error warnings should be reviewed and corrected if appropriate, to ensure the data uploaded is accurate and complete .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (Residents #189) of eight residents reviewed for Medical Records. The facility failed to ensure all of Resident #189's MDS Assessments dated 10/18/23 and 01/29/24 were coded accurately, that she was a female. The facility failed to ensure Resident #189's face sheet identified her as a female. These failures could affect residents by placing them at risk of not getting appropriate care and services due to the possible denial of payment for inhouse and outside services. And could get inaccurately prescribed medication dosages, out of range laboratory reports and increased chance of addressing the resident by the wrong gender, resulting in a decline in the resident's health, self-esteem, and psycho-social well-being. Findings included: Record Review of Resident #189's Face Sheet revealed she was a male. Record review of Resident #189's admission MDS assessment dated [DATE] by MDS Coordinator B revealed an [AGE] year-old male who admitted [DATE] with a BIMS score 15 (No cognitive impairment) partial to moderate assist with most ADL care. He used a wheelchair with other orthopedic conditions, and diagnoses Atrial Fibrillation, Deep Vein Thrombosis, HTN (high blood pressure), DM II (diabetes II), hyperlipidemia (high fat lipids in blood), Thyroid disorder (hormone irregularity), other fracture (broken bone), and anxiety. Record review of Resident #189's Modified MDS assessment dated [DATE] and signed on 03/20/24 by Corporate RN and MDS Coordinator B revealed Resident #189's record was coded to female. Record review of Resident #189's Hospital Discharge Report dated 10/16/23 resident was an [AGE] year-old female. Interview on 03/20/24 at 5:02 pm, the Administrator stated Resident #189 was a female resident that she knew of and would have to go and check with the BOM and Admissions Director. She stated they needed to ensure the resident's medical information was accurate. She stated the face sheet automatically populated the resident's gender onto the MDS Assessments. She stated she reviewed Resident #189's MDS Assessments and Face sheet had her listed as a male. Interview on 03/20/23 at 5:40 pm, the Administrator stated Resident #189's face sheet and MDS Assessments stating she was a male was wrong. She stated the resident's demographic information was received from the hospital system and added she was in the process of correcting the issue. Interview on 03/21/24 at 1:55 pm, MDS Coordinator B stated Resident #189 was a female but her demographics on her face sheet showed she was a male. She stated she needed to make sure she went and looked at the resident and checked what their gender was for herself. She stated it was missed but now that they know they submitted a modification on all of Resident #189's MDS Assessments and her face sheet. She stated not being sure why she did not notice male was on her face Sheet and MDS Assessments. She stated the BOM and Admissions Director needed to also make sure the demographics were accurate and stated if she came across any inconsistencies, she would let the BOM and admission Director aware to change it. She stated the Admissions Director, BOM and herself were responsible for ensuring the records were accurate and would be closely monitoring the accuracy of the residents' records. She stated going forward they were currently checking the other residents' records for accuracy. She stated having incorrect gender info could cause a dignity issue if someone thought a female resident was a male and greeted her as Mr . Interview of 03/21/24 at 6:11 pm, the Administrator stated she just found out yesterday (03/20/24) about Resident #189's inaccurate medical records from the HHSC Surveyor. She stated the Admissions Director first verified the resident's demographics with the hospital staff, then the BOM checked the demographics to ensure accuracy. She stated the nurses were to also check for errors and added she was not sure if the typo was from the Admissions Director or someone from corporate also did pre admits and sent the resident's information to them at times. She stated they also received resident's medical information from a hospital-based medical records system and added the Admissions Director received the medical information to ensure the medical records were accurate. She stated ultimately the Medical Records Director was responsible for ensuring the resident's records were accurate. Record Review of the Facility's MDS Error Correction policy revised September 2010 revealed, Policy Statement: The assessment coordinator and/or interdisciplinary assessment team will follow the established processes for making correction to the MDS. Policy interpretation and implementation: .7. Modification requests are used when information in the record contains clinical or demographic errors Record review of the facility's Content of Medical Record policy revised January 2020 revealed, Policy: It is the policy of the facility to maintain clinical records on each patient in accordance with accepted professional health information management standards and practices .Responsibility: Medical Records Technician .Procedures: 2. h. Patient's date of birth , age, sex, race, nationality, and religion .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility for one (Resident #1) of five residents reviewed for resident rights. 1. The facility failed to ensure Resident #1 and her RPs were treated fairly and assisted with obtaining a new attending physician at the facility when the previous attending physician discontinued services due to his opinion that he and a family member had a non-therapeutic relationship. As a result, the facility attempted to discharge Resident #1 several times in 2022 and 2023 for not having an attending physician and did not facilitate adequate attempts to help locate a new one. The two physicians available refused to see Resident #1 based on the previous attending physician's recommendation. 2. The facility's medical director/attending physician for Resident #1 issued a discharge notice stopping routine medical care to Resident #1 after the facility was investigated and cited by HHSC related to physician care. 3. The facility did not provide contact information for Resident #1's newly chosen attending physician in April 2023 and May 2023. The facility required a care plan meeting only with the POA, and no other family members, in order to see if the doctor would accept Resident #1 as a patient, which was not a practice used with any other residents when choosing a physician. This resulted in the RPs feeling like they were being interviewed in order to get the doctor to accept Resident #1 due to their past negative history with the previous attending physician. The failure could place residents at risk of a loss of self-determination and dignity. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included Alzheimer's disease, hypertension, heart failure, atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), coronary artery disease and anxiety disorder. Resident #1 had clear speech, no hearing issues or impaired vision and her BIMS score was 08, which indicated moderate cognitive impairment. Resident #1 had no signs or symptoms of delirium, mood issues, or behaviors (which included psychosis and rejection of care). Review of Resident #1's Face Sheet (not dated) reflected her attending physician was PHY D (date active 03/31/23) and her medical director was MD F (date active 04/12/23). It also reflected that she had two family members as her essential caregivers and contacts. Neither of those family members were designated power of attorney by the facility. Review of the Resident #1's clinical chart revealed no evidence of a medical power of attorney. Review of Resident #1's clinical chart from March 2022 through May 2023 (including nursing notes, medication/lab/x-ray orders and emergency notification for change in conditions from March 2022 through May 2023), reflected that MD E was the previous attending physician until 05/24/22, when he issued Resident #1 a discharge from services letter. Additionally, there was no documentation by the facility or physician in Resident #1's medical records to indicate any conflict with the family, conflict relating to medications or course treatments made by the family members or conflicts in care with PHY D. Review of MD E's discharge letter dated 05/24/22 reflected, An effective patient-physician relationship is essential to providing good primary care. Based on recent and on-going events, it is clear the therapeutic relationship we shared no longer exists. As a result of this, I can no longer serve as your physician. Therefore, effective 30 days after the date of this letter, our patient-physician relationship will terminate. You will need to discuss with Crestview Court which other primary care physicians in the facility are available to attend to your regular healthcare needs. Moreover, my services to you will be available only for emergency purposes during the next 30 days. I recommend you establish care with a new provider as soon as possible and continue to receive healthcare services. [Signed MD E]. An interview with Resident #1's family member on 04/27/23 at 9:13 AM revealed there had been four facility-initiated discharge notices given to Resident #1 and her responsible parties due to the facility not having a doctor available to provide medical care, all which went to a hearing and were overturned by the hearing officer. The family member said the facility had stated that since Resident #1 did not have an attending physician anymore in the facility, but still had a primary care physician in the community, then they would contact that physician for routine visits and emergencies. However, if he was not reachable, they told the family member they would send Resident #1 to the hospital emergency room. The family member stated, I know part of the state and federal regulations states they have to have a physician. The family member said there had been several incidents with MD E, but there was one in particular where he failed to prescribe an antibiotic when she had double pneumonia. The family member said the facility had done an -x-ray on Resident #1 and MD E was aware of the results, but he did not start her on any antibiotics. The family member said MD E told the family he overlooked it because he was reading the x-ray results on his phone. The family member stated he/she was upset and told MD E that was no excuse and he could have killed Resident #1. A complaint was lodged with HHSC and an investigation was conducted and the family member stated MD E was upset that a complaint on him had been made. The family member stated there was another time MD E was negligent of providing standard care to Resident #1 around late September 2021 when the facility nurses and MD E did not notice that the resident had an infected toe down to the bone. The family member stated that HHSC ended up completing an investigation in April 2022 related to the complaint and cited/fined the facility and they were angry. On 05/26/22, The family member stated on 5/26/22 the facility ADM notified the RP that MD E was terminating his care due to an HHSC P1 complaint being lodged against him. The family member stated, He [MD E] did not want to own up to his mistakes and would only provide emergency care. The family member stated, They tried to put her out three or four times. They are saying it is because she doesn't have a physician. It is against state and federal laws. [Ombudsman] has drilled this over and over at the hearings. The family member stated 05/26/22 was when the facility issued the first discharge notice and as soon as the hearing officer ruled for Resident #1 to stay, the facility kept issuing more discharge notices. The family member felt like the situation was [NAME] to harassment. The family member said Resident #1 did have a doctor in the community, PHY D, who would always see her if needed, but the facility tried to say during the discharge hearings that he was going to be her attending physician, which was a lie. The family member said the same thing kept being brought up at each discharge hearing, but PHY D never agreed to be the attending physician. The family member stated, I mean this, god forbid something happens to [Resident #1] without physician care. It is to the point where they are harassing her. They are upset because of what had transpired starting with the toe thing. The family member also felt the facility was retaliating against the family and Resident #1. The family member stated that she received an email (no date given) from the ADM that was very concerning where it was said that PHY D would be her attending physician and they could reach him up to 7 pm or 8 pm at night, but after that time, they would contact a new assistant doctor at another facility to see her on an emergency basis. The family member stated, So in essence, [Resident #1] doesn't have a physician. I am so worried, you are going to just sit there and let her die or not render aid. I pray to god nothing happens. The family member said prior to MD E stopping his services for Resident #1, he had been her physician since 2016. Now, the family member stated on a day-to-day basis, no physician was overseeing her care. The family member said the facility claimed they had contacted other doctors to be the attending physician for Resident #1 but the said no. The family member said one of the doctors asked by the facility to be Resident #1's attending physician worked with MD E and the family member felt MD E told that potential doctor a lot of negative things about Resident #1 and the family, which caused that doctor to say no, even though he had never seen Resident #1. The family member said after the most recent attempt to discharge Resident #1 in 2023 due to the facility stating she did not have an attending physician, the family appealed and won, however, the family was notified after that that MD E would not even provide care for emergencies for Resident #1. The family member said PHY D had been Resident #1's outside physician during the seven years she had been at the facility and she periodically went to see him during those years because she was comfortable with him, but not for everyday care. The family member stated the Ombudsman would say the situation was retaliation and even the disability lawyer at the hearing said it was retaliation. The family member stated, They want her out, [MD E] got in trouble, I do not trust them, this doctor thing is huge, god forbid somethings happens to my [Resident #1] and she doesn't have the care. This is very hurtful for [Resident #1], she feels like they don't want her there. Her friends are there, that is all she knows. Review of an email exchange provided by Resident #1's family member to the facility's DON, ADM, Ombudsman, VP of Clinical Operations, VP of Operations dated 04/12/23 reflected, We are requesting that the new co medical director [MD F} be designated as [Resident #1]'s attending physician. The ADM responded back to the family member on 04/12/23, [MD F] does not want to be attending, sorry. I asked him and he emailed saying he didn't want to. An interview with the local Ombudsman on 04/27/23 at 4:41PM revealed the facility had not issued a subsequent discharge notice to Resident #1 since the last hearing on 03/30/23, however, subsequent to the hearing and after the hearing decision was issued, the facility issued another email indicating they did not have a doctor for Resident #1. The Ombudsman stated, The facility keeps doing this because he doesn't want to be the attending, which he has the right to be. The other doctor there, he doesn't want to do it because of the consultation with [MD E]. At the end of the day, the resident needs an attending physician. Her doctor, who she has seen in the community for years, he does not want to be credentialed by the facility. The Ombudsman said there had been a recent communication in the past couple of weeks where the ADM stated the facility had a new co-medical director [MD F]. The family responded saying they were okay with that new co-medical director being Resident #1's attending physician, but the response from the facility was that he did not want to do it. The Ombudsman stated the situation was bordering on discrimination and she was concerned Resident #1 was going to be discriminated against if she ever did have to move to other facilities in the metroplex where MD E and MD F had affiliations directly or with other doctors in their practice. The Ombudsman stated, I didn't find anything in the regs that residents can be discharged because a doctor doesn't want to provide care. That's why we are back to the regs. They are responsible for providing an attending physician. Who is overseeing her medical care now? Who is writing orders for her? The Ombudsman said after 03/30/23 when the hearing officer reversed the facility's action related to discharge, Resident #1's two RP's were sent an email from the ADM informing them that if any emergencies happened to Resident #1, they would contact PHY D or send Resident #1 to the hospital ER for treatment and the staff had been informed to contact the family if they were unable to contact the outside physician. At that time, the facility requested a care plan meeting to ensure everyone was on the same page. The Ombudsman said that email was sent on 03/30/22 and then the vice president of operations responded in an email to the RPs that the facility had not heard back from them regarding the care plan meeting about the physician issues and that MD E would no longer be the physician, even for emergency situations. The email also stated, per the Ombudsman, We have attempted to find another physician but were unsuccessful. You have identified [PHY D] as attending of choice, this includes after business hours. At this time [PHY D] has not provide us with after-hours information. The Ombudsman said that meant any emergencies for clinical issues would be to contact PHY D and if no response, then send Resident #1 to the hospital. The Ombudsman said the family did not know what to do because they had no opposition to any of the doctors at the facility being the attending physician because the resident must have an attending in the nursing home. So the issue then is back to the resident does not have a doctor available to oversee her care while in the nursing home. The Ombudsman said there was another email from