Does COURTYARD NURSING AND REHABILITATION have any serious inspection findings?

Yes, COURTYARD NURSING AND REHABILITATION has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 20 total deficiencies from recent inspections.

What are the staffing levels at COURTYARD NURSING AND REHABILITATION?

COURTYARD NURSING AND REHABILITATION has a one-star staffing rating from CMS with 0.21 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is COURTYARD NURSING AND REHABILITATION located?

COURTYARD NURSING AND REHABILITATION is located in HOUSTON, TX. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does COURTYARD NURSING AND REHABILITATION have?

COURTYARD NURSING AND REHABILITATION has 120 certified beds.

Who owns COURTYARD NURSING AND REHABILITATION?

COURTYARD NURSING AND REHABILITATION is a for profit - corporation facility and is part of the FOURCOOKS SENIOR CARE chain.

COURTYARD NURSING AND REHABILITATION

Q: What is COURTYARD NURSING AND REHABILITATION's CMS rating?

COURTYARD NURSING AND REHABILITATION has a two-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Q: Do nurses at COURTYARD NURSING AND REHABILITATION stick around?

COURTYARD NURSING AND REHABILITATION has high staff turnover at 70%. High turnover can mean less continuity of care as staff change frequently.

Q: Was COURTYARD NURSING AND REHABILITATION ever fined?

Yes, COURTYARD NURSING AND REHABILITATION has been fined $36,170 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Q: Is COURTYARD NURSING AND REHABILITATION on any federal watch list?

No, COURTYARD NURSING AND REHABILITATION is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

7499 STANWICK DR, HOUSTON, TX 77087 · (713) 644-8048

For profit - Corporation 120 Beds FOURCOOKS SENIOR CARE Data: November 2025 1 Immediate Jeopardy citation

Trust Grade

28/100

#680 of 1168 in TX

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Last Inspection: August 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Courtyard Nursing and Rehabilitation in Houston, Texas, has received a Trust Grade of F, indicating poor performance with significant concerns about resident care. They rank #680 out of 1168 facilities in Texas, placing them in the bottom half, and #55 out of 95 in Harris County, suggesting limited local options for families seeking better care. The facility is worsening, with reported issues increasing from 6 in 2023 to 10 in 2024. Staffing is a critical weakness, rated at only 1 out of 5 stars, with a concerning turnover rate of 70%, much higher than the Texas average of 50%. There have been serious incidents, including a resident who fell and suffered a fatal head injury due to inadequate supervision and assistance. Additionally, the facility has failed to maintain a pest control program, leading to the presence of insects in the kitchen and other areas, which could risk residents’ health. On a positive note, the quality measures rating is 4 out of 5, indicating some areas of care are performing well despite these significant weaknesses.

Trust Score: F
In Texas: #680/1168
Safety Record: High Risk
Inspections: Getting Worse
Staff Stability: 70% turnover. Very high, 22 points above average. Constant new faces learning your loved one's needs.
Penalties: $36,170 in fines. Lower than most Texas facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 12 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 20 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★★★☆

4.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2023: 6 issues

2024: 10 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

2-Star Overall Rating

Below Texas average (2.8)

Below average - review inspection findings carefully

Staff Turnover: 70%

24pts above Texas avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $36,170

Above median ($33,413)

Moderate penalties - review what triggered them

Chain: FOURCOOKS SENIOR CARE

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is very high (70%)