the ADM dated around 04/10/23 where she notified Resident #1's RPs that MD F agreed to see her for emergencies only when the attending is not available and had agreed to speak with the POA if any emergencies come about and the DON had reached out to PHY D who agreed to see Resident #1 twice a month, do health and physical assessments, and progress notes and would be available until 8pm, and provided an after-hours number, but we still want a care plan meeting to discuss any issues. However, further inquiry by Resident #1's RPs to PHY D revealed he did not agree to any of that. On 04/12/23, Resident #1's RPs notified the DON that PHY D did not agree to anything and requested the new co-medical director [MD F], be designated as her attending physician but was told in writing by the ADM that he did not want to be. The Ombudsman stated, So we have a resident in the building with no attending physician; a [AGE] year-old resident, been there 7 years, no issues with the resident, only with the family. They [facility] have to work with them, there is no threat on life, so where are you going to discharge her to? I am telling you, this I reaping of discrimination. The Ombudsman said she went through Resident #1's clinical chart for the appeal hearing and there was no documentation from MD E to indicate he was going to terminate his relationship with her, which was brought up in the hearing, only a letter was issued, but nothing in the chart, nothing documented. The Ombudsman said she told Resident #1's RP that if MD E did not want to provide care or services, the regulations allowed that. However, that was not the issue, the issue was the regulation that the facility provided a doctor for Resident #1, The facility must assist the resident or the resident's representative in finding a replacement. [Facility] is a large company and there is something unethical in discharging resident, who's to say you won't come in contact with that same doctor at a sister facility or another facility because the doctor is still affiliated or had doctors they are connected with who don't want to work with the resident. She is being blackballed, you have a person, the resident, who hasn't been resistant. This is about not having a doctor. Resident needs care, has permanent medical necessity and who is overseeing her care? They are required to do H&Ps, write medication orders, do all those kinds of things, who does it? .the communication says they will just send her to the hospital. Review of Resident #1's clinical chart (including her physician visits in the facility) revealed the last time she was seen for a face to face visit by MD E was 06/07/22 for shoulder pain. There were no changes made in her care management as Resident #1 stated it only hurt when she raised her arm over her head. Her range of motion was not affected. The exam reflected MD E remained her supervisor and rendering provider. Review of Resident #1's progress notes reflected she was not seen by MD E face to face for required physician visits or by his extenders from June 7, 2022, through April 2023 (10 months). An interview with the ADM on 04/27/23 at 1:14 PM revealed one of the family members drives care and had been like that for a long time. Last year in the fall, the ADM said the family member had words with MD E and he felt like she was treating him like a child, the ADM did not witness the interaction. However, she said as a result of that conversation, MD E issued Resident #1 a discharge notice saying he would not provide any more care to her due to a non-therapeutic relationship with the family member and that the family member was controlling over Resident #1's care. The ADM stated, If he wants to order a pill, she will take the resident to [PHY D] in the community who will reverse it. The ADM said the family member would not let MD E do his job, overstepped and changed what his treatment of medications were, she wants PHY D's second opinion, So [MD E] figured what is the point, she doesn't trust me. The ADM stated the facility recently got a new co-medical director (MD F), But you know how doctors talk, he talked to [MD F], as well as a physician I reached out to at another facility and they know from [MD E] that the family member is going to cause problems so they say no. The ADM stated that MD F had not met Resident #1 yet but said he would agree to see her on an emergency basis only but would require a care plan meeting with the medical POA to discuss it. Regarding PHY D, the ADM stated he said he would see Resident #1 in person at his office when needed and would be available for orders, H&P, progress notes and so forth, but he was only available from 8am-8pm and refused to get credentialed to contract with the facility because that would mean he would be on call, which he did not want to do. The ADM stated, At this time, [MD E] agreed to maybe be available for emergency only after a care plan meeting is held with the POA first. The ADM said it was not an issue with the resident, she never refused any doctors or anything, it was the family member causing the issues that made the attending physician not want ot be her doctor. The ADM stated, [MD E] is not going to put his license at risk and he has rights. An interview with the DON on 04/27/23 at 1:48 PM revealed she never talked directly to MD E, only the receptionist at his office on 04/10/23. She asked the receptionist where the facility could send the current month's physician's orders and that the facility needed a current H&P and progress notes from the visits Resident #1 had with MD E because she had been to see him a few times. The DON said there was some miscommunication between the family of Resident #1 and the facility on how often the resident needed to be seen and that the facility said MD E would see the resident every two weeks, but the DON said that was not what she had said, and she had never talked to him. The DON said, I have never been able to talk to [MD E] to this day. She said the facility had a written statement from him because at one point last year when the facility issues a discharge notice to Resident #1 due to not having an attending physician, MD E wrote a letter stating that Resident #1 did not need to leave the facility because she had dementia and he agreed to be our primary care provider. The DON said she did not know if MD E or MD F talked to PHY D. She said MD E had been seeing Resident #1 for years and when the DON and ADM came to work at the facility in May 2022, we walked into this situation, [MD E] was already trying to remove himself as her doctor. The DON stated at this point, MMD F had agreed to be contacted for any life threatening or acute changed in condition for Resident #1, she had no current H&P from MD E. The DON said there were no residents in the facility currently that had ever seen an attending physician in the community only and not a facility physician for every day care. The DON stated, At this point, it stands that the family now wants [MD F] as attending. We are waiting for a care plan meeting, the family is not responding for multiple requests for a meeting. The DON said she did not know if MD E, as the medical director for the facility, had reached out to PHY D to discuss the situation. The DON said that during one of the discharge hearings for Resident #1, the fine print stated that the medical director had to specifically state why he did not want to continue with care, I don't know if he did. I think legal from corporate is handling it now. The DON conformed that Resident #1 had no H&P since February 2022, which was completed by MD E. The DON said the last note MD E wrote for Resident #1 was on 06/07/22. She said she asked PHY D for any documentation on Resident #1 but only received medical documentation from 2020 and 2021, nothing current. An interview with MD E on 04/27/23 at 3:56 PM revealed he was the medical director for the facility and had been the attending physician for Resident #1 for the past five to six years but was no longer her attending physician. MD E stated the circumstances that caused him to cease being Resident #1's attending physician were cumulative and I think it was more differences in our philosophies in care was our biggest difference. It had been many years and it came to an aggressive stance with the [family member], I am not sure which [family member], but it was mainly [name]. MD E said Resident #1's family member behaved in a way that was more like harassment, questioning his decisions, send her out to the hospital then come back, I don't think she trusted my care. She is the only resident I have had to part ways with. I have been doing this for ten years. The MD said he worked in a large physicians' group in general, but for the facility, it was himself, his PA and NP. When asked what does being a physician for emergencies entail, MD E replied, That is kind of funny, I am still trying to figure out if I am there for emergencies I am getting my legal involved so we can figure out what it entails. If I see something as a medical director, I would intervene. I just don't know what that means legally. MD E said if a facility physician refused to see a resident as a patient, their care would have to be monitored by an outside physician. MD E said Resident #1 had PHY D for many years and she would follow up with him as well, So I think she resumed care with [PHY D] and I think the facility transports to him now every 60 days. MD E was asked what was his responsibility as the medical director of the facility to assist the facility in locating another attending physician for Resident #1. MD E stated, You know what, that is a great question, I don't know if as a medical director, is that something I have to do a responsibility. I think the facility has to do it, like trying to recruit another physician but I don't think in my medical director's contract it is in there. MD E confirmed that is a resident did not have an attending physician, then it was the medical director's role to oversee that resident's care. MD E said he had not personally contacted any doctors to see if they could be Resident #1's attending physician. MD E stated, I guess because she had a doctor. It's a tough situation, I guess it is confusing to me. It was kind of like a distrust or conflict of our philosophy. MD E said he had not talked to MD F since he had taken over as co-medical director and that the facility decided who would have which residents on their caseload for both he and MD F. MD E was asked if he felt refusing to be her attending physician was punitive to the resident when she had no other physician available to see her int eh facility. MD E stated, You know it's hard to say because I think [PHY D] can do everything I do. It seems like they follow up with him even when I was still her physician. I would say something, like he prescribed and antibiotic I didn't agree with. They were comfortable with him so I thought, then you have a provider and if I am there, I am never going to withhold care on someone, but there is also a time for mental well-being for physicians. I felt they were badgering me, the family. [PHY D] was doing what I am doing, we would probably manage it the same. MD E stated most of the time when something happened with Resident #1 medically, the family requested her to be sent out, for example, when there was a snow storm and Resident #1 missed dialysis. MD E said he told the facility was okay for her to miss a couple of days of dialysis but the family send her to the ER and she came back with no new orders. He said one a Hoyer mechanical lift bumped Resident #1, a x-ray on her ribs was done, there was a question of pneumonia, his NP saw it and the resident was asymptomatic but the family wanted to send her out. MD E stated, The family will supersede whatever I say. If there is an emergency situation, one of us is going to handle it. And I have. I am not going to withhold care. It's difficult to figure out what do we do now. Maybe I just don't need to be medical director there anymore. MD E was asked if he had reached out to PHY D in anyway, to discuss continuity of care for Resident #1 and he replied no. A follow up interview with the ADM on 04/27/23 at 5:31 PM revealed MD F had been referring a lot of his patients from the hospital he worked at so she wanted to ask him to be the medical director. He agreed to come over and take over as the attending physician for the residents he had referred to the facility, which were skilled residents and he initially did not want to be the attending physician for those residents once they went long-term, but he agreed to be, if they were his skilled residents prior. The ADM stated MD F said he would consider being Resident #1's attending for emergencies, If the family would meet with him first. The ADM was asked where does it state in the facility's policy or medical director/attending physician contract that a doctor has to meet a with resident and their RP prior to deciding if he would accept them. The ADM stated, He agreed to see his patients only that he referred from the hospital. I am not going to lose him over this family. The ADM was asked if MD F was able to contact the family via phone to talk about Resident #1 and she said a care plan meeting had been requested by him. The ADM continued to state that PHY D agreed to be Resident #1's attending physician and she had the letter confirming it and would look for it, however she was unable to provide any evidence. An interview with MD F on 04/27/23 at 5:40 PM revealed he did not deny Resident #1 as his patient. MD F stated, I guess she didn't' want to see or had some issues with [MD E] so basically, they gave her to me until I guess something worked out, so I didn't deny her. I understand she had to have someone so I went and picked her up. MD F said he had not seen Resident #1 face to face yet but she had been put on his caseload. MD F stated, I have no problem with it. People from time to time, it happens quite a bit, they might not gel with one physician but might gel better. I guess the family didn't want to see him anymore or he dropped care. [ADM] came to me and asked me and I said yeah, I will pick her up until something else happens or if nothing else happens, we are good. I want to talk to them before I see [Resident #1] to see what the issues were from their stand point in regards from care, that was all, so I wanted to get an overall of what was happening. MD F said the facility told him what happened with caseload assignment was when a new resident arrived at the facility, the facility would contact him and say he had a new patient and he added them to his list. MD F stated, But in this case, I was at the facility when they came up and told me what the issue was. They asked me and I said yes. MD F said in the past, he had to drop a resident from his caseload before, like if there was unprofessional language being heralded at him. MD F stated, None of us need to deal with that especially after long days, patients and stress, so if you are being cursed out, explicit language, unprofessional conduct, flirtations, sexual advances, making any threats to my license or safety. With disagreement with care, as a provider, you have to ask then what are your concerns, next questions why don't you want the treatment and maybe it could be explained by the family as to why they don't agree, it's an opportunity to teach. I want to make the family feel like they are included in the care. They may be lay people but it's an opportunity as a physician to teach, which is what I love teaching So to me, it's always a teaching point and I think that's an obligation as physician. An interview with the ADM on 04/27/23 at 6:01 PM occurred where she stated, I am willing to take a tag on this at this point. No other state investigators have tagged me though because they say as long as she has a doctor and her needs are being met, even if a doctor in the community, it's okay. I don't want to lose [MD F] over this. The same thing will end up happening, where the [family member] will do the same thing she was doing to [MD E] to [MD F] and he is going to leave as our medical director. I am now out of it because of the complaints the family has against me, corporate is the one making the decisions. A confidential interview with a facility staff member on 05/01/23 occurred where they were familiar with Resident #1 and wanted to state that the facility did not exactly create this whole situation to try and get her discharged for not having an attending physician, per say, but they saw it as an opportunity and didn't do anything to prevent it from happening, in trying to work it out and help find a doctor. Attempted to contact the VP of Operations for the facility on 05/01/23 at 2:39 PM with no success. An interview on with the SW on 05/01/23 at 3:22 PM revealed she had not received any grievances from the family for Resident #1, but she had only started employment in January 2023. She said the last time they approached her, it was about a laundry issue and it was taken care of immediately. The SW said she did not know anything about issues with not having an attending physician but started seeing communications about it because she was cc'ed in emails by the facility. Then the SW said she remembered what happened, that Resident #1's family wanted both physicians, one on the outside and one on the inside, but the outside physician would cancel orders MD E wrote and that is how this whole thing got started. The SW could not remember the circumstances but thought it had happened more than once related to an issue with some lab results or x-rays, or a combination of things. The SW said she did not make the decision on doctors but would work with families or residents if the wanted a different doctor then they had. She said Resident #1 and her family had never asked to be assigned a different doctor. The SW said when a resident or family member requested a new attending physician at the facility, it was not normal practice to have a care plan meeting prior, to decide if the doctor was accept the resident on their caseload. She said typically when a resident or family wanted a new doctor, she would just rea[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care for one (Resident #1) of five residents reviewed for physician services and resident rights. The facility failed to provide Resident #1's RPs with MD F's contact information when they chose him to be the resident's physician on 04/12/23. The failure could place residents at an increased risk of not receiving quality care and treatment due to their lack of free choice. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included Alzheimer's disease, hypertension, heart failure, atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), coronary artery disease and anxiety disorder. Resident #1 had clear speech, no hearing issues or impaired vision and her BIMS score was 08, which indicated moderate cognitive impairment. Resident #1 had no signs or symptoms of delirium, mood issues, or behaviors (which included psychosis and rejection of care). Review of Resident #1's Face Sheet (not dated) reflected her attending physician was PHY D (date active 03/31/23) and her medical director was MD F (date active 04/12/23). It also reflected that she had two family members as her essential caregivers and contacts. Neither of those family members were designated power of attorney by the facility. Review of the Resident #1's clinical chart revealed no evidence of a medical power of attorney. Review of Resident #1's clinical chart (including nursing notes, medication/lab/x-ray orders and emergency notification for change in conditions), reflected that MD E was the previous attending physician until 05/24/22, when he issued Resident #1 a discharge from services letter. Review of MD E's discharge letter dated 05/24/22 reflected, An effective patient-physician relationship is essential to providing good primary care. Based on recent and on-going events, it is clear the therapeutic relationship we shared no longer exists. As a result of this, I can no longer serve as your physician. Therefore, effective 30 days after the date of this letter, our patient-physician relationship will terminate. You will need to discuss with Crestview Court which other primary care physicians in the facility are available to attend to your regular healthcare needs. Moreover, y services to you will be available only for emergency purposes during the next 30 days. I recommend you establish care with a new provider as soon as possible and continue to receive healthcare services. [Signed MD E]. Review of an email exchange provided by Resident #1's family member to the facility's DON, ADM, Ombudsman, VP of Clinical Operations, VP of Operations dated 04/12/23 reflected, We are requesting that the new co medical director [MD F} be designated as [Resident #1]'s attending physician. The ADM responded back to the family member on 04/12/23, [MD F] does not want to be attending, sorry. I asked him and he emailed saying he didn't want to. An interview with the local Ombudsman on 04/27/23 at 4:41PM revealed there had been a recent communication in the past couple of weeks where the ADM stated the facility had a new co-medical director [MD F]. The family responded saying they were okay with that new co-medical director being Resident #1's attending physician, but the response from the facility was that he did not want to do it. The Ombudsman said there was another email from the ADM dated around 04/10/23 where she notified Resident #1's RPs that MD F agreed to see her for emergencies only when the attending is not available and had agreed to speak with the POA if any emergencies come about and the DON had reached out to PHY D who agreed to see Resident #1 twice a month, do health and physical assessments, and progress notes and would be available until 8pm, and provided an after-hours number, but we still want a care plan meeting to discuss any issues. However, further inquiry by Resident #1's RPs to PHY D revealed he did not agree to any of that. On 04/12/23, Resident #1's RPs notified the DON that PHY D did not agree to anything and requested the new co-medical director [MD F], be designated as her attending physician but was told in writing by the ADM that he did not want to be. Review of Resident #1's progress notes reflected she was not seen by MD E face to face for required physician visits or by his extenders from June 7, 2022 through April 2023 (10 months). An interview with the ADM on 04/27/23 at 1:14 PM revealed the facility recently got a new co-medical director (MD F), but MD F had not met Resident #1 yet but said he would agree to see her on an emergency basis only but would require a care plan meeting with the medical POA to discuss it. An interview with the DON on 04/27/23 at 1:48 PM MD E had been seeing Resident #1 for years and when the DON and ADM came to work at the facility in May 2022, we walked into this situation, [MD E] was already trying to remove himself as her doctor. The DON stated at this point, MMD F had agreed to be contacted for any life threatening or acute changed in condition for Resident #1, she had no current H&P from MD E. The DON said there were no residents in the facility currently that had ever seen an attending physician in the community only and not a facility physician for every day care. The DON stated, At this point, it stands that the family now wants [MD F] as attending. We are waiting for a care plan meeting, the family is not responding for multiple requests for a meeting. A follow up interview with the ADM on 04/27/23 at 5:31 PM revealed MD F had been referring a lot of his patients from the hospital he worked at so she wanted to ask him to be the medical director. He agreed to come over and take over as the attending physician for the residents he had referred to the facility, which were skilled residents and he initially did not want to be the attending physician for those residents once they went long-term, but he agreed to be, if they were his skilled residents prior. The ADM stated MD F said he would consider being Resident #1's attending for emergencies, If the family would meet with him first. The ADM was asked where does it state in the facility's policy or medical director/attending physician contract that a doctor has to meet a with resident and their RP prior to deciding if he would accept them. The ADM stated, He agreed to see his patients only that he referred from the hospital. I am not going to lose him over this family. The ADM was asked if MD F was able to contact the family via phone to talk about Resident #1 and she said a care plan meeting had been requested by him. The ADM continued to sated stated that PHY D agreed to be Resident #1's attending physician and she had the letter confirming it and would look for it. An interview with MD F on 04/27/23 at 5:40 PM revealed he did not deny Resident #1 as his patient. MD F stated, I guess she didn't' want to see or had some issues with [MD E] so basically, they gave her to me until I guess something worked out, so I didn't deny her. I understand she had to have someone so I went and picked her up. MD F said he had not seen Resident #1 face to face yet but she had been put on his caseload. MD F stated, I have no problem with it. People from time to time, it happens quite a bit, they might not gel with one physician but might gel better. I guess the family didn't want to see him anymore or he dropped care. [ADM] came to me and asked me and I said yeah, I will pick her up until something else happens or if nothing else happens, we are good. I want to talk to them before I see [Resident #1] to see what the issues were from their stand point in regards from care, that was all, so I wanted to get an overall of what was happening. MD F said the facility told him what happened with caseload assignment was when a new resident arrived at the facility, the facility would contact him and say he had a new patient and he added them to his list. MD F stated, But in this case, I was at the facility when they came up and told me what the issue was. They asked me and I said yes. MD F said in the past, he had to drop a resident from his caseload before, like if there was unprofessional language being heralded at him. MD F stated, None of us need to deal with that especially after long days, patients and stress, so if you are being cursed out, explicit language, unprofessional conduct, flirtations, sexual advances, making any threats to my license or safety. With disagreement with care, as a provider, you have to ask then what are your concerns, next questions why don't you want the treatment and maybe it could be explained by the family as to why they don't agree, it's an opportunity to teach. I want to make the family feel like they are included in the care. They may be lay people but it's an opportunity as a physician to teach, which is what I love teaching So to me, it's always a teaching point and I think that's an obligation as physician. An interview with the ADM on 04/27/23 at 6:01 PM occurred where she stated, I am willing to take a tag on this at this point. No other state investigators have tagged me though because they say as long as she has a doctor and her needs are being met, even if a doctor in the community, it's okay. I don't want to lose [MD F] over this. The same thing will end up happening, where the [family member] will do the same thing she was doing to [MD E] to [MD F] and he is going to leave as our medical director. I am now out of it because of the complaints the family has against me, corporate is the one making the decisions. An interview with the ADM on 05/01/23 at 3:46 PM revealed if MD F and the facility had to meet with Resident #1 family in order for him to be the attending physician. The ADM responded no, that was why the VP of Clinical Operations said it was going to be to clarify and the family did not have to attend. The ADM said in the beginning, MD F did not want to pick up any long-term residents but the previous attending physician had too many complaints on him (PHY H) and is no longer the attending at the facility, so when MD F came over, MD E had too many residents and MD F had to have some of them assigned to his caseload. The ADM was asked again, if MD F refused to be the attending for Resident #1 and if she had documentation of him, as well as the other physicians she contacted saying no to being Resident #1' attending. She said she would look for the email exchanges. The ADM said, We want her to sit down and have [MD F] explain to the family what the expectations are. The ADM was asked if Resident #1 and her family were being treated differently than other residents regarding having to have a care plan meeting prior to getting an attending assigned. The ADM stated, They are being treated differently. All of our care plans are for the patient, what is different, we wouldn't give him this resident because he only took [PHY H's caseload], we are trying to avoid a nightmare. What is going to happen is he is not used to her questioning the labs and questioning [PHY D] and I am trying to be like hey, let's sit at the table, sit down and tell him what the issues are, then [MD F] is an advocate of the facility and we have to call him and do orders and do what he says so how can we all sit down and make a relationship? The ADM confirmed that no one had contacted the family to notify that MD F was assigned at Resident #1's physician and had not provided the family with his contact information. She said they tell the families what days the doctor will be here and if they want to talk to the doctor, we give the doctor that message. Review of an email exchange provided by the ADM on 05/01/23 between herself and MD F on 04/10/23 reflected, ADM-I am confirming out conversation regarding [Resident #1]. You agree that you are available to see the resident for emergency purposes or if the outside attending is not available. Due to previous concerns with Medical director, you do not want to be the attending only back up for emergencies. You also agree to only communicate with the facility staff and POA regarding the resident care. If this correct? To which MD F responded, I accept. Review of the facility's policy titled, Physician Services revised February 2021, reflected, Policy Statement: The medical care of each resident is supervised by a licensed physician. Policy Interpretation and Implementation: .2. Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS); 3. Supervising the medical care of residents includes (but is not limited to): a. participating in the resident's assessment and care planning; b. monitoring changes in resident's medical status; c. providing consultation or treatment when called by the facility; d. prescribing medications and therapy; e. ordering transfer to the hospital if necessary; f. conducting routing required visits; g. delegating and supervising follow-up visits by non-physician practitioner (NPs, PA, CNS's); and h. overseeing a relevant plan of care for the resident; 4. Each resident remains under the care of a physician. An alternate physician supervises the care of residents when his or her attending physician is not available: a. The attending physician may designate another physician to act on his or her behalf when unavailable., b. If the attending physician does not delegate another physician, the facility will have a physician available to supervise the care of the resident; 5. The attending physician will determine the relevance of any recommended interventions from other disciplines. The physician is not obligated to accept those recommendations is he or she had clinically valid reasons for not doing so; 6. Physicians orders and progress notes are maintained in accordance with current OBRA regulations and facility policy; 7. Physician visits, frequency of visits, emergency care of resident, etc., are provided in accordance with current OBRA regulations and facility policy; 8. Consultative services are made available from community-based consultants or from a local hospital or medical center; 9. The medical director identifies attending physician qualifications and responsibilities, based on clinical and regulatory requirements and the recommendations of relevant professional associations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to permit the resident to remain in the facility, and not transfer or discharge the resident from the facility from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility for one (Residents #1) of five residents reviewed for transfer and discharge requirements. The facility initiated a 30-day discharge to Resident #1 saying the facility could not meet her needs when Resident #1's attending physician resigned as her physician. This failure could result in residents being discharged without appropriate reasons and documentation communicated to help with the transition of care. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included Alzheimer's disease, hypertension, heart failure, atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), coronary artery disease and anxiety disorder. Resident #1 had clear speech, no hearing issues or impaired vision and her BIMS score was 08, which indicated moderate cognitive impairment. Resident #1 had no signs or symptoms of delirium, mood issues, or behaviors (which included psychosis and rejection of care). Review of Resident #1's Face Sheet (not dated) reflected her attending physician was PHY D (date active 03/31/23) and her medical director was MD F (date active 04/12/23). It also reflected that she had two family members as her essential caregivers and contacts. Neither of those family members were designated power of attorney by the facility. Review of the Resident #1's clinical chart revealed no evidence of a medical power of attorney. Review of Resident #1's clinical chart (including nursing notes, medication/lab/x-ray orders and emergency notification for change in conditions), reflected that MD E was the previous attending physician until 05/24/22, when he issued Resident #1 a discharge from services letter. Review of MD E's discharge letter dated 05/24/22 reflected, An effective patient-physician relationship is essential to providing good primary care. Based on recent and on-going events, it is clear the therapeutic relationship we shared no longer exists. As a result of this, I can no longer serve as your physician. Therefore, effective 30 days after the date of this letter, our patient-physician relationship will terminate. You will need to discuss with Crestview Court which other primary care physicians in the facility are available to attend to your regular healthcare needs. Moreover, y services to you will be available only for emergency purposes during the next 30 days. I recommend you establish care with a new provider as soon as possible and continue to receive healthcare services. [Signed MD E]. An interview with Resident #1's family member on 04/27/23 at 9:13 AM revealed there had been several facility-initiated discharge notices given to Resident #1 and her responsible parties due to the facility not having a doctor available to provide medical care, all which went to a hearing and were overturned by the hearing officer. The family member said the facility had stated that since Resident #1 did not have an attending physician anymore in the facility, but still had a primary care physician in the community, then they would contact that physician for routine visits and emergencies. However, if he was not reachable, they told the family member they would send Resident #1 to the hospital emergency room. The family member stated, I know part of the state and federal regulations states they have to have a physician. The family member said there had been several incidents with MD E, but there was one in particular where he failed to prescribe an antibiotic when she had double pneumonia. The family member said the facility had done an -x-ray on Resident #1 and MD E was aware of the results, but he did not start her on any antibiotics. The family member said MD E told the family he overlooked it because he was reading the x-ray results on his phone. The family member stated he/she was upset and told MD E that was no excuse and he could have killed Resident #1. A complaint was lodged with HHSC and an investigation was conducted and the family member stated MD E was upset that a complaint on him had been made. The family member stated there was another time MD E was negligent of providing standard care to Resident #1 around late September 2021 when the facility nurses and MD E did not notice that the resident had an infected toe down to the bone. The family member stated that HHSC ended up completing an investigation in April 2022 related to the complaint and cited/fined the facility and they were angry. On 05/26/22, the family member stated the facility ADM notified the RP that MD E was terminating his care due to an HHSC P1 complaint being lodged against him. The family member stated, He [MD E] did not want to own up to his mistakes and would only provide emergency care. The family member stated, They tried to