22 points above Texas average of 48%

The Ugly 20 deficiencies on record

1 life-threatening

Aug 2024 10 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to properly discharge and include all other necessary information, including a copy of the resident's discharge summary, and any other documentation, to ensure a safe and effective transition of care for 1 of 5 residents (Resident #61) reviewed for transfer and discharge requirements. The facility failed to provide all necessary information and/or documentation for a safe and effective transition to the resident, responsible party (RP), ombudsman, or the home health agency upon discharge for Resident #61. This failure could place residents at risk of not receiving the necessary care and services when discharged to meet their physical and psychological needs. Findings included: Record review of Resident #61's Face sheet revealed an [AGE] year-old male who admitted to the facility on [DATE] with the following diagnoses, osteomyelitis (a bone infection that causes inflammation and swelling in the bone), essential hypertension (a form of hypertension without an identifiable physiologic cause), mixed hyperlipidemia (a generic condition that causes higher than normal levels of certain fats in the blood), muscle wasting and atrophy (a gradual process that causes muscles tissue to decrease in size and waste away), and pressure ulcer of right heel, stage 4. Record review on Resident #61's admission MDS assessment dated [DATE], revealed he had a BIMS score of 12 out of 15, indicating he had moderate cognitive impairments. Further record review revealed he was independent for oral hygiene. He required partial/moderate assistance for roll to the left and the right. He used a walker and a manual wheelchair for mobility. Record review on of Resident #61's Baseline Plan of Care revised on 5/09/2024, Focus, Goal and interventions were blank. There was no initiated date or revision date for a discharge. There was no discharge summary found in Resident #61's medical record. Record review of Resident #61's Progress Notes dated 06/18/2024 created by RN A revealed; Resident was transported via stretcher by the ER for noncompliance/refusal of medications and wound care. When EMS arrived to put resident on stretcher he refused, stating he is not going on stretcher but by wheelchair, explained the wheelchair will be taken with him in the ambulance, then he started demanding two of his social security checks from writer, I'm not leaving without those damn checks Bitch informed resident writer knew nothing about any checks, he then raised his cane as if he was going to hit writer who stood her ground and informed the resident he does not scare her, he put cane down and called writer a Bitch again, this is normal behavior this resident exhibits toward staff who has not provoked him in any way. Resident then got on the stretcher after two male medics helped him onto the stretcher, resident left facility with medications and medical records and was transported to ER, he refused to have assessment, including vital signs taken prior to discharge. Interview on 8/14/2024 at 11:01a.m., with the Administrator, he said the normal procedure for a discharge, was for the social worker to contact the guardian. He said if it was an emergency discharge, or if the resident was causing issues, they would do an emergency discharge and contact the responsible party. He said Resident #61 was sent to the hospital. He said there should have been more documentation regarding Resident #61's discharge. He said the documentation should have told what happened and that Resident #61 was not coming back to the facility due to his behaviors he exhibited at the facility. He said it was not documented that it was discussed with the hospital that Resident #61 was not to return to the facility. He said it was important to have a proper discharge to make sure the resident was in a safe place. He said a proper discharge and documentation was the general reason what it was important to make sure Resident #61 maintained services. Interview on 8/14/2024 at 11:23a.m., with the ADON, she said the way the facility would do a proper discharge would be to let the doctor know the issues that were going on with the resident, request an order for the resident to transferred out of the facility, notify the family, set up transportation, and to call and report the discharge to the hospital to give the hospital a heads up on what was going on and who was coming in. She said she could not give a reason as to why the discharge was not done. She said she was not in the building when the discharge took place. She said when a proper discharge happens, it was best to notify the family and the doctor so they would understand what was going on with the resident. The ADON said they should have given the hospital a full and accurate report on Resident #61's behaviors and diagnoses so they could have adequate staff to handle his discharge . She said once the facility hangs up with the hospital, they do not check back in with the resident. She said it was important to make sure Resident #61 was in a safe place. She said moving forward she would check to make sure the family had been called and notes have been put into place. She said she would call the hospital to make sure the resident was under their care and arrived safely. Interview on 8/14/2024 at 11:33a.m., with the MDS Coordinator, she said the proper way to have discharged Resident #61 would have been to document, no return not anticipated and provided information on who was notified about the discharge. She said the social worker should have contacted the family, and RP. She would complete paperwork and document the reason for discharge, and where Resident #61 was going. She said if it was not done it there could be a problem with following through with his care and safety. She said next time she would make sure the resident has a proper discharge and would be make sure they have the proper people in place to check everything and to make sure the documentation was there. Follow-up interview at 4:03p.m., with the MDS Coordinator, she said she considered yelling, shouting, refusing medication, and care from Resident #61 to be considered as a behavior. She said she was not sure if they told the resident that he cannot return to the facility. She said it was protocol to tell the resident that he was not able to return to the facility . Record review of the facility's policy titled Transfer, Discharge, and Return revision date not listed, read in part . Preparation and orientation of the resident is essential to ensure safe and orderly transfer or discharge from the facility. Sufficient preparation means that the facility will inform the resident where he/she is going and takes steps under its control to ensure safe transportation. The facility will involve the resident and the resident's family in selecting the new residence. All information will be in the manner in which they can understand; The facility will provide the resident or representative with the following information: The reason for transfer or discharge; The effective date of transfer or discharge; The location to which the resident is transferred or discharged ; If a Medicaid Eligible resident: A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain and appeal form and assistance in completing the form and submitting the appeal hearing request, If PASRR positive residents or those with a mental disorder or related disability: mailing and email address and telephone number of the agency responsible for the protection and advocacy of such residents. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman if the discharge is considered involuntary and does not apply to residents who request a discharge .