put her out three or four times. They are saying it is because she doesn't have a physician. It is against state and federal laws. [Ombudsman] has drilled this over and over at the hearings. The family member stated 05/26/22 was when the facility issued the first discharge notice and as soon as the hearing officer ruled for Resident #1 to stay, the facility kept issuing more discharge notices. The family member felt like the situation was [NAME] to harassment. The family member said Resident #1 did have a doctor in the community, PHY D, who would always see her if needed, but the facility tried to say during the discharge hearings that he was going to be her attending physician, which was a lie. The family member said the same thing kept being brought up at each discharge hearing, but PHY D never agreed to be the attending physician. The family member stated, I mean this, god forbid something happens to [Resident #1] without physician care. It is to the point where they are harassing her. They are upset because of what had transpired starting with the toe thing. The family member also felt the facility was retaliating against the family and Resident #1. The family member stated that she received an email (no date given) from the ADM that was very concerning where it was said that PHY D would be her attending physician and they could reach him up to 7 pm or 8 pm at night, but after that time, they would contact a new assistant doctor at another facility to see her on an emergency basis. The family member stated, So in essence, [Resident #1] doesn't have a physician. I am so worried, you are going to just sit there and let her die or not render aid. I pray to god nothing happens. The family member said prior to MD E stopping his services for Resident #1, he had been her physician since 2016. Now, the family member stated on a day-to-day basis, no physician was overseeing her care. The family member said the facility claimed they had contacted other doctors to be the attending physician for Resident #1 but the said no. The family member said one of the doctors asked by the facility to be Resident #1's attending physician worked with MD E and the family member felt MD E told that potential doctor a lot of negative things about Resident #1 and the family, which caused that doctor to say no, even though he had never seen Resident #1. The family member said after the most recent attempt to discharge Resident #1 in 2023 due to the facility stating she did not have an attending physician, the family appealed and won, however, the family was notified after that that MD E would not even provide care for emergencies for Resident #1. The family member said PHY D had been Resident #1's outside physician during the seven years she had been at the facility and she periodically went to see him during those years because she was comfortable with him, but not for everyday care. The family member stated the Ombudsman would say the situation was retaliation and even the disability lawyer at the hearing said it was retaliation. The family member stated, They want her out, [MD E] got in trouble, I do not trust them, this doctor thing is huge, god forbid somethings happens to my [Resident #1] and she doesn't have the care. This is very hurtful for [Resident #1], she feels like they don't want her there. Her friends are there, that is all she knows. Review of an email exchange provided by Resident #1's family member to the facility's DON, ADM, Ombudsman, VP of Clinical Operations, VP of Operations dated 04/12/23 reflected, We are requesting that the new co medical director [MD F} be designated as [Resident #1]'s attending physician. The ADM responded back to the family member on 04/12/23, [MD F] does not want to be attending, sorry. I asked him and he emailed saying he didn't want to. An interview with the local Ombudsman on 04/27/23 at 4:41PM revealed the facility had not issued a subsequent discharge notice to Resident #1 since the last hearing on 03/30/23, however, subsequent to the hearing and after the hearing decision was issued, the facility issued another email indicating they did not have a doctor for Resident #1. The Ombudsman stated, The facility keeps doing this because he doesn't want to be the attending, which he has the right to be. The other doctor there, he doesn't want to do it because of the consultation with [MD E]. At the end of the day, the resident needs an attending physician. Her doctor, who she has seen in the community for years, he does not want to be credentialed by the facility. The Ombudsman said there had been a recent communication in the past couple of weeks where the ADM stated the facility had a new co-medical director [MD F]. The family responded saying they were okay with that new co-medical director being Resident #1's attending physician, but the response from the facility was that he did not want to do it. The Ombudsman stated the situation was bordering on discrimination and she was concerned Resident #1 was going to be discriminated against if she ever did have to move to other facilities in the metroplex where MD E and MD F had affiliations directly or with other doctors in their practice. The Ombudsman stated, I didn't find anything in the regs that residents can be discharged because a doctor doesn't want to provide care. That's why we back to regs. They are responsible for providing an attending physician. Who is overseeing her medical care now? Who is writing orders for her? The Ombudsman said after 03/30/23 when the hearing officer reversed the facility's action related to discharge, Resident #1's two RP's were sent an email from the ADM informing them that if any emergencies happened to Resident #1, they would contact PHY D or send Resident #1 to the hospital ER for treatment and the staff had been informed to contact the family if they were unable to contact the outside physician. At that time, the facility requested a care plan meeting to ensure everyone was on the same page. The Ombudsman said that email was sent on 03/30/22 and then the vice president of operations responded in an email to the RPs that the facility had not heard back from them regarding the care plan meeting about the physician issues and that MD E would no longer be the physician, even for emergency situations. The email also stated, per the Ombudsman, We have attempted to find another physician but were unsuccessful. You have identified [PHY D] as attending of choice, this includes after business hours. At this time [PHY D] has not provide us with after-hours information. The Ombudsman said that meant any emergencies for clinical issues would be to contact PHY D and if no response, then send Resident #1 to the hospital. The Ombudsman said the family did not know what to do because they had no opposition to any of the doctors at the facility being the attending physician because the resident must have an attending in the nursing home. So the issue then is back to the resident does not have a doctor available to oversee her care while in the nursing home. The Ombudsman said there was another email from the ADM dated around 04/10/23 where she notified Resident #1's RPs that MD F agreed to see her for emergencies only when the attending is not available and had agreed to speak with the POA if any emergencies come about and the DON had reached out to PHY D who agreed to see Resident #1 twice a month, do health and physical assessments, and progress notes and would be available until 8pm, and provided an after-hours number, but we still want a care plan meeting to discuss any issues. However, further inquiry by Resident #1's RPs to PHY D revealed he did not agree to any of that. On 04/12/23, Resident #1's RPs notified the DON that PHY D did not agree to anything and requested the new co-medical director [MD F], be designated as her attending physician but was told in writing by the ADM that he did not want to be. The Ombudsman stated, So we have a resident in the building with no attending physician; a [AGE] year-old resident, been there 7 years, no issues with the resident, only with the family. They [facility] have to work with them, there is no threat on life, so where are you going to discharge her to? I am telling you, this I reaping of discrimination. The Ombudsman said she went through Resident #1's clinical chart for the appeal hearing and there was no documentation from MD E to indicate he was going to terminate his relationship with her, which was brought up in the hearing, only a letter was issued, but nothing in the chart, nothing documented. The Ombudsman said she told Resident #1's RP that if MD E did not want to provide care or services, the regulations allowed that. However, that was not the issues, the issue was the regulation that the facility provided a doctor for Resident #1, The facility must assist the resident or the resident's representative in finding a replacement. [Facility] is a large company and there is something unethical in discharging resident, who's to say you won't come in contact with that same doctor at a sister facility or another facility because the doctor is still affiliated or had doctors they are connected with who don't want to work with the resident. She is being blackballed, You have a person, the resident, who hasn't been resistant. This is about not having a doctor. Resident needs care, has permanent medical necessity and who is overseeing her care? They are required to do H&Ps, write medication orders, do all those kinds of things, who does it? .the communication says they will just send her to the hospital. Review of Resident #1's clinical chart (including her physician visits in the facility) revealed the last time she was seen for a face to face visit by MD E was 06/07/22 for shoulder pain. There were no changes made in her care management as Resident #1 stated it only hurt when she raised her arm over her head. Her range of motion was not affected. The exam reflected MD E remained her supervisor and rendering provider. Review of Resident #1's progress notes reflected she was not seen by MD E face to face for required physician visits or by his extenders from June 7, 2022 through April 2023 (10 months). A follow up interview with the ADM on 04/27/23 at 5:31 PM revealed MD F had been referring a lot of his patients from the hospital he worked at so she wanted to ask him to be the medical director. He agreed to come over and take over as the attending physician for the residents he had referred to the facility, which were skilled residents and he initially did not want to be the attending physician for those residents once they went long-term, but he agreed to be, if they were his skilled residents prior. The ADM stated MD F said he would consider being Resident #1's attending for emergencies, If the family would meet with him first. The ADM was asked where does it state in the facility's policy or medical director/attending physician contract that a doctor has to meet a with resident and their RP prior to deciding if he would accept them. The ADM stated, He agreed to see his patients only that he referred from the hospital. I am not going to lose him over this family. The ADM was asked if MD F was able to contact the family via phone to talk about Resident #1 and she said a care plan meeting had been requested by him. The ADM continued to sated state that PHY D agreed to be Resident #1's attending physician and she had the letter confirming it and would look for it. A confidential interview with a facility staff member on 05/01/23 occurred where they were familiar with Resident #1 and wanted to state that the facility did not exactly create this whole situation to try and get her discharged for not having an attending physician, per say, but they saw it as an opportunity and didn't do anything to prevent it from happening, in trying to work it out and help find a doctor. Attempted to contact the VPCO for the facility on 05/01/23 at 2:39 PM with no success. An interview with the ADM on 05/01/23 at 3:46 PM revealed MD F and the facility did not have to meet with Resident #1 family in order for him to be the attending physician. The ADM responded no, that was why the VP of Clinical Operations said it was going to be to clarify and the family did not have to attend. The ADM said in the beginning, MD F did not want to pick up any long-term residents but the previous attending physician had too many complaints on him (PHY H) and is no longer the attending at the facility, so when MD F came over, MD E had too many residents and MD F had to have some of them assigned to his caseload. The ADM said prior to PHY leaving, she asked him to be Resident #1's attending and he said no. She said she asked a doctor at a sister facility if he would do it, and he said no. The ADM was asked again, if MD F refused to be the attending for Resident #1 and if she had documentation of him, as well as the other physicians she contacted saying no to being Resident #1' attending. She said she would look for the email exchanges. The ADM said, We want her to sit down and have [MD F] explain to the family what the expectations are. The ADM was asked if Resident #1 and her family were being treated differently than other residents regarding having to have a care plan meeting prior to getting an attending assigned. The ADM stated, They are being treated differently. All of our care plans are for the patient, what is different, we wouldn't give him this resident because he only took [PHY H's caseload], we are trying to avoid a nightmare. What is going to happen is he is not used to her questioning the labs and questioning [PHY D] and I am trying to be like hey, let's sit at the table, sit down and tell him what the issues are, then [MD F] is an advocate of the facility and we have to call him and do orders and do what he says so how can we all sit down and make a relationship? The ADM confirmed that no one had contacted the family to notify that MD F was assigned at Resident #1's physician and had not provided the family with his contact information. She said they tell the families what days the doctor will be here and if they want to talk to the doctor, we give the doctor that message. Review of Resident #1's clinical documentation from PHY D reflected she was seen on 05/24/22 for a hospital follow up. The exam notes reflected Resident #1 originally went to the hospital after she was hit in the chest with a Hoyer lift and a chest x-ray showed infiltrates. She was diagnosed with pneumonia and antibiotics. She was noted to have a low fever at onset. PHY D documented Resident #1's visit diagnoses were : History of pneumonia, pressure injury of the right buttock-stage 3, hypertensive heart and kidney disease with HF and ESRD, ESRD on dialysis, chronic combined systolic and diastolic congestive heart failure, late onset Alzheimer's disease without behavioral disturbance and type 2 diabetes. No treatment or medications were ordered. Review of previous facility initiated discharge notices and fair hearing results provided by the ombudsman on 05/10/23 reflected: A. Resident #1 was issued the first facility-initiated 30-day discharge letter on 05/26/22 due to physician termination of services and the facility not having another physician available to accept responsibility. A Fair Hearing was completed on 07/26/22. A Fair Hearing Decision, Appeal ID 3576402, dated 09/12/22 reflected the hearing officer reversed the facility's action. B. Resident #1 was issued a second facility-initiated 30-day discharge letter on 10/17/22 due to physician termination of services and the facility not having another physician available to accept responsibility. A Fair Hearing was completed on 12/01/22. A Fair Hearing Decision, Appeal ID 3605691, dated 12/16/22 reflected the hearing officer reversed the facility's action. The Hearing Officer stated in part, Evidence was not provided by the nursing facility showing documentation was made by the Appellant's physician prior to the discharge notice of the specific resident's needs that could not be met and the services available at the receiving facility to meet the Appellant's needs. C. Resident #1 was issued a third facility-initiated 30-day discharge letter on 12/19/22 due to physician termination of services and the facility not having another physician available to accept responsibility. A Fair Hearing was completed on 12/19/22. A Fair Hearing Decision, Appeal ID: 3624346, dated March 03/30/23 reflected the hearing officer reversed the facility's action. On 05/09/23, review of an HHSC complaint was reviewed that indicated Resident #1 had been issued a fourth facility-initiated 30-day discharge notice. Review of a facility initiated 30-day discharge notice dated 05/09/23 reflected, .I. This discharge is necessary for the resident's welfare as each and every available physician has either terminated their services to [Resident #1] or otherwise refused to take her as a patient. Despite efforts, the facility is not able to obtain an attending physician who will agree to take [Resident #1] as a patient. Without a physician overseeing [Resident #1]'s care, the facility cannot meet the needs of [Resident #1]. The physicians who have refused to take [Resident #1] as a patient include [MD E], [PHY M], [PHY N], [MD F] and [PHY D] (who was also [Resident #1's] outside primary care physician). Most recently, [MD F] declined to serve as [Resident #1]'s attending physician and is only seeing [Resident #1] on an 'as needed' basis; . [Resident #1] requires an attending physician. A physician treating her on an 'as needed basis' does not amount to an attending physician, does not meet [Resident #1's] needs, and does not allow the facility to adequately meet [Resident #1's] needs and welfare The facility has exhausted all possible credentialed attending physician provider sources beyond [MD F]. On 05/09/23, review of an HHSC complaint was reviewed that indicated Resident #1 had been issued a 30-day facility-initiated discharge notice. Review of a facility initiated 30-day discharge notice dated 05/09/23 reflected, .I. This discharge is necessary for the resident's welfare as each and every available physician has either terminated their services to [Resident #1] or otherwise refused to take her as a patient. Despite efforts, the facility is not able to obtain an attending physician who will agree to take [Resident #1] as a patient. Without a physician overseeing [Resident #1]'s care, the facility cannot meet the needs of [Resident #1]. The physicians who have refused to take [Resident #1] as a patient include [MD E], [PHY M], [PHY N], [MD F] and [PHY D] (who