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Safe Transfer (Tag F0626)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to establish and follow a written policy on permitting residents to return to the facility after they were hospitalized for 1 of 5 residents (Resident #61) reviewed for return to the facility. - The facility failed to readmit Resident #61 after sending the resident to the hospital and refusing to readmit him back to the facility. -The facility failed to provide evidence they notified Resident #61's Responsible Party or the physician about his discharge to the hospital. These failures could place residents, who transfer to the hospital, at risk of being denied readmission to the facility and could result in a decreased quality of life and resident rights violations. Findings included: Record review of Resident #61's Face sheet revealed an [AGE] year-old male who admitted to the facility on [DATE] with the following diagnoses, osteomyelitis (a bone infection that causes inflammation and swelling in the bone), essential hypertension (a form of hypertension without an identifiable physiologic cause), mixed hyperlipidemia (a generic condition that causes higher than normal levels of certain fats in the blood), muscle wasting and atrophy (a gradual process that causes muscles tissue to decrease in size and waste away), and pressure ulcer of right heel, stage 4. Record review on Resident #61's admission MDS assessment dated [DATE], revealed he had a BIMS score of 12 out of 15, indicating he had moderate cognitive impairments. Further record review revealed he was independent for oral hygiene. He required partial/moderate assistance for roll left and right. He uses a walker and a manual wheelchair for mobility. Record review on of Resident #61's Baseline Plan of Care revised on 5/09/2024, Focus, Goal and interventions were blank. There was no initiated date or revision date for a discharge. There was no discharge discharge summary for Resident #61 in his medical record. Record review of Resident #61's Progress Notes dated 06/18/2024 created by RN A revealed; Resident was transported via stretcher by the ER for noncompliance/refusal of medications and wound care. When EMS arrived to put resident on stretcher he refused, stating he is not going on stretcher but by wheelchair, explained the wheelchair will be taken with him in the ambulance, then he started demanding two of his social security checks from writer, I'm not leaving without those damn checks Bitch informed resident writer knew nothing about any checks, he then raised his cane as if he was going to hit writer who stood her ground and informed the resident he does not scare her, he put can down and called writer a Bitch again, this is normal behavior this resident exhibits toward staff who has not provoked him in any way. Resident then got on the stretcher after two male medics helped him onto the stretcher, resident left facility with medications and medical records and was transported to the ER, he refused to have an assessment, including vital signs taken prior to discharge . Interview on 8/14/2024 at 11:01a.m., with the Administrator, said the normal procedure for a discharge, was for the social worker to contact the guardian. He said if it was an emergency discharge, or if the resident was causing issues, they would do an emergency discharge and contact the responsible party. He said Resident #61 was sent to the hospital. He said there should have been more documentation regarding Resident #61's discharge. He said the documentation should have told what happened and that Resident #61 was not coming back to the facility due to his behaviors he exhibited at the facility. He said it was not documented that it was discussed with the hospital that Resident #61 was not to return to the facility. He said it was important to have a proper discharge to make sure the resident was in a safe place. He said a proper discharge and documentation was the general reason what it was important to make sure Resident #61 maintained services. Interview on 8/14/2024 at 11:23a.m., with the ADON, said the way the facility would do a proper discharge would be to let the doctor know the issues that was going on with the resident, request an order for the resident to transferred out of the facility, notify the family, set up transportation, call and report the discharge to the hospital to give the hospital a heads up on what was going on and who was coming in. She said she could not give a reason as to why the discharge was not done. She said she was not in the building when the discharge took place. She said when a proper discharge happens, it was best to notify the family and the doctor so they would understand what was going on with the resident. She said they should have given the hospital to where Resident #61 was being discharged , information about his behavior so the hospital could have adequate staff. She said once the facility hangs up with the hospital, they do not check back in with the resident. She said it was important to make sure Resident 61 was in a safe place. She said moving forward she would check to make sure family had been called and notes have been put into place. She said she would call the hospital to make sure the resident was under their care and arrived safely. Interview on 8/14/2024 at 11:33a.m., with the MDS Coordinator, said the proper way to have discharged Resident #61 would have been to document, no return not anticipated and provided information on who was notified about the discharge. She said the social worker should have contacted family, and RP. She would complete paperwork and document the reason for discharge, and where Resident #61 was going. She if it was not done it there could be a problem with following through with his care and safety. She said next time to make sure to a resident has a proper discharge would be make sure they have the proper people in place to check everything and to make sure the documentation is there. Follow-up interview at 4:03p.m., with the MDS Coordinator, said she considered yelling, shouting, refusing medication and care from Resident #61 to be considered as a behavior. She said she is not sure if they told the resident that he cannot return to the facility. She said it is protocol to tell the resident that he is not able to return to the facility. Record review of the facility's policy titled Transfer, Discharge and Return revision date not listed, read in part . Preparation and orientation of the resident is essential to ensure safe and orderly transfer or discharge from the facility. Sufficient preparation means that the facility will inform the resident where he/she is going and takes steps under its control to ensure safe transportation. The facility will involve the resident and the resident's family in selecting the new residence. All information will be in the manner in which they can understand; The facility will provide the resident or representative with the following information: The reason for transfer or discharge; The effective date of transfer or discharge; The location to which the resident is transferred or discharged ; If a Medicaid Eligible resident: A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain and appeal form and assistance in completing the form and submitting the appeal hearing request, If PASRR positive residents or those with a mental disorder or related disability: mailing and email address and telephone number of the agency responsible for the protection and advocacy of such residents. A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman if the discharge is considered involuntary and does not apply to residents who request a discharge .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to conduct initial and periodical and comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 2 (Residents #46, #113) of 16 residents reviewed for accuracy of resident assessments. Residents #46 and #113 were not assessed accurately on their annual comprehensive MDS assessments. These failures could place residents at risk of not receiving the care needed to maintain their highest, practicable, physical, social, and psychosocial level of well-being. Findings included: Resident # 46 Record review of Resident #46's electronic face sheet, revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. His diagnoses included Type 2 diabetes, pulmonary emphysema, benign prostate hyperplasia (a condition in which the flow of urine is blocked due to the enlargement of prostate gland), essential hypertension (high blood pressure), muscle weakness, and lack of coordination. Record review of Resident #46's annual comprehensive MDS assessment dated [DATE] indicated Resident #46 had a BIMS score of 11 out of 15 indicating he had moderate cognitive impairment. Record review of section L for Oral\Dental status revealed he was checked as having no problem on his oral cavity. Observation and interview on 08/12/24 at 01:29 PM, Resident #46 said he had dentures. He said his dentures were new because he broke the first ones while in the hospital and he had to get new ones. He said he had his dentures on and pointed to his dental care products on his nightstand. Resident #113 Record review of Resident #113's face sheet dated 08/14/24, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included, essential hypertension (primary) (high blood pressure), fall on same level from slipping, tripping, and stumbling without subsequent striking against object, neuropathy diseases, fracture of first lumbar (Fractures), heart failure, heart disease with heart failure, chronic obstructive pulmonary disease, generalized muscle weakness, muscle wasting and atrophy, and other abnormalities of gait and mobility. Record review of Resident #113's annual