was also [Resident #1's] outside primary care physician). Most recently, [MD F] declined to serve as [Resident #1]'s attending physician and is only seeing [Resident #1] on an 'as needed' basis; . [Resident #1] requires an attending physician. A physician treating her on an 'as needed basis' does not amount to an attending physician, does not meet [Resident #1's] needs, and does not allow the facility to adequately meet [Resident #1's] needs and welfare The facility has exhausted all possible credentialed attending physician provider sources beyond [MD F]. On 05/11/23 at 9:15 AM, HHSC re-entered the facility due to an additional complaint made related to Resident #1 being given another facility-initiated discharge notice on 05/09/23. A follow up interview on 05/11/23 at 9:30 AM with the ADM revealed since the completion of the HHSC's initial investigation on 05/01/23, the facility decided to issue Resident #1 a discharge notice because she did not have an attending physician and he got results and based of state surveyors and what is going on, he doesn't want to take the risk and he talked to [MD E] and after talking to the family, he didn't feel confident in taking them on. The ADM stated she sent MD F HHSC's preliminary findings for deficient practice after the state visit on 05/01/23 and the facility had a QAPI meeting. The ADM said he write wrote a note and since she was out of the discharge process, she sent it up to the facility's attorney and corporate and they were handling it at the corporate level. The ADM stated MD F agreed to see Resident #1 and did an H&P and told the family he would continue to see her as the facility needed, and he was listed as her doctor on her face sheet for nurses to call, but he did not want to say he was her attending. The ADM stated MD F was out of the country presently. The ADM was asked why she continued to stated she was out of it related to Resident #1's discharge. The ADM stated, I felt the need, I am still the ED and they have to discuss with me, but [family member]'s comments have gotten name calling and I do still send the emails, be very polite, but as far as discharge, going in from the appeals, I am letting the attorney's do that. The ADM stated MD F took on skilled patients now because MD E could not take them all, and that was the agreement when MD F agreed to be the co-medical director. She said MD F took some of PHY N's patients (who was a previous attending at the facility) because he was a part of his same group practice. The ADM said PHY N was removed from the building due to not visiting his residents and was having issues, so MD F stepped in and took over his residents already there, then the facility asked if he would be interested in being the co-medical director and he agreed. The ADM said first, MD F agreed to be available for emergency basis for Resident #1, then he talked to the family, I told him I didn't even want to know what happened with the family, I just wanted to know what the result was. He sent me a letter the next day. The ADM was queried if she felt the newest facility initiated discharge was retaliation towards Resident #1 and she responded no, she felt he facility did a great job of taking care of the resident, The discharge is more based off of the latest visit by State and findings. Her not having an attending has nothing to do with it, it is the dynamics between the physician, the physician is the one who gave is a discharge, [MD F] did not give her any notice no 30-day notice. He was not her attending. The risk we take is the State continues to come and writes us tags for not having an attending, so we are forced to discharge her because we cannot continue to take tags. The ADM was asked if MD F had a problem directly with Resident #1. She replied, I don't think anyone has issues with [Resident #1]. An interview with the SW on 05/11/23 at 10:02 AM revealed her role presently was to help the family find a suitable facility for Resident #1 and she did not have any part of the discharge notice being issued. The SW stated there was supposed to be a scheduled care plan meeting that was postponed because someone couldn't make it, then it was re-scheduled but then MD F had an emergency and could not make it, So the plan was to discharge after the care plan meeting or pending the outcome of the care plan meeting but the meeting never happened. The meeting was to see if we could meet Resident #1's medical needs, meaning if she doesn't have a doctor, we are not meeting her needs. My understanding is we have to have a physician and my understanding is [MD F] would see her for emergency situations or something to that effect until she could find another physician. I have no idea why [MD F] said no, because we didn't have that meeting. The SW was asked if she felt Resident #1 was being retaliated against by the facility and she replied, No I do not. Because if we have done our very best we can do and the family is still not happy with the care they are receiving here, it is my professional opinion they should seek a facility elsewhere that can meet her needs. The family has a right to file complaints with the state, that is what you are there for and I fully support that, but there have been numerous reports made by this family to the state and it's always the same thing, I don't think none of them have been substantiated. Therefore if the family is not happy, it is in the best interest of [Resident #1] to find an environment in which she would be happy and the family would be happy. An interview with MD E on 05/11/23 at 10:16 AM revealed when he gave Resident #1 a discharge notice a year ago, and he was still dealing with it, if that doesn't tell you why I don't want to deal with this, I told her it was a philosophical difference in our care. It is kind of exhausting, I have been dealing with this for a long time .the family dictates her care, so I guess they were driving her care clinically, so that is where the philosophical difference goes hand in hand MD E was asked to provide any previous clinical documentation that would show the specific issues, times and circumstances that caused him to stated they did not agree and he was not able to. He stated he had no more documentation and the 30-day notice should suffice. An interview with the VPCO on 05/11/23 at 10:27 AM revealed Resident #1 was given a facility initiated discharge because as it stated in the letter, the facility did not have a doctor as her primary physician and there was not another one to take her on and everyone that had been asked, said no. The VPCO stated she had not asked any physicians herself, to be Resident #1's doctor. The VPCO stated her expectation for the facility to find an attending physician was that normally, they had two tot here to three credentialed doctors with the facility and they ask them if they would like to take on a patient and if they would, easy breezy let's go, if not, then the facility would talk to the facility to see if there was one they would like and it would work out, but in this care, it's not. The VPCO stated she was in her position when MD E discharged Resident #1 and she recalled the resident had gone to the hospital, MD E was trying to get information and she believed the family said no which was alarming to him. The VPCO stated the family conflict with the doctor happened prior to the current ADM coming to the facility and there had been multiple meetings with the family, including the doctors, but the family would not show up or refused to. When a meeting has happened, the VPCO stated everyone tended to leave on a better note, but the family member sort of sleeps on it and gets angry again, so it's back to ground zero, so if we take a step forward, we take a step back. The VPCO stated she understood MD F to only do as needed basis for emergencies for Resident #1 until she discharged , but she had not spoken to him, so she did not know for sure. The VPCO stated, He does not want ot take it on. My understanding is he did speak to the facility on the phone so I don't [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accidents and supervision. CNA J and CNA K failed to complete a proper Hoyer lift transfer with Resident #1, resulting in the Hoyer lift falling over and Resident #1 being struck in the face by the Hoyer lift and causing emotional distress. The failure placed residents at risk for accidents and injuries, limiting their quality of life. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included Alzheimer's disease, hypertension, heart failure, atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), coronary artery disease and anxiety disorder. Resident #1 had clear speech, no hearing issues or impaired vision and her BIMS score was 08, which indicated moderate cognitive impairment. Resident #1 had no signs or symptoms of delirium, mood issues, or behaviors (which included psychosis and rejection of care). Resident #1 required extensive physical assistance of two or more staff for transfers to or from her bed, chair and wheelchair. Resident #1 weighed 164 pounds and was 64 inches tall (five foot, four inches). Review of Resident #1's care plan effective 05/28/19-present reflected Resident #1 was at risk for falls related to impaired mobility and cognition due to an active fall (no date given). The goal was to not have any signs or symptoms of harm or injury while in her wheelchair or transfers. The care plan also reflected that Resident #1 required extensive assistance with transfers with a Hoyer and two staff. Interventions included to explain the procedure during transfers, tell Resident #1 step by step what was happening and on-going education to staff and new staff including outside vendor staff about Hoyer lift and two person at all times while operating for safety; Meeting held with family 04/13/22 about concerns and interventions. Additionally, Resident #1's care plan reflected she had a diagnosis of osteoporosis/osteopenia (Osteopenia is a condition where people's bone density is lower than is usual for their age. Osteoporosis is a more severe case of bone loss that weakens the bones and makes them more likely to fracture) and was at risk for spontaneous fractures (a fracture that occurs in seemingly normal bone with no apparent blunt-force trauma)/falls. Interventions included to assist Resident #1 carefully when providing care. An interview with Resident #1's family member on 04/27/23 at 9:13 AM revealed Resident #1 was hit in the chest, head and face with a Hoyer lift bar in May 2022 and had been dropped during a Hoyer lift transfer in the past while at the facility. The family member said Resident #1's skin was thin and she could get hurt easily, so staff needed to stop, take a break, and regroup if the resident told them what they were doing was hurting her. A follow up written correspondence with Resident #1's family member on Sunday, 04/30/23 at 2:34 PM contained video footage through the AEM in her room the morning of 04/29/23 at 7:44 AM, where the family member felt it indicated the facility staffs' failure and negligence of Hoyer lift use. The family member stated the Hoyer lift continued to be an ongoing issue and it had been brought the attention of the ADM many times. The family member stated, We are extremely concerned about transfers at the facility using the Hoyer lift improperly. The family member stated that Resident #1 had been dropped from the Hoyer lift in the past, hit in the head twice with the Hoyer bar, hit in the face twice with the Hoyer bar, hit in the chest with the Hoyer bar, and now hit in the face/head again. The family member stated that in the video footage included, the staff could be seen shoving Resident #1's wheelchair over the base legs of the Hoyer lift, which caused the wheelchair to hit her on the left side while she was in the sling without either staff holding the sling as she sat there. The family member felt the staff should have positioned the Hoyer lift and wheelchair properly to prevent the wheelchair from hitting her in her side. The family member stated, These actions once again, caused [Resident #1] pain and anxiety, she cried due to their actions. The family member stated after that, the video showed improper use again of the Hoyer lift, as the bar hit her in the head/face and the entire Hoyer lift flipped over as they placed her in the wheelchair. The family member stated, This could have been deadly. It's been statistically proven, improper use of Hoyer lifts for transfers and staff negligence have caused death of some of the most vulnerable nursing home residents. An interview with the ADM on 05/01/23 at 10:00 AM revealed there had been an incident over the weekend where the Hoyer lift lightly grazed Resident #1's forehead. The ADM stated there were staff in Resident #1's room and that in general, staff were nervous when they went in and provided care or did transfers because of the history with the family and they were always watching on the video camera. The ADM stated two staff were doing a transfer Saturday, 04/29/23 and at one point, the bar of the Hoyer lift grazed her [Resident #1]. MD F was contacted and was out of town, so his physician's extender told the facility out of an abundance of caution, he would order an x-ray. The ADM stated Resident #1 was not complaining of pain and did not remember anything happening, but the family chose to send her to the ER to make sure she was okay. Review of in-room video surveillance footage provided by the family member and time stamped 04/29/23 at 12:44PM through 12:45 UTC [which was 7:44 AM] and lasting about one and a half minutes, started with Resident #1 already in the Hoyer sling being lifted off her bed. CNA J and CNA K left the Hoyer lift's base legs partially under the bed with the lift not fully cleared from under the bed. The Hoyer lift's base legs were not observed to be fully opened. Both CNAs then are seen taking Resident #1's wheelchair and lift the wheelchair's front wheels over the left side of the Hoyer's left base leg. The motion shakes the Hoyer lift and Resident #1 can be heard saying, Oh my lord. When they get the wheelchair's front wheels over the base legs, Resident #1 cries out and says, Oooo, ow, you hit me in my thigh!. CNA K then tries tried to lift the back straps of Resident #1's Hoyer sling to center her in the wheelchair with one arm but let's her go. CNA K was not able to hold Resident #1's Hoyer sling straps to lift her up and place her into her wheelchair as she was only using her right arm. CNA K then went to the back of the Hoyer lift and CNA J went behind Resident #1's wheelchair. Resident #1 can be heard saying lord have mercy. When CNA K lifted up on the Hoyer sling straps (which are located under the sling on the back of Resident #1), the entire Hoyer lift immediately tilted to the left. CNA K can be seen unable to use her left arm to grab the Hoyer Lift stand to stabilize it. Resident #1 was still hanging in the sling when the Hoyer lift leaned and fell over to the left, which inadvertently placed Resident #1 in her wheelchair. The weight of the Hoyer lift could be seen resting partially on Resident #1's lower extremities, as she was still attached to lift via the sling. The right side of the Hoyer lift's two base legs and two wheels were entirely off the floor (front facing perspective) and reached to the top of her Resident #1's mattress, which showed how far the lift fell over. Resident #1 screamed out Oooow!, covered her face with both hands and started crying. After the Hoyer lift fell over, CNA J and CNA K were unable to immediately lift it off of Resident #1. Review of Resident #1's Accident/Incident Report reflected on 04/29/23 at 8:20 AM, CNA/LVN attempting to transfer resident via Hoyer lift to be for incontinent care. While moving Hoyer towards resident, lift bar moved and bumped resident on head. LVN immediately assessed with no visible injuries note. Attempted to notify [PHY D], unable to reach by phone, facility medical director notified with new order received to obtain skull series to R/O injury. RP/ED/DON notified of new orders received. Review of the witness statement by CNA J dated 04/28/23 [sic] and obtained by the facility as part of the incident report reflected, I [CNA J] was helping the patient in her chair when the Hoyer leaned and slightly touched her. We both immediately were able to avoid any errors, me and another CNA. We immediately notified the charge nurse and supervisor. Review of the witness statement by CNA K dated 04/29/23 and obtained by the facility as part of the incident report reflected, I [CNA K] was helping another CNA put a patient [Resident #1] in her chair when the Hoyer lift leaned and slightly touched her face. We both were immediately able to avoid any errors We immediately notified the charge nurse and supervisor. Review of Resident #1's hospital records post-incident dated 04/29/23 reflected she arrived at the emergency room at 11:02 AM via an ambulance with an admission type as Urgent; History: Fall with left knee injury, left knee pain, acute, initial episode. Resident #1 had an x-ray to her knees with no fracture indicated, however she was noted to have severe tri compartment osteoarthritis (a type of arthritis that affects the knee). Resident #1 also had a CT of the cervical spine CT of the head with no negative findings. An observation and interview with Resident #1 on 05/01/23 at 12:08 PM revealed she remembered going to the hospital the previous weekend (04/29/23). When asked what happened, Resident #1 stated the thing hit her in the face. She could not remember but stated it happened when they were moving her and it fell over. Resident #1 could not recall the who, when and time. Resident #1 could not remember where on her face the Hoyer lift hit her, she just remembered it hit her and it hurt. She said her family wanted her to go to the hospital. Resident #1 did not remember what happened at the hospital and stated she was not hurting anymore, but she was not sure if she was going to let those girls mess with me and that thing [Hoyer lift] going forward. Resident #1 stated, It scared me. An interview with CNA J on 05/01/23 at 12:36 PM revealed on the morning of the incident (04/29/23), she was working with CNA K, a new CNA who she did not normally work with. CNA J stated she was the assigned staff to Resident #1 and had gotten her up that morning to get her dressed and then called for help and CNA K was the only person that came to help her. CNA J said this was around 7:00 AM, because Resident #1 liked to get up early. CNA J stated she and CNA K put the sling around