comprehensive MDS assessment dated [DATE] indicated Resident #113 had a BIMS score of 13 out 15 indicating her cognition was intact. Record review of section L for Oral\Dental status revealed she was checked as having no problem on her oral cavity. Observation and interview on 08/12/24 at 09:31 AM, revealed resident #113 had no teeth in her oral cavity. In an interview she said she had dentures, and they don't fit. Resident #113 said they hurt when she wears them. She pointed to her dentures in two separate containers and stated, they make me sick and they hurt bad. She said no one at the facility had asked her about them and she managed to eat what she could. In an interview on 08/13/24 at 3:45PM, the MDS Coordinator said Resident #113 had no teeth in her oral cavity. She said Resident # 113 had dentures but did not wear them. She looked at the MDS coding and said it was coded wrong which was an inaccurate assessment. She said inaccurate assessments may lead to delay in providing needed services. She said she remembered Resident # 46 telling her about his dentures. She said she would modify both MDS assessments. In an interview with the facility Administrator on 08/14/24 at 1:50 PM, he said he expected all MDS assessments to accurately reflect resident's conditions. HE said the MDS staff was responsable to ensure that all assessment accuretly reflected Residents condition . He said inaccurate assessment may delay services. Policy on Accuracy of MDS assessment was requested on 08/13/24 at 3:50PM and on 08/13/24 at 1:00PM. Provided Policy did not address MDS accuracy.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide appropriate care, treatment, and services to maintain or improve his or her ability to carry out the ADLs for 1 of 16 residents (Resident #23) reviewed for ADL care. The facility failed to assist and provide Resident #23 nail care. This failure could lead to self-injuries and diminish health conditions. Resident # 23 Record review of Resident #23's admission Record dated 08/14/24 revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included cerebrovascular diseases (a condition that affect blood flow and blood vessel in the brain), blindness, essential hypertension, osteoarthritis of knee (deterioration of the knee joints), and depression. Record review of Resident #23's Annual MDS dated [DATE] revealed he was cognitively intact, with a BIMs score of 14 out of 15. Section B of the MDS related to Vision, was coded as highly impaired. Section GG of the MDS related to Functional Abilities and goals revealed he required supervision/touching assistance for personal hygiene. Record review of Resident #23's care plan dated 05/16/24 with a revision date of 9/13/24 revealed Resident #23 was care planned as Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner requiring supervision and limited assistance with ADLs. Intervention Resident #23 will maintain a sense of dignity by being clean, dry, odor free, and well-groomed through the next review date of 09/12/24. Observation and interview on 08/12/24 at 1:00 PM, revealed resident #23 was in his room sitting up on his bed. Observation revealed he was blind and eating with his hands. He was alert and oriented. He said he was doing fine. Observation revealed he had long dirty fingernails. Observation on 08/13/24 09:58 AM revealed Resident #23 had long dirty fingernails. In an interview he said has asked for his nails to be trimmed down but he was always told that they would come back and they never returned. He said he had nail clippers but he could not see well enough to trim them himself. He said he had scratched himself several times especially his eyes. Resident #23 said that trimming his fingernails was one thing he needed help with because he knew how his room was arranged and where most of his things were located but struggled with some ADL care. In an interview with RN A on 08/12/24 at 10:00AM, she observed Resident # 23's fingernails and assured Resident #23 that she would personally trim his fingernails. She did not say how long it had been since his fingernails had been trimmed and did not say who was responsible for trimming them or ensuring they had been trimmed. She said untrimmed long fingernails could caused injuries by scratching himself. Record review of facility's undated policy on ADL care to dependent's residents titled Fingernails and Toenails, read in part . Basic Responsibility Licensed Nurse, Nursing Assistant. PURPOSE: To clean the nail bed, to keep nails trimmed, and to prevent infections. To aid in the prevention of skin problems around the nail bed. To prevent accidental scratching and injuring skin from rough/jagged nails. ASSESSMENT GUIDELINES: May contain, include, but not limited to: Any diagnoses of Diabetes and/or circulatory impairments. Condition of nails, nail bed, and surrounding skin. Any scratches or skin injury caused by nails .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles reviewed for medications, 1 of 2 medication aide carts, and 2 out 3 of nurse's carts. Station 1 nurse medication cart A had a blister packet of Lorazepam, 0.5mg for a discharged Resident control medication, was still in the medication cart in station 1 nurse's cart. Station 1 medication aide cart B had 6 blister packets of medications: Lipitor 40 mg, sertraline HCL 25 mg, LevETIRAcetarn 75 mg, metoprolol tartrate 25mg, baclofen 10mg, gabapentin 100mg, Sertraline HCL 25 mg was left in the cart, and the resident was discharged from the facility on [DATE]. fluticasone propionate nasal spray that was open and not dated. Station 2 nurse medication cart B had opened and undated: Imodium A-D Loperamide hydrochloride tablet's 2mg expired 07/2024. Latanoprost ophthalmic solution 0.0005%125mcg/2.5ml was opened on [DATE], it read to discard after 24 days. These failures could affect residents, placing them at risk for altered effectiveness of the medication and worsening of the resident's symptoms, requiring medical intervention. The findings included: During an observation of Station 1 nurse medication cart A on [DATE] at 1:25 p.m., with RN A and the ADON revealed a blister packet of Lorazepam 0.5mg for discharged Resident #300. The controlled medication was still in the medication cart. During an interview on [DATE] at 1:26 p.m., RN A said the controlled medication should be taken out of the medication cart by the nurse and given to the DON upon discharge. RN A said the discharged resident's medication should not be left in the cart because the nurse might administer the medication to another resident, or it could cause drug diversion. RN A said she was in- serviced on medication administration and storage. RN A said the ADON, and the pharmacist monitored the nurse and ensured there were no discontinued medications in the cart. During an interview on [DATE] at 1:27 p.m., the ADON said the discharged resident's medication should be kept from the cart to prevent the nurses from administering the wrong medication. The ADON said she would be responsible for pulling the medication now since the facility did not have a DON. During an observation of station 1 medication aide cart B on [DATE] at 1:46 p.m. with MA N revealed 6 blister packets of medications: Lipitor 40 mg, sertraline HCL 25 mg, levetiracetam 75 mg, metoprolol tartrate 25mg, baclofen 10mg, and gabapentin 100mg was left in the cart and the resident was discharged from the facility on [DATE]. There was a fluticasone propionate nasal spray that was open and not dated. During an interview on [DATE] at 1:46 p.m., MA N said she placed the resident medication in the bottom drawer of the cart when the resident was sent to the hospital, and she did not know what the protocol was for medication storage when the resident was discharged from the facility. MA N said the nurse, the DON, and the pharmacist checked the medication cart and ensured the medication in the cart was for the residents in the facility. MA N said she had skills checks-off for medication administration and storage. MA N said she did not open the nasal spray, which should be dated to prevent the nurse from administering expired medication. During an interview on [DATE] at 2:12 p.m., the ADON said if a resident went to the hospital and stayed for 72 hours, the computer discharged the resident. The ADON said the medication was kept in the cart for 30 days, but she was not sure. She said she would check the facility policy and protocol and get back to the state surveyor. During an interview on [DATE] at 2:14 p.m., the ADON said the nasal spray should be labeled to prevent the nurse from administering expired medication to the resident. The ADON said if the medication were administered when it was expired, the medication would not be effective. The ADON said that she and the pharmacist would check behind