Resident #1, attached all four sides, lifted her up and when they lifted her, everything was open and the latch was open. She said, So we lifted her up, got latches/legs open, we had it all open. So when I had got her in the .no, what happened, I was leading the back and [CNA K] tried to put her in the chair but was struggling, [CNA K] don't have but one usable arm, I saw she was struggling, I said let's switch. I don't know what happened but I had the chair ready for her, but when I went to pull her back, the Hoyer started leaning . [CNA K] went to guide the button that goes up and down, the Hoyer remote. CNA J then stated, She [Resident #1] was already down in the chair. When in her wheelchair, the legs of the Hoyer, [Resident #1] was to the side and the legs were open for the chair or whatever, she was to the side because at that time, it was easier because the room was so congested and you don't want to do too much. CNA J stated the Hoyer lift started to lean and she told CNA K to hold on. CNA J stated, If it was me, I would have prevented it. If it was me at the remote and [CNA K] putting her in her chair, I would have made some kind of way for it not to tip over. It happened so fast. Thank god the bar went over her head and the straps touched her face. CNA J stated the Hoyer lift did not fall all the way to the ground, it leaned. CNA J stated she kept apologizing to Resident #1, but She was fussing about it. She didn't say anything was hurting. She kept saying y'all is just crazy. Even after it happened, she forgot about it. CNA J said if she could have done things different, she would not have put Resident #1 in her wheelchair from the Hoyer lift from the side. CNA J stated they should have gotten Resident #1's wheelchair front-facing with the Hoyer lift instead of having the wheelchair pulled over the Hoyer legs coming from the side, But see because she was already fussy that morning, we just really wanted it to be simple for her. CNA J stated she had been employed at the facility for about a month. An interview with CNA K on 05/01/23 at 1:17 PM revealed she had been employed at the facility for four days and Saturday, 04/29/23 was her last day of training. She stated she had finished her OJT and orientation. CNA K stated on 04/29/23 in the morning, she was doing a Hoyer transfer with Resident #1 and the lady she was with [CNA J] was holding the wheelchair and CNA K was trying to turn the wheelchair. CNA J told her to just leave the wheelchair where it was and lower the resident, so she leaned the resident down and lowered it. Then the wheelchair got caught on the Hoyer lift and made the lift tilt, So I had to catch it and it lightly grazed her head, the top of the Hoyer lift, not the black part, the arm, that white part that the arm that the arm is attached to. CNA K stated the Hoyer lift fell to the right side but did not fall all the way to the floor. CNA K stated, The lady that I was with, so the Hoyer lift, she didn't position the wheelchair properly. It wasn't between the legs, it was on the side of the Hoyer, so the front wheels were in the middle of the two legs, so it caught. I was trying to move it because I had the wheelchair first. I was trying to move the wheelchair between the legs, move the Hoyer, and she (CNA J) was just like 'no no no I got it, just lower it'. I said are you sure? She said yeah, so I lowered it. CNA K stated when CNA J pulled the wheelchair back was when it got caught and tilted over. CNA K stated she thought Resident #1 was scared more than anything, because the Hoyer lift lightly grazed her. CNA K stated Resident #1 did not have any scratches, bumps or bruises, It just shocked her more than anything. CNA K said she had recently gotten certified as CNA and was fully paralyzed on her left arm from birth, so when it comes to the Hoyer and sit-to-stand procedures, I make sure I do it properly because not only is it going to hurt you, it's going to hurt my arm, so I am not going to put myself in that situation. CNA K stated this incident occurred on her third day of training and it was her first time working with CNA J. CNA K stated, I was in training, not out of it. I felt like I was ready to do a Hoyer transfer because I have seen those before, it was just the [NAME] of the caregiver, not wanting to listen to someone new telling her something. If you would have followed what you were supposed to do .resident would not have bumped her head. An interview with CNA L on 05/01/23 at 2:16 PM revealed she was also the facility's staffing coordinator and did skills checks on the new hires. CNA L stated she was not present on 04/29/23 for the incident with Resident #1. CNA L stated she remembered seeing CNA K doing a Hoyer lift and she could only work the back end of the Hoyer, not the front end, and she could control the remote. Once a resident was up in the sling in the Hoyer, then CNA K could make sure that resident's legs were safe, however, CNA K could not be the person who pulled on the sling straps to place the resident into a wheelchair which would prevent the resident's legs from hitting the Hoyer lift. Review of the facility's Mechanical Lift education provided to staff (undated), reflected, Patient falls from lifts may cause injuries, including head trauma, fractures and death .Prepare Environment: .Base legs are usually more stable in full open position, .Ensure there is space for lift to pivot and move freely to receiving area; .Lower the Patient: 1. Use gentle hands-on pressure to guide patient as you slowly move lift toward receiving surface- Holding or supporting patient's weight while in sling may cause straps or hooks to detach from lift; 2. Slowly lower patient toward receiving surface. Move patient's body into correct position on receiving surface before releasing body weight; 3. Release patient's weight, do not let sling bar hit patient Review of the facility's policy titled, Safe Patient Handling and Movement Program (not dated), reflected, compliance: It is the duty of employees to take reasonable care of their own health and safety, as well as that of their co-workers and Patients during Patient handling activities by following this policy .Procedures: .Use available mechanical lifting devices and other approved handling aids in accordance with instructions and training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter or alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner or clinical nurse specialist for one (Resident #1) of five residents reviewed for physician services. The facility failed to ensure Resident #1 was seen by the facility's attending physician and/or the physician's extender at least once every 60 days from December 2022 through April 2023. The failure could place residents at an increased risk of not receiving appropriate and adequate medical care. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included Alzheimer's disease, hypertension, heart failure, atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), coronary artery disease and anxiety disorder. Resident #1 had clear speech, no hearing issues or impaired vision and her BIMS score was 08, which indicated moderate cognitive impairment. Resident #1 had no signs or symptoms of delirium, mood issues, or behaviors (which included psychosis and rejection of care). Review of Resident #1's Face Sheet (not dated) reflected her attending physician was PHY D (date active 03/31/23) and her medical director was MD F (date active 04/12/23). PHY D was not a contracted physician with the facility, he was a doctor in the community. Review of Resident #1's clinical chart (including nursing notes, medication/lab/x-ray orders and emergency notification for change in conditions), reflected that MD E was the previous attending physician until 05/24/22, when he issued Resident #1 a discharge from services letter. Review of MD E's discharge letter dated 05/24/22 reflected, An effective patient-physician relationship is essential to providing good primary care. Based on recent and on-going events, it is clear the therapeutic relationship we shared no longer exists. As a result of this, I can no longer serve as your physician. Therefore, effective 30 days after the date of this letter, our patient-physician relationship will terminate. You will need to discuss with [facility] which other primary care physicians in the facility are available to attend to your regular healthcare needs. Moreover, my services to you will be available only for emergency purposes during the next 30 days. I recommend you establish care with a new provider as soon as possible and continue to receive healthcare services. [Signed MD E]. Review of Resident #1's clinical chart (including her physician visits in the facility) revealed the last time she was seen for a face-to-face visit by MD E was 06/07/22 for shoulder pain. There were no changes made in her care management as Resident #1 stated it only hurt when she raised her arm over her head. Her range of motion was not affected. The exam reflected MD E remained her supervisor and rendering provider. Review of Resident #1's progress notes on 04/27/23 reflected she was not seen by MD E face to face for required physician visits or by his extenders from June 7, 2022 through April 2023 (10 months). An interview with Resident #1's family member on 04/27/23 at 9:13 AM revealed there had been several facility-initiated discharge notices given to Resident #1 and her responsible parties due to the facility not having a doctor available to provide medical care, all which went to a hearing and were overturned by the hearing officer. The family member said the facility had stated that since Resident #1 did not have an attending physician anymore in the facility, but still had a primary care physician in the community, then they would contact that physician for routine visits and emergencies. However, if he was not reachable, they told the family member they would send Resident #1 to the hospital emergency room. The family member stated, I know part of the state and federal regulations states they have to have a physician. An interview with the DON on 04/27/23 at 1:48 PM revealed she never talked directly to PHY D, only the receptionist at his office on 04/10/23. She asked the receptionist where the facility could send the current month's physician's orders and that the facility needed a current H&P and progress notes from the visits Resident #1 had with PHY D because she had been to see him a few times. The DON said there was some miscommunication between the family of Resident #1 and the facility on how often the resident needed to be seen and that the facility said MD E would see the resident every two weeks, but the DON said that was not what she had said and she had never talked to him. The DON said, I have never been able to talk to [PHY D] to this day. The DON conformed confirmed that Resident #1 had not had no a H&P since February 2022, which was completed by MD E. The DON said the last note MD E wrote for Resident #1 was on 06/07/22. The DON said she asked PHY D (no date given) for any documentation on Resident #1 but only received medical documentation from 2020 and 2021, nothing current. An interview with MD E on 04/27/23 at 3:56 PM revealed he was the medical director for the facility and had been the attending physician for Resident #1 for the past five to six years but was no longer her attending physician. MD E stated the circumstances that caused him to cease being Resident #1's attending physician were cumulative and I think it was more differences in our philosophies in care was our biggest difference. MD E said Resident #1 had PHY D for many years and she would follow up with him as well, So I think she resumed care with [PHY D] and I think the facility transports to him now every 60 days. MD E confirmed that if a resident did not have an attending physician, then it was the medical director's role to oversee that resident's care. An interview with MD F on 04/27/23 at 5:40 PM revealed he was a new co-medical director for the facility as of April 2023 and he had not seen Resident #1 face to face yet but she had been put on his caseload. An interview with PHY D on 05/01/23 at 4:49 PM revealed he had not seen Resident #1 in about a year and prior to that, he had rarely seen her. He said looking back, it looked like 2020 was the first time they saw her as a patient and he only saw Resident #1 when the family brought her to his clinic. PHY D said, I assumed she was being seen there. I only see her on an outpatient basis. We have no treatment with her at the facility. I don't know what facility she is in. PHY D said his role in caring for Resident #1 was when the family brought her to him, that was it, that was the only care he provided for her. He said he had a few patients that lived in nursing homes and periodically, they could come and see him. PHY D said he was not Resident #1's attending physician, he was technically listed as her primary care provider, But I can't take care of someone who never sees me. Any care she needs at the facility had to be from a contracted physician. The facility had never asked me to be the attending and I never would. Review of Resident #1's clinical documentation from PHY D reflected she was last seen on 05/24/22 for a hospital follow up. The exam notes reflected Resident #1 originally went to the hospital after she was hit in the chest with a Hoyer lift and a chest x-ray showed infiltrates (an abnormal substance that accumulates gradually within cells or body tissues). She was diagnosed with pneumonia and placed on antibiotics. She was noted to have a low fever at onset. PHY D documented Resident #1's visit diagnoses were : History of pneumonia, pressure injury of the right buttock-stage 3, hypertensive heart and kidney disease with HF and ESRD, ESRD on dialysis, chronic combined systolic and diastolic congestive heart failure, late onset Alzheimer's disease without behavioral disturbance and type 2 diabetes. No treatment or medications were ordered. Review of previous facility initiated discharge notices and fair hearing results provided by the ombudsman on 05/10/23 reflected: A. Resident #1 was issued the first facility-initiated 30-day discharge letter on 05/26/22 due to physician termination of services and the facility not having another physician available to accept responsibility. A Fair Hearing was completed on 07/26/22. A Fair Hearing Decision, Appeal ID 3576402, dated 09/12/22 reflected the hearing officer reversed the facility's action. B. Resident #1 was issued a second facility-initiated 30-day discharge letter on 10/17/22 due to physician termination of services and the facility not having another physician available to accept responsibility. A Fair Hearing was completed on 12/01/22. A Fair Hearing Decision, Appeal ID 3605691, dated 12/16/22 reflected the hearing officer reversed the facility's action. The Hearing Officer stated in part, Evidence was not provided by the nursing facility showing documentation was made by the Appellant's physician prior to the discharge notice of the specific resident's needs that could not be met and the services available at the receiving facility to meet the Appellant's needs. C. Resident #1 was issued a third facility-initiated 30-day discharge letter on 12/19/22 due to physician termination of services and the facility not having another physician available to accept responsibility. A Fair Hearing was completed on 12/19/22. A Fair Hearing Decision, Appeal ID: 3624346, dated March 03/30/23 reflected the hearing officer reversed the facility's action. On 05/09/23, review of an HHSC complaint was reviewed that indicated Resident #1 had been issued a fourth facility-initiated 30-day discharge notice. Review of a facility initiated 30-day discharge notice dated 05/09/23 reflected, .I. This discharge is necessary for the resident's welfare as each and every available physician has either terminated their services to [Resident #1] or otherwise refused to take her as a patient. Despite efforts, the facility is not able to obtain an attending physician who will agree to take [Resident #1] as a patient. Without a physician overseeing [Resident #1]'s care, the facility cannot meet the needs of [Resident #1]. The physicians who have refused to take [Resident #1] as a patient include [MD E], [PHY M], [PHY N], [MD F] and [PHY D] (who was also [Resident #1's] outside primary care physician). Most recently, [MD F] declined to serve as [Resident #1]'s attending physician and is only seeing [Resident #1] on an 'as needed' basis; . [Resident #1] requires an attending physician. A physician treating her on an 'as needed basis' does not amount to an attending physician, does not meet [Resident #1's] needs, and does not allow the facility to adequately meet [Resident #1's] needs and welfare The facility has exhausted all possible credentialed attending physician provider sources beyond [MD F]. On 05/11/23 at 9:15 AM, HHSC re-entered the facility due to an additional complaint made related to Resident #1 being given another facility-initiated discharge notice on 05/09/23. An interview with the ADM on 05/30/23 at 11:42 AM revealed she was going to try and contact MD E and his NP to see if they had any documentation of visits made to Resident #1 when she had COVID-19 in 2022. A follow up interview with the ADM on 05/30/23 at 4:00 PM revealed she talked to the MD E and said Remember, you saw her when she got covid, and he was like, oh yeah, I did. The ADM said she asked MD E to write note from that visit. Review of MD E's progress note provided by the ADM and dated 11/09/22 reflected, patient assessed during rounds 11/08/2023, abnormal CXR, some report of cough, will go ahead and cover for bacterial pna in an abundance of caution. Please see nursing notes for full details. Review of MD E's nurse practitioner's visit progress note provided by the ADM dated 09/05/22 reflected he saw Resident #1 face to face. There were no more physician or physician extender visits from 11/10/22 through April 2023. An interview with MD F on 05/30/23 at 10:24 AM revealed he had seen Resident #1 for an H&P and was not required to see her but once a year and his mid-levels could see her every 60 days. He said, I don't have to see her if she is long term. He said if something acute was going on, I don't have to see her if I don't want to. If I want to, I can see her once a year as a custodial patient and my mid-levels can see her once a month if they want to. Review of the facility's policy titled, Physician Services revised February 2021, reflected, Policy Statement: The medical care of each resident is supervised by a licensed physician. Policy Interpretation and Implementation: .2. Once a resident is admitted , orders for the resident's immediate care and needs can be provided by a physician, physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS); 3. Supervising the medical care of residents includes (but is not limited to): a. participating in the resident's assessment and care planning; b. monitoring changes in resident's medical status; c. providing consultation or treatment when called by the facility; d. prescribing medications and therapy; e. ordering transfer to the hospital if necessary; f. conducting routing required visits; g. delegating and supervising follow-up visits by non-physician practitioner (NPs, PA, CNS's); and h. overseeing a relevant plan of care for the resident; .7. Physician visits, frequency of visits, emergency care of resident, etc., are provided in accordance with current OBRA regulations and facility policy .