the nurses and MA to make sure the medication was stored appropriately. During an observation and interview of station 2 nurse cart check with LVN R on [DATE] at 2:34 p.m., revealed stock medication: Imodium A-D Loperamide hydrochloride tablet's 2mg expired 07/2024, latanoprost ophthalmic solution 0.0005% 125mcg/2.5ml was opened on [DATE] and it read to discard after 24 days. LVN R said she did not open it, and she did not administer the medication today because it was for bedtime. LVN R said the medication should not be administered after the expiration date because it would not be effective. LVN R said she was trained in medication administration and storage. LVN R said the ADON, and the pharmacist monitor the cart and make sure the medications were not expired or outdated. LVN R said the stock medication should be removed from the cart as soon as it expired and replaced with the current medication. During an interview on [DATE] at 2:40 p.m., the ADON said the nurse should date medication as soon as it was opened and discard it by the expiration date to prevent administering the expired medication, which would not be effective. The ADON said she would monitor the nurses. Record review of the facility undated storage of medication policy read in part . no discontinued outdated, or deteriorated medications are available for use in the facility . Record review the facility undated policy renewal of discontinued medication after discharge and return read in part . establish uniform guideline concerning the facility's procedures for discontinuing medications when a resident is discharged from the facility .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to to provide appropriate dental care for 1 (Residents #113) of 16 residents reviewed for dental. The facility failed to provide proper dental care and assure her denture concerns were addressed with Resident #113. These failures could place residents at risk of not receiving the care needed to maintain their highest, practicable, physical, social, and psychosocial level of well-being. Findings included: Resident #113 Record review of Resident #113's face sheet dated 08/14/24, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included, essential hypertension (primary) (high blood pressure), fall on same level from slipping, tripping, and stumbling without subsequent striking against object, neuropathy diseases, fracture of first lumbar (Fractures), heart failure, heart disease with heart failure, chronic obstructive pulmonary disease, generalized muscle weakness, muscle wasting and atrophy, and other abnormalities of gait and mobility. Record review of Resident #113's annual comprehensive MDS assessment dated [DATE] indicated Resident #113 had a BIMS score of 13 out 15 indicating her cognition was intact. Record review of section L for Oral\Dental status revealed she was checked as having no problem on her oral cavity. Observation and interview on 08/12/24 at 09:31 AM, revealed resident #113 had no teeth in her oral cavity. In an interview she said she had dentures, and they don't fit. Resident #113 said they hurt when she wears them. She pointed to her dentures in two separate containers and stated, they make me sick and they hurt bad. She said no one at the facility had asked her about them and she managed to eat what she could. In an interview on 08/13/24 at 3:45PM, the MDS Coordinator said Resident #113 had no teeth in her oral cavity. She said Resident # 113 had dentures but did not wear them. In an interview with the facility Administrator on 08/14/24 at 1:50 PM, he said he expected all MDS assessments to accurately reflect resident's conditions. He said inaccurate assessment may delay services.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure that the deep fryer grease was changed regularly and kept clean. The facility failed to ensure that the dishwashing area was free of stagnant water and the walls were clean. This failure placed residents at risk for foodborne illness. Findings included: Kitchen observation and interview on 08/12/24 at 08:14AM to 8:50 AM, revealed the deep fryer had dark looking grease with brownish looking substances on top of the grease. One of one oven range had grease build up around the oven range. In an interview with the Dietary Manager, she said the deep fryer grease was due to be changed and she would change the grease from the deep fryer and make sure that the oven would be cleaned. She said it was usually changed every Friday or Monday but had not been changed. Observation of the dishwasher on 08/12/24 at 8:50AM, revealed standing water between the rinse sink and the dishwasher. In an interview, Dietary Aide N said the water was from spraying dishes and the dish washing machine. An observation revealed black looking substances around the walls behind and around the dishwashing area. The Dietary Manager said this was her first time observing the stagnant water on the floor between the sink and that she would tell the Maintenance Director to look at it and she would have the walls cleaned. Observation and interview on 08/12/24 at 2:30PM, with the Facility's Administrator, revealed the stagnant water was between the sink and the dishwashing machine. Multiple unidentified flying insects under the sink and around the dishwashing machine. The facility Administrator said to clean the area and call the pest control company. He said the facility was sprayed about a week ago. Record review of facility's undated policy on 08/14/24 titled {The facility} , Section 9-Dietary -Food Service: Policy Cleaning read in part. Procedure: All equipment, food contact surfaces and utensils shall be cleaned: Surfaces must be cleaned with a sanitizing agent/solution .Chlorine, iodine, or quaternary ammonium compounds are approved sanitizing agents. All food surfaces will be cleaned at the end of each food preparation session. Grid panels in the fire suppression hood over the stove will be removed and run through the dish machine once a month. Rubber mats on the floor in the kitchen must be cleaned daily. The floor of the kitchen must be cleaned daily and after each spill or contamination. Refrigerator units must be cleaned monthly. Wall surfaces that become splattered during the food preparation process must be cleaned daily .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 6 residents (Housekeeper C, and CNA L) observed for infection control. 1. The facility failed to ensure Housekeeper C followed proper infection control and PPE while pushing a dirty trash can on section 1 hallway. 2. The facility failed to ensure CNA L followed proper infection control and hand washing procedure during incontinent care for Resident #25. These failures could place residents at risk for infection. Findings included: Observation and interview on 08/12/24 at 1:46 p.m., Housekeeper C was pushing the trash barrel into the station one hallway, and she had gloves on. Housekeeper C said she was not supposed to wear gloves in the hallway because of the risk for cross-contamination. Housekeeper C said she had been in-serviced on PPE use and infection control. Housekeeper C said the Environmental Manager monitored her during rounding. During an interview on 08/14/24 at 8:50 p.m., the Administrator said Housekeeper C should not have worn gloves in the hallway because of the risk for cross-contamination. During an interview on 08/14/24 at 12:15 p.m., Staff M said Housekeeper C should not have worn gloves while she pushed the trash barrel in the hallway because it was an infection control issue because of cross-contamination and the spread of germs. Staff M said Housekeeper C was in- serviced on infection control and PPE use. Staff M said she monitored all housekeepers when she made random rounds. Record review of Resident #25's face sheet dated 08/23/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #25 had diagnoses which included: atrial fibrillation (an irregular heartbeat), hypertension (when the pressure in your blood vessel is too high), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and need for assistance with personal care. Record review of Resident #25's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 of 15 which indicated moderate impaired cognition. Further review revealed the resident needed extensive assistance with ADL's which required at least one staff assistance. Record review of Resident #25's care plan initiated on 07/23/24 revealed resident had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner. Performance deficit related to impaired cognition and muscle weakness. Intervention: provide shower, shave, oral care, and nail care, per schedule and when needed. During an observation on 08/13/24 at 10:10 a.m., incontinent care provided by CNA D and CNA L revealed, CNA L used the same gloved hands, when she wiped Resident #25's peri area, and took wipes from the multi-wipe packet, 15 times. CNA L changed her gloves thrice during the care and did not wash or sanitize her hands before she donned another glove. During an interview on 08/13/24 at 1030 a.m., CNA D said he saw CNA L took wipes from the multi wipe packet many times with the same gloved hands she used to clean Resident #25's bowel movement, and she changed her gloves three times, and she did not sanitize or wash her hands before she donned another glove. CNA D said it was an infection control issue because CNA L would have transferred germs from her gloves to the wipe packet or other surfaces she touched. During an interview on 08/13/24 at 11:00 a.m., CNA L said she forgot to change her gloves before going from dirty to clean, and she did not wash or sanitize her hands before she donned clean gloves. CNA L said it was an infection control issue, and she could have contaminated the multi wipe packet. During a telephone interview on 08/13/24 at 11:35 a.m., the Interim DON said CNA L was supposed to pull wipes out of the wipe packet before she started to wipe Resident #25's peri area and buttocks. The Interim DON said if CNA L needed more wipes, she should have removed the gloves and sanitized her hands before she went back to the multi wipe packet. The Interim DON said it was because of the risk for cross-contamination. The Interim DON said CNA L should have washed or sanitized her hands before she donned new gloves. The Interim DON said the facility did not train or in-service agency aides before the aide would be assigned to the floor because they had a contract with the agency. They know the facility's needs, but she would check with the COO and get back to the surveyor. During an interview on 08/14/24 at 1:28 p.m., the ADON said CNA L should have pulled some wipes out of the container, and if she needed more, she should have changed her gloves before she pulled more wipes from the container. The ADON said if CNA L did not wash or sanitize her hands, it was an infection control issue because it was cross-contamination. The ADON said CNA L could have transferred germs from her used gloves to the multi-wipe packets, and she should have washed or sanitized her hands because the gloves could have had holes. She said CNA L was an agency aide, and the facility did not provide training or in-services before the aide started working. Still, if the agency aide were in the facility during in-service, the agency aide would attend the in-service. Record review of the facility undated policy on housekeeping read in part . provide a safe environment for resident . Record review of the facility undated policy on personal protective equipment - gloves read in part . to prevent the spread of infection . miscellaneous #5 . wash hands after removing gloves. (Note: gloves do not replace handwashing) . Record review of the facility undated policy on hand washing read in part . hand washing will be regarded by this facility as the single most important means of preventing the spread of infections . procedure #2h . after contact . body fluid excretion .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure all mechanical, electrical, and patient care equipment was in safe operating condition for 1 of 6 residents (Resident #25) reviewed for safe operating patient care equipment. The facility failed to maintain Resident #25's electric bed remote in safe operating condition. This failure could put residents in the facility at risk of injury. The findings included: Record review of Resident #25's face sheet dated 08/23/24 revealed she was a[AGE] year-old female admitted to the facility on [DATE]. Resident #25 had diagnoses which included: atrial fibrillation (an irregular heartbeat), hypertension (when the pressure in your blood vessel is too high), dementia (impair ability to remember, think, or make decisions that interferes with doing everyday activities), and need for assistance with personal care Record review of Resident #25's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 of 15 indicated moderate impaired cognition. Further review revealed the resident needed extensive assistance with ADL one staff assist. Record review of Resident #25's care plan initiated on 07/23/24 revealed resident had ADL self-care performance deficit and at risk for not having her needs met in a timely manner. Performance deficit related to impaired cognition and muscle weakness. Intervention: provide shower, shave, oral care, and nail care, per schedule and when needed. During an observation on 08/12/24 at 10:40 a.m., revealed Resident #25's bed was in a high position. During an observation and interview on 08/12/24 at 1:30 p.m., RN A said the remote control for Resident #25's bed had not been working, and she was not sure if it was reported to the maintenance, and she could not remember reporting it. RN A said Resident #25's bed was in a high position because the remote control would not let the bed down, and if Resident #25 Fell out of the bed, Resident#25 could sustain an injury. During an observation and interview on 08/13/24 at 10:10 a.m., revealed Resident # 25 bed was still in a high position. After CNA L and CNA D provided incontinent care for Resident #25, CNA L tried to lower Resident #25's bed, but the bed would not go down. CNA L said she could not lower the bed because the remote malfunctioned. Then CNA D took the bed remote from CNA L and manipulated the bed remote for about 5 minutes. CNA D was able to lower the bed, and he said the remote was not working properly because there was wiring shortage, and the remote needed to be fixed. CNA B said he did not tell the nurse or the maintenance because today was his second orientation day. During an interview on 08/13/24 at 11:00 a.m., CNA L said she worked with Resident #25 yesterday (08/12/24). CNA L said she could not lower Resident #25's bed because the remote control was not working correctly, and she did not tell the nurse or the maintenance because she was an agency aide and did not know who to report to about the bed remote. CNA L said she did not get any training on equipment safety from her agency and the facility. CNA L said if Resident #25 had fallen out of the bed because the bed was left on a high level, Resident #25 could hurt herself. CNA L said the charge nurse monitored the aides when she made rounds. During an interview on 08/14/24 at 8:10 a.m., the ADON said the remote to Resident #25's bed had an electrical shortage, which affected the remote's function and caused the bed not to go down. The ADON said that since the remote was not functioning, this could cause harm to Resident #25 if Resident #25 happened to fall out of the bed because the bed was left in a high position because the remote was not functioning. The ADON said she was not aware the bed remote for Resident #25 had an electrical issue until this week, Monday (08/12/24), and she did not notify maintenance. During an interview on 08/14/24 at 8:14 a.m., the Maintenance assistant said he would become aware that Resident #25's bed remote was not working when one of the nurses told him, and he would get the remote fixed. The Maintenance Assistant said they had an order book at the nursing station for repairs, and there was no repair request for Resident #25's bed remote. The Maintenance Assistant said he was not aware that the bed remote for Resident #25 was not working until yesterday at around 11:00 a.m. (08/13/24). The Maintenance Assistant said the maintenance Director made rounds and checked on the bed remote, but he did not know how often the maintenance director made rounds. The Maintenance Assistant said the Maintenance Director was off this week because he was sick. The Maintenance Assistant said Resident #25 could have fallen out of bed, and Resident #25 could have hurt herself if the bed was left high because the bed remote was not functioning. During an interview on 08/14/24 at 8:42 a.m., The Administrator said the staff that goes into Resident #25's room should have told the manager. The manager would put the order in the telling system, and the maintenance would fix Resident #25's call light. Then the Administrator said he would prefer the nurses to tell maintenance immediately so the maintenance would fix it immediately. The Administrator said if Resident #25 fell from a bed left in a high position, Resident #25 could hurt herself. Record review of the facility undated policy on preventative maintaince read in part . the facility will ensure that a comprehensive preventive maintenance program is in place for essential operating equipment. Preventive maintenance will be completed routinely. and accordingly, to protocol by the maintenance supervisor .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