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical director was responsible for implementation of resident care policies and the coordination of medical care in the facility for one (Resident #1) of five residents reviewed for medical director. The facility's medical director failed to assist the facility to locate an alternate attending physician when he chose to discontinue being the attending physician for Resident #1. The failure placed residents at an increased risk of not receiving appropriate and adequate medical care in a timely fashion. Findings included: Review of Resident #1's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included Alzheimer's disease, hypertension, heart failure, atrial fibrillation, coronary artery disease and anxiety disorder. Resident #1 had clear speech, no hearing issues or impaired vision and her BIMS score was 08, which indicated moderate cognitive impairment. Resident #1 had no signs or symptoms of delirium, mood issues, or behaviors (which included psychosis and rejection of care). Review of Resident #1's Face Sheet (not dated) reflected her attending physician was PHY D (date active 03/31/23) and her medical director was MD F (date active 04/12/23). Review of Resident #1's clinical chart (including nursing notes, medication/lab/x-ray orders and emergency notification for change in conditions), reflected that MD E was the previous attending physician until 05/24/22, when he issued Resident #1 a discharge from services letter. Review of MD E's discharge letter dated 05/24/22 reflected, An effective patient-physician relationship is essential to providing good primary care. Based on recent and on-going events, it is clear the therapeutic relationship we shared no longer exists. As a result of this, I can no longer serve as your physician. Therefore, effective 30 days after the date of this letter, our patient-physician relationship will terminate. You will need to discuss with [facility] which other primary care physicians in the facility are available to attend to your regular healthcare needs. Moreover, my services to you will be available only for emergency purposes during the next 30 days. I recommend you establish care with a new provider as soon as possible and continue to receive healthcare services. [Signed MD E]. An interview with Resident #1's family member on 04/27/23 at 9:13 AM revealed there had been several facility-initiated discharge notices given to Resident #1 and her responsible parties due to the facility not having a doctor available to provide medical care. The family member said the facility had stated that since Resident #1 did not have an attending physician anymore in the facility, but still had a primary care physician in the community, then they would contact that physician for routine visits and emergencies. However, if he was not reachable, they told the family member they would send Resident #1 to the hospital emergency room. The family member stated, I know part of the state and federal regulations states they have to have a physician. The family member stated, I mean this, god forbid something happens to [Resident #1] without physician care. The family member stated, I am so worried, you are going to just sit there and let her die or not render aid. I pray to god nothing happens. The family member said prior to MD E stopping his services for Resident #1, he had been her physician since 2016. Now, the family member stated on a day-to-day basis, no physician was overseeing her care. The family member said the facility claimed they had contacted other doctors to be the attending physician for Resident #1 but they said no. The family member said one of the doctors asked by the facility to be Resident #1's attending physician worked with MD E and the family member felt MD E told that potential doctor a lot of negative things about Resident #1 and the family, which caused that doctor to say no, even though he had never seen Resident #1. The family member said after the most recent attempt to discharge Resident #1 in 2023 due to the facility stating she did not have an attending physician, the family appealed and won, however, the family was notified after that that MD E would not even provide care for emergencies for Resident #1. An interview with the DON on 04/27/23 at 1:48 PM revealed she never talked directly to MD E, only the receptionist at his office on 04/10/23, she stated I have never been able to talk to [MD E] to this day. The DON said she did not know if MD E talked to PHY D. She said MD E had been seeing Resident #1 for years and when the DON and ADM came to work at the facility in May 2022, we walked into this situation, [MD E] was already trying to remove himself as her doctor. The DON said she did not know if MD E, as the medical director for the facility, had reached out to PHY D to discuss the situation. An interview with MD E on 04/27/23 at 3:56 PM revealed he was the medical director for the facility and had been the attending physician for Resident #1 for the past five to six years but was no longer her attending physician. MD E stated the circumstances that caused him to cease being Resident #1's attending physician were cumulative and I think it was more differences in our philosophies in care was our biggest difference. It had been many years and it came to an aggressive stance with the [family member], I am not sure which [family member], but it was mainly [name]. MD E said Resident #1's family member behaved in a way that was more like harassment, questioning his decisions, sending her out to the hospital then coming back, I don't think she trusted my care. She is the only resident I have had to part ways with. I have been doing this for ten years. The MD said he worked in a large physicians' group in general, but for the facility, it was himself, his PA and NP. When asked what does being a physician for emergencies entail, MD E replied, That is kind of funny, I am still trying to figure out if I am there for emergencies I am getting my legal involved so we can figure out what it entails. If I see something as a medical director, I would intervene. I just don't know what that means legally. MD E said if a facility physician refused to see a resident as a patient, their care would have to be monitored by an outside physician. MD E said Resident #1 had PHY D for many years and she would follow up with him as well, So I think she resumed care with [PHY D] and I think the facility transports to him now every 60 days. MD E was asked what was his responsibility as the medical director of the facility to assist the facility in locating another attending physician for Resident #1. MD E stated, You know what, that is a great question, I don't know if as a medical director, is that something I have to do a responsibility. I think the facility has to do it, like trying to recruit another physician but I don't think in my medical director's contract it is in there. MD E confirmed that is if a resident did not have an attending physician, then it was the medical director's role to oversee that resident's care. MD E said he had not personally contacted any doctors to see if they could be Resident #1's attending physician. MD E stated, I guess because she had a doctor. It's a tough situation, I guess it is confusing to me. It was kind of like a distrust or conflict of our philosophy. MD E said he had not talked to MD F since he had taken over as co-medical director and that the facility decided who would have which residents on their caseload for both he and MD F. MD E was asked if he felt refusing to be her attending physician was punitive to the resident when she had no other physician available to see her in the facility. MD E stated, You know it's hard to say because I think [PHY D] can do everything I do. It seems like they follow up with him even when I was still her physician. I would say something, like he prescribed and antibiotic I didn't agree with. They were comfortable with him so I thought, then you have a provider and if I am there, I am never going to withhold care on someone, but there is also a time for mental well-being for physicians. I felt they were badgering me, the family. [PHY D] was doing what I am doing, we would probably manage it the same. MD E stated most of the time when something happened with Resident #1 medically, the family requested her to be sent out, for example, when there was a snow storm and Resident #1 missed dialysis. MD E said he told the facility it was okay for her to miss a couple of days of dialysis but the family sent her to the ER and she came back with no new orders. He said once a Hoyer lift bumped Resident #1, a x-ray on her ribs was done, there was a question of pneumonia, his NP saw it and the resident was asymptomatic (producing or showing no symptoms) but the family wanted to send her out. MD E stated, The family will supersede whatever I say. If there is an emergency situation, one of us is going to handle it. And I have. I am not going to withhold care. It's difficult to figure out what do we do now. Maybe I just don't need to be medical director there anymore. MD E was asked if he had reached out to PHY D to discuss continuity of care for Resident #1 and he replied no. Review of an email exchange almost a year ago, provided by the ADM on 05/01/23 between herself and PHY H on 05/25/22 reflected, ADM-I understand after out our discussion related to taking on this resident, you feel that that [sic] would not be a good choice for you due to the medical director concerns, is that correct? To which PHY H responded, I am very uncomfortable in taking care of this patient due to medical director concerns. Review of an email exchange provided by the ADM on 05/01/23 between herself and PHY I on 10/25/22 reflected, ADM-As discussed today about being attending physician for [Resident #1], I understand that you have chosen not to pick her up. To which PHY I responded, Correct, I have chosen not to be [Resident #1's] doctor. Review of an email exchange provided by the ADM on 05/01/23 between herself and MD F on 04/10/23 reflected, ADM-I am confirming our conversation regarding [Resident #1]. You agree that you are available to see the resident for emergency purposes or if the outside attending is not available. Due to previous concerns with Medical director, you do not want to be the attending only back up for emergencies. You also agree to only communicate with the facility staff and POA regarding the resident care. If this correct? To which MD F responded, I accept. Review of an email exchange provided by Resident #1's family member to the facility's DON, ADM, Ombudsman, VP of Clinical Operations, VP of Operations dated 04/12/23 reflected, We are requesting that the new co medical director [MD F] be designated as [Resident #1]'s attending physician. The ADM responded back to the family member on 04/12/23, [MD F] does not want to be attending, sorry. I asked him and he emailed saying he didn't want to. An interview with PHY D on 05/01/23 at 4:49 PM revealed he had not seen Resident #1 in about a year and prior to that, he had rarely seen her. PHY D said the family never asked him to be Resident #1's attending physician at the facility and the medical director (MD F) never reached out to him. PHY D stated, When she shows up here at the clinic, for acute care, there is little coordination between the nursing home and outpatient care. I don't have records for from the nursing home or a clue what they do with her there. I would be more of a second opinion type of person and there are limitations to that, especially when I don't know what the primary's opinion is. PHY D said he had not been seeing Resident #1 for routine health care needs and there was no agreement or understanding with the facility that he would do any specific tasks. Review of the facility's Agreement for Medical Director Services dated 01/15/21 and signed by MD F, reflected, .I. Duties and Obligations of Program Director: A. Services-Medical Director agrees to provide administrative and professional services required as needed and requested and to assist the Facility to ensure the adequacy and appropriateness of the care rendered to patients of the Facility and to supervise the medical care of patients at the Facility; .2. Physician Services Policies-Medical Director shall participate as requested in the ongoing development of Physician Service Policies specifying the duties, responsibilities and rights of each physician attending patients of the Facility, including, but not limited to, the appropriate and timely intervals for physician visits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 2 medication carts (200 hall nurses' medication cart and 400 hall nurses' medication cart) of 3 medication carts reviewed for pharmacy services in that: The facility failed to ensure: 1. The 200 Hall medication cart had a container of Rena Vite tablets dietary supplement expired. 2. RN E reported one damaged blister pack of Resident #66's APAP/Codeine 300-30 mg tablet (controlled medication used for pain). These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: Observation on [DATE] at 11:47 AM revealed the 200-hall nurse's medication cart had a container of Rena Vite tablets dietary supplement expired. The expiration date on the container was 12/2022. In an interview on [DATE] at 11:47 AM, LVN F stated the Rena Vite dietary supplement was prescribed to two or three residents. LVN F stated he did not check if it was expired. LVN F stated the medication cart should not contain any expired medication. LVN F stated that expired medication would not be effective. LVN F stated nurses were responsible the check the cart for expired medication every day. An observation on [DATE] at 12:07 PM of the Nurse Cart Hall 400 revealed the blister pack for Resident #66's APAP/Codeine 300-30 mg (pain reliver) had one blister seal broken and the pill was still inside the broken blister. In an interview on [DATE] at 12:10 PM, RN E stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blister pack seal. She said the risk of a damaged blister pack would be a potential for drug diversion. She said the nurses were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She said the count was done at shift change and the count was correct. She said she did not see the broken blister pack during the count. At this time the surveyor checked the medication; the count was compared to the blister pack and the count was correct. Interview on [DATE] at 1:33 PM, the DON stated if a blister pack medication seal was broken the pill should be discarded. The DON said it would not be acceptable to keep a pill in a blister pack that was opened. The DON said the risk would be losing the medication because the seal was broken. She said nurses were responsible for checking the medication blister packs for broken seals during the medication count on the change of shifts. The DON said all nurses were responsible to check the medication carts and the medication rooms for expiration and labeling of medication. DON said the pharmacy consultant checks the medication room and the medication cart monthly. Review of the facility's policy Storage of medications, revised [DATE], reflected the following: . 3. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for One of One medication room reviewed for storage. The facility failed to ensure: A vial of TB serum that was opened and used was dated in the medication room refrigerator. This failure could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications The findings included: Observation on 01/11/23 at 1:00 PM of the medication room revealed a vial of TB PPD serum was opened, had been used and was not dated. In an interview on 01/11/23 at 1:05 PM, the DON stated the TB PPD vial was open and the rubber seal breached and was not dated or initialed. She said the risk would be a wrong TB reading if used. She said the nurse was responsible to check the vial for the open date before use. The DON stated all nurses were responsible to check the vial before administration and if it was not dated, they should discard it and order a new one. She said the risk would be the wrong reading of the PPD result. The DON said all nurses were responsible to check the medication carts and the medication rooms for expiration and labeling of medication. DON said the pharmacy consultant checks the medication room and the medication cart monthly. Record review of the facility's policy titled Storage of Medications, dated April 2007, revealed in part .3. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed