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Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests. The facility failed to ensure the facility was free from pests/insects in multiple areas including one of one kitchen and one of one conference room. This failure could place residents at risk for insect borne illnesses, and cause residents to live in an uncomfortable environment free of pests. Findings included: Observation on 08/12/24 at 10:00am, revealed flies and other flying insects in one of one conference room. Observation and interview with the facility Administrator on 08/12/24 at 2:30PM, revealed the following- Under the kitchen sink revealed multiple flying insects. On the wall above the sink by the window was a live roach. Observation of the dishwasher was a live roach. The facility Administrator asked the dietary Manager to call the pest control company. The Dietary Manager said the company had sprayed the facility a few weeks ago. Observation on 08/13/24 at 12:40PM, revealed live spider crawling from the wall in the conference room. The Administrator was notified. He said he would call the pest control company. Observation and interview on 08/13/24 at 12:30PM revealed a live roach and flies in the conference room. During an interview with the facility Administrator, he said the building was old and the facility had a pest control contract with a local company. He said all staff are responsible to report any pest control problem as to call in the pest control company for treatment. During an interview on 08/13/2024 at 10:12 AM, Resident #113 stated that she had seen cockroaches in her room. She said she believed the facility was aware. During an interview on 08/13/2024 at 9:31 AM, an Anonymous pest control staff said ng the kitchen. He said the only way to get rid of the rodents was to keep the floors around the dishwashing machine dry. During an interview on 08/13/24 at 1:00pm, Housekeeper T said that she had seen roaches in the resident's rooms and around, but they would always call pest control. DA stated that the bug on the wall next to the sink was a cockroach. He stated that they were everywhere in the building. He stated that pest control only came once and wished they came more often. He stated that when he saw cockroaches, he usually just killed them. He stated that he had not seen the cockroaches on clean dishes. He stated that they were in the outlet in the hallway and between the wheels of the trash can. He stated that the bug on the wall was next to a clean tray cart and was also a cockroach. During an interview with AFSS on 08/06/2024 at 11:37 AM, he stated that he has worked at the facility for two to three weeks. He stated that he noticed cockroaches shortly after he started. He stated he had not seen cockroaches in food. On 08/06/2024 at 11:39 AM, during an interview with [NAME] A, she stated that she had seen some cockroaches in the kitchen. She stated that she was unsure why they were in the kitchen but had not seen any in the food. Record review of facility's pest control policy undated section 10 read in part: The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department. Procedure: .Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required. Facility will maintain appropriate screens, close fitting doors, properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents. Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places, etc. for insects or rodents. Deliveries of food and supplies will be monitored for prevention of insect and rodent access .