Based on observation, interview, and record review of the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure stored canned goods, had an uncompromised seal, free from dents. 2.The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The facility failed to ensure the ice machine vent/grate and outer surface was free from dirt and dust. 5. The facility failed to have Dietary staff wash hands or change gloves when they touched other surfaces while handling food or upon re-entering the kitchen. 6. The facility failed to have both handwashing sinks in working order with both hot and cold water. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the Kitchen with Dietician on 01/11/23 at 10:53 AM revealed the following: -Ice Machine plastic vent, located on the right side of the machine, the vent slats had dust on them. Ice Machine: in front of the machine, just above the ice chest compartment, there was a dried white calcified/hardened substance along the bottom and the bottom right side of the machine. -Ice Machine: door to the ice chest was very hard to open. Had to get a male staff open it, after the Dietician also tried to open the chest door. Observations of Walk-in Refrigerator on 01/11/23 at 09:38 AM revealed the following: -Immediately inside the door to the left, a rolling rack next to door with 5 rows of trays with approximately 76 varying cups of juice with lids, there was no label of item description, no pull/prep date and no consume or use by date. - Shelf on left side near door, on the 3rd from the top row, there was a large clear square container covered with plastic wrap with baked ziti, dated 1/4/23 with an consume by date of 1/7/23. -1 medium clear plastic container covered with plastic wrap with ground beef, dated 1/08/23 and consume by 01/11/23, there was no label of item description. -1 small metal square pan covered with plastic wrap with gravy, dated 1/10/23 and consume by 1/13/23, there was no label of item description. Assistant DM entered the Walk-in Refrigerator and stayed for most of the remaining observation, he left intermittently. -1 large square metal pan covered with plastic wrap had soup dated 1/7/23 and consume by date 1/10/23 (remained in fridge). -1-30 oz. plastic jar with mayo, there was no received by date. Assistant DM removed the jar before the surveyor could write down the manufacturer's expiration date. -1- approximately10 lbs. plastic container with lid had fruit salad in liquid, dated 11/22/22 on the distributor label, no received by date, no consume by or use by date. *As the surveyor was trying to verify the date, the Assistant DM grabbed the tub, opened it and the fruit smelled bad as if they had started to spoil/ferment. He would not tell the surveyor the weight when asked or turn it back around to see the label. -1-5 lbs. plastic container with lid of cottage cheese dated 12/20/23 on the distributor label, manufacturer expiration date 01/04/23. -1 large zip top bag, with previously opened fresh cilantro, there was no received by date, no open date and no facility use by date. Manufacturer expiration 01/04/23. -1gallon jar of olives, dated 10/27/22 (per distributor label), there was no facility received by date other than the distributor label, no manufacturer expiration date reflected. -1-12 lbs. white plastic tub with lid of vanilla heat and icing, dated 1/3/23, the lid was unsecured closed. Observation of Dry Storage Room with Assistant Manager on 01/11/23 at 10:19 AM revealed the following: -1-6 lbs. 12 oz. can of cut sweet potatoes, no received by date. The can was dented and stored with the regular canned goods. -1-6 lbs. 12 oz. can of tropical Fruit, no received by date, no manufacturer expiration date. -5-6 lbs. 12 oz. can of tropical fruit, no received by date, no manufacturer expiration date. The can was dented and stored with the regular canned goods. -1 Extra-large can of potatoes, no received by date. The can was dented and stored with the regular cans. Dietician entered the Dry storage room and remained for the observation; the Assistant DM went back out into the kitchen. -1-5lbs bag of cake mix wrapped in plastic wrap, there was no label of item description, no open date and no consume by or discard date. -1 large bag of season salt in a zip top bag, there was no label of item description, no open date, no consume by or discard date. -3-105 oz. container of yellow mustard, no received by dates. -1-5 lbs. cylindrical container with lid of baking powder, dated 03/04/20, no open date, no consume by or discard date. Manufacturer expiration date February 11, 2021. -2-35 oz. bags of raisin bran cereal, there was no received by date. -1-32 oz. bag of biscuit gravy mix rolled in plastic wrap, there was no open date, no consume by or discard date. -1-2 lbs. bag of powdered sugar in a zip top bag dated 6/17/22, opened 8/31/22, there was no consume by or discard date. Observations of Walk-in Freezer on 01/11/23 at 10:40 AM revealed the following: -1 large zip top bag of breaded chicken patties, there was no label of item description, no open date, no consume by or discard by date. Observation of the Kitchen on 1/13/23 at 11:45 AM revealed the following: -Eyewash station, next to the handwashing sink#1, was dirty, there was dust in the bowl/basin. -The garbage receptacle, at handwashing sink #1, had other items then paper towels in it. There was photocopy paper, a black sharpie marker, gloves. -The garbage receptacle at handwashing sink #1, was full and needed to be emptied. The lid was not closed because the amount of garbage that prevented it from closing completely. -11:54 AM Just before lunch service trays started going out, the Interim DM went to main entry door of kitchen, handled a meal ticket from a staff member on the other side of the door. She then put her hands in her pocket but did not go wash her hand. -11:55AM, Interim DM put on gloves. -Dietary Aide B, while deep frying corn nuggets with gloves on, touched her shirt to pull it up. She did not change gloves. -Dietary Aide B went to get some chicken patties out of the freezer to put in the deep fryer, on the way back to the deep fryer, she touched her shirt but did not change her gloves. She then touched the wall as she came around the corner but did not change her gloves. She then proceeded to make a grill cheese sandwich. -Dietary Aide A took out a warmer with food in it to the 200 Hall. She returned to the kitchen through the main door, did not change gloves. Then she pulled up her mask to cover her nose and did not change gloves. - Dietary Aide A was noted 4 more times pulling up her mask to cover her nose (she was not wearing the mask properly). Each time after she pulled her mask up over her nose or touched her mask, she did not remove her gloves and put on new gloves or wash her hands. - Dietary Aide A exited the kitchen through a side door that led out into the facility, near nurses' station. When she returned to the kitchen, she did not wash her hands or donned gloves, then she went into the refrigerator to get 2 health shakes at the request of the Assistant DM. -Handwashing sink #2, adjacent to ice machine, hot water did not work but the cold water did. -Garbage receptable for handwashing sink #2, had other items then paper towels. There was plastic lids, gloves and a small amount of red liquid. In an interview on 1/11/23 at 09:48 AM with Assistant DM, he stated he had been back with this facility for 6 months. He stated the Dietary Manager was out. He stated that they do not write the received by date on the items in the fridge, freezer, and dry storage room because this company says they can use the distributor label (a computer generated printed, adhesive backed label). He was unsure of what to do if that adhesive pre-printed label came off, was ripped, got wet, was illegible or was not on all the other prepackaged items or unwrapped items in the boxes or packages they came in. He stated he just knew that they were not required to write the received by date. He stated the reason there was some cans unlabeled with a received by date, that we came across in the dry storage room, was they got a shipment in last night and the cook must not have labeled them before putting them up. The Assistant DM stated that they kept leftover items in the refrigerator, for 3 days and the same for open items in the refrigerator. He stated that they had a list in the kitchen to refer to for how long they keep canned goods. But he could not answer if the list also applied to, how long to keep, if the canned goods did not have a manufacturer dates. In an interview on 1/11/23 at 10:27 AM with the Dietician, she stated that they use the distributor pre-printed adhesive backed labels that come on the products but that was just this facility department's thing that was done not a company mandate. She stated they used the First In First Out system, they go through things fast, open items in the dry storage were kept until they expire and items without expiration dates were kept according to the leftover guidelines for dry storage, says to. She referred to a list that they use that tells them how long to keep canned goods. The Dietician stated items in the dry storage area do not need open dates placed on them. She stated that if the distributor label that they are using ripped or was illegible then the staff would need to write the received by date. But she did not have an answer for how to label items with received by date when the label had previously been removed from the outer box or container and now the outer box and dated label were no longer there, like some items found in the dry storage room. She stated that a bottle of pickled peppers that was previously opened, did not need an open date or to be refrigerated. She had a copy of the list of leftover guidelines for the kitchen, made for the surveyor. The Dietician stated the dented canned goods were kept in the Dietary Manager's office. In an interview on 01/11/23 at 03:46 PM with the Dietary Manager, he said, yes, the staff was supposed to put open dates on the food items with some exceptions like salt packets and sugar packets, pepper, and cracker packets, for example. He stated there did not need to be opened dates on open boxes but there should be received by dates put on the boxes. In an interview on 01/11/23 at 03:57 PM with the Dietary Manager, he stated the Food Storage Guidelines that they used in their kitchen, that the Assistant DM and Dietician made mentioned of earlier, was for closed/unopened food items. He stated the time period changed when the item was opened, depending on what the item was. In an interview on 01/13/23 at 11:50 AM with Interim DM, she introduced herself and stated since this facility's Dietary Manager was on vacation, she was notified to come to the facility. She stated she was the company's Traveling NSD (Nutrition Services Director), traveling throughout the state and goes from facility to facility helping out. In an interview on 01/13/23 at 12:15 PM with Assistant DM, he stated that they had put in a maintenance request for the ice machine, but that issue was recently fixed, but he was unsure if a maintenance request had been submitted for handwashing sink #2's hot water not working. He stated snacks were put out at night before the kitchen staff leaves, the staff takes the snacks to the nurse's station and the nurses dispense the diabetic snacks. He stated his expectation was for staff to enter into the kitchen and wash their hands and to change gloves when they were torn, soiled or other surfaces other than for food have been touched. When it was mentioned he and the Interim DM were noted touching surfaces other than food with gloved hands but did not change gloves, he remarked oh. Review of the facility's Nutrition Services Policy & Procedures Food Production & Food Safety dated March 2009: Revision March 2019, reflected Food Storage Policy: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination. Procedure: . 4. All food items should be dated with the received date, unless labeled with a readable label from the food vendor. 5. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables and broken lots of bulk foods. All containers must legible and accurately labeled, including the date the package was opened. 7. Scoops are to be washed and sanitized on a weekly bases, or as needed. 8. Hand s must be washed after unloading supplies and prior to handling food items. 9. All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. A. Old stock is always used fist (First in- First out method.) b. Supervision is necessary to make sure that the person designated to put stock away is rotating int properly. 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 2-3 days or discarded. 15. Refrigeration .e. All foods should be covered, labeled and dated.16. Frozen Foods .c. Foods should be covered, labeled and dated. Review of the US Food Code, version 2022, dated 01/19/2023, reflected . 4. Advantage of Uniform Standards The advantages of well-written, scientifically sound, and up-to-date model codes have (p. FDA Food Code 2022 Preface iii) - long been recognized by industry and government officials. Industry conformance with acceptable procedures and practices is far more likely where regulatory officials speak with one voice about what is required to protect the public health, why it is important, and which alternatives for compliance may be accepted. Model codes provide a guide for use in establishing what is required. They are useful to business in that they provide accepted standards that can be applied in training and quality assurance programs. The model Food Code provides guidance on food safety, sanitation, and fair dealing that can be uniformly adopted for the retail segment of the food industry. The document is the cumulative result of the efforts and recommendations of many contributing individuals, agencies, and organizations with years of experience using earlier model code editions. It embraces the concept that our quality of life, state of health, and the public welfare are directly affected by how we collectively provide and protect our food. The model Food Code provisions are consistent with, and where appropriate incorporate, federal performance standards for the same products and processes. Federal performance standards in effect define public food safety expectations for the product, usually in terms of lethality to a pathogenic microorganism of particular concern. Use of performance standards as the measure of regulatory compliance means establishments are free to use innovative approaches in producing safe products, in lieu of adherence to traditional processing approaches, such as specified cooking times and temperatures, that achieve the same end. Federally inspected establishments demonstrate compliance with performance standards by showing that their process adheres to an appropriately designed, validated HACCP plan. (p. Food Code 2022 Preface iv).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 (Resident #94, Resident #106, and Resident#168) of 5 residents reviewed for infection control. The facility failed to ensure MA D disinfected the blood pressure cuff in between blood pressure checks for Residents #94, #106, and #168. This failure could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Record review of Resident #94's Comprehensive MDS assessment, dated 10/11/22, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses including elevated blood pressure, acute kidney failure (kidneys suddenly become unable to filter waste products from the blood), and hypernatremia (a rise in serum sodium concentration. She had a BIMS of 15 indicating she was cognitively intact. Record review of Resident #94's physician orders dated 01/13/23 reflected, diltiazem CD 240 mg capsule, extended release, give 1 capsule by mouth one time daily - Special instruction: Hold for systolic blood pressure less than 110, diastolic blood pressure less than 60 and heart rate less than 60. Coreg tablet 12.5 mg, give 1 tablet by mouth two times per day - Special instruction: Hold for systolic blood pressure less than 110, diastolic blood pressure less than 60, and heart rate less than 60. Record review of Resident #106's Comprehensive MDS, dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including elevated blood pressure, hyperlipidemia (an abnormal high concentration of fats or lipids in the blood), and shortness of breath. He had a BIMS of 11 indicating he was moderately impaired. Record review of Resident #106's physician orders dated 01/13/23 reflected, carvedilol 25 mg, give 1 tablet by mouth, two times a day - Special instruction: Hold for systolic blood pressure less than 110, diastolic blood pressure less than 60, and when the heart rate is less than 60. Review of Resident 168's Comprehensive MDS, dated [DATE], revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included elevated blood pressure and end stage renal disease (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). He had a BIMS of 08 indicating he was moderately impaired. Record review of Resident #168's physician orders dated 01/13/23 reflected, amlodipine tablet; 10 mg, give 1 tablet by mouth, one time per day - Special instruction: Hold for systolic blood pressure less than 110 and or diastolic blood pressure less than 60. Observation on 01/12/23 at 8:16 AM revealed MA D performing morning medication pass, during which time she checked the blood pressures on Resident #94. MA D did not sanitize the blood pressure cuff before or after using it on Resident #94. MA D put the blood pressure cuff on top of the medication cart after use. Observation on 01/12/23 at 8:27 AM revealed MA D performing morning medication pass, during which time she checked the blood pressure on Resident #106. MA D used the same blood pressure cuff right after using it on Resident#94. MA D did not sanitize the blood pressure cuff before or after using it on Resident #106. She left the blood pressure cuff on top of the medication cart. Observation on 01/12/23 at 8:52 AM revealed MA D performing morning medication pass, during which time she checked the blood pressure on Resident #168. MA D used the same blood pressure cuff right after using it on Resident#106. MA D did not sanitize the blood pressure cuff before or after using it on Resident #168. Interview on 01/12/23 at 9:27 AM, MA D stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use (before and after use on each resident) in order to prevent transmitting an infection from one resident to another. She stated she forgot to wipe the cuff this time. Interview on 01/13/23 at 1:33 PM, the DON stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. She said she was responsible for training staff on infection control. She said that she did routine rounds in the floor to ensure the nurses and med aids were following proper infection control procedures. Record review of the facility's policy Cleaning Multi Use Medical Equipment, dated August 2012, reflected Policy - Multi use medical equipment such as glucometers, blood pressure cuffs, stethoscopes, lifts and other medical equipment that goes in and out of Patient's rooms will be disinfected before and after using the equipment with an antiviral wipe or approved disinfectant solution. Procedure - Prior to entering the Patient's room clean any medical equipment you will be using on the Patient with the appropriate antiviral wipe. Allow to dry. Immediately after exiting the Patient's room clean the medical equipment, you used with the appropriate antiviral wipe. Allow to dry. This must be done again prior to entering another Patient's room to use the same equipment.