Jun 2023 6 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 43 residents (CR #229) reviewed for free of accidents, hazards, supervision, and devices. -The facility failed to develop any interventions following CR #229's fall on [DATE]. CR #229 fell again on [DATE], suffered a traumatic head injury and died as a result of his injuries. On [DATE] at 3:09 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE] at 2:36 p.m., the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). This failure could affect residents who require assistance with ADLs and place them at risk for physical harm, pain, mental anguish, or emotional distress. Findings included: Record review of CR #229's face sheet revealed he was a [AGE] year-old male who was admitted on [DATE]. His diagnosis included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), anxiety (intense excessive, and persistent worry and fear about everyday situations), and cerebrovascular disease (includes stroke, carotid stenosis, vertebral stenosis and intracranial stenosis, aneurysms, and vascular malformations). Record review of CR #229's Comprehensive MDS dated [DATE] revealed CR #229 had a BIMs score of 6 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of CR #229's Record review CR #229's undated comprehensive care plan revealed the following: Fall risk: CR #229 has the potential for falls r/t unsteady gait, history of falls, and poor safety awareness with poor impulse control .Date: [DATE] .Created on: [DATE] .Revision on: [DATE]. Goal the resident will be free of falls during the next 90 days .Date initiated [DATE] .Revision on: [DATE] .Target date: [DATE]. Interventions anticipate and meet the resident's needs .Date initiated:[DATE] .Created on: [DATE] .Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter, remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes .Date initiated: [DATE] .Created on: [DATE]. Therapy for strengthening .Date initiated; [DATE] .Created on [DATE] .Revision on: [DATE]. Record review of CR #229's Progress Notes dated [DATE] at 4:39 a.m. entered by Agency Nurse, read in part, .CNA reported to this nurse that during rounds, res was observed on the floor surrounded with red drainage. Res is alert with difficulties hearing. Res is unable to tell nurse what happened. Res has a wound to left temporal region. Res able to move all extremities x4 without pain. Res BP:99/56 HR 65 RR 15 o2 97RA T: 98.9. this nurse called EMS to transport res to [Hospital A] . Record review of CR #229's incident report dated [DATE] at 3:35a.m., read in part, .Nurse Description: CNA reported to this nurse that during rounds, res as observed on the floor surrounded with red drainage. Res is alert with difficulties hearing. When asked what happened resident did gesture to the bathroom. Res has a wound to the left temporal region. Resident is able to move extremities x4 without pain. Res BP:99/56 HR 65 RR 15 o2 97RA T: 98.9. Resident Description: Asked to give more details as to what happened resident pointed to bathroom but did not say anything else. Immediate Action Taken: Res transported to Hospital A of head injury. Record review of CR #229's Patient Record-Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .DISPO: pending evals, likely return to nursing home. Patient is critically ill at risk for at least one organ failure. I spend 45 mins of critical care time . NERO: #Acute traumatic subdural hemorrhage, on admission. #Acute traumatic IPH . Record review of CR #229's PT Evaluation & Plan of Treatment dated [DATE] at 6:47a.m., read in part, New Goal/Short Term Goals: Patient will safely ambulate on level surfaces 60 feet using RW with Min assist for task segmentation with reduced risk for falls in order to increase independence with all functional ambulation and to reduce risk for loss of balance (Target date: [DATE]). New Goal/Bed Mobility: Patient will safely perform functional transfers with Stand Assist for push up from arms of chair and for correct hand/foot placement with reduced risk for falls in order to facilitate increased (I) with functional mobility throughout facility and decreased level of assistance from caregivers (Target Date: [DATE]). New Goal/Transfers: Patient will safely ambulate on level surfaces 125 feet using RW with Stand by assist for task segmentation with reduced risk for falls in order to increase independence with all functional ambulation and to reduce risk for loss of balance (Target date [DATE]) . Interview on [DATE] at 10:27a.m., with RN A said she came into work and LVN A told her CR #229 had gotten out of bed and fell on [DATE]. She said during the day he stayed in his wheelchair, and at night he was in the bed. She said CR #229 has not been at the facility since his fall. She said she is not sure how long CR #229 was at the facility. She said he is supposed to turn on his call light when he needs help, but he is non-compliant. She said he would sometimes try to walk on his own, and staff would tell him that he had to use his wheelchair. She said there are three nurses that works station one. Interview on [DATE] at 10:30 a.m. with CNA F said she used to assist CR #229 with everything. She said she would transfer him to the chair and assist him to the bathroom. She said his balance was unsteady. She said the resident would tell her he didn't need any help. She said she was not present when the resident fell. She said his behavior was always good towards her. She said this was the first incident of him falling. Interview on [DATE] at 10:41 a.m., with CNA D said she came into work the next morning and was told CR #229 got up to go to the restroom and he fell. She said she never allowed him to go to the restroom by himself. She said she did not allow him to do things on his own. She said she has been working at the facility for a year. She said there are two CNAs on each hall. Interview on [DATE] at 12:10 p.m. the Administrator said he was told by staff that CR #229 had fallen and was able to explain what happened to staff. He said it was an agency nurse that was working the night when CR #229 fell. He said CR #229 had a fall once before on [DATE]. Follow-up interview on [DATE] at 2:18p.m., the Administrator said he is in challenging times. He said he has had challenges with staffing. He said some of the staff do not care. He said, trying to get staff to adhere to his rules is overwhelming. He said regarding CR #229, he was going off the information that was given to him by some of the staff. He said he was told CR #229 was able to gesture what happened and he assumed he fell in the restroom. He said he was not sure as to why the initial fall assessment wasn't done. He said he does not know when they received the information that CR #229 was deceased . He said he never documented the updates on residents that they follow up on. He said they have not documented what is discussed in the morning meetings, especially when it has been documented that they discharged a resident. He said CR #229 died at the hospital. He said they do not go back in to document that kind information. He said he has never done that at any facility he has worked at. He said if a resident dies outside of the facility, staff will be notified by word of mouth. He said they will have to call to receive that kind of information. He said the facility does not receive a death certificate on a resident. He said the family will call and give information about the resident. He said the only way someone at the facility would know about a deceased resident is by asking. He said he acknowledges that there was conflicting information. Interview on [DATE] at 2:40 p.m. with the DON said she did not talk to CR #229 about his fall. She said CR #229 was gone from the facility when she arrived at work. She said she was notified by staff that he had fallen, and staff noticed he was injured, and was sent to Hospital A. She said staff didn't know how or where he hit his head. She said they wanted to get CR #229 assessed. She said she did not report the incident because he was discharged to the Hospital A, and no one witnessed the incident. Interview on [DATE] at 12:50 p.m. with RN A, said she worked with CR #229 for the short time he was at the facility. She said she provided day to day care for him. She said CR #229 had to be redirected a lot because he wanted to be self-sufficient. She said on her shift, he did well with staying in his wheelchair. She said the night the CR #229 had the fall; she came into work and LVN A reported it to her. She said she is not sure if it was LVN A who gave her the report. She said staff told her that CR #229 got up in the middle of the night and was found on the floor in front of the sink. She said she was told he was bleeding from his head, and they sent him out for evaluation. She said she cannot remember if there was anything put in place prior to the second fall. She said CR #229 had a low bed. She said if he asked for assistance to the bathroom, they would help him, but he would not ask for assistance. She said he thought he could do everything on his own, but he couldn't anymore. She said she checked on him a lot. She said he was able to get up and go to the restroom by himself, but he had an unsteady gait. She said CR #229 did not need two persons assist. She said he only needed one person assists to go to the bathroom. She said when she would assist him to the restroom, she would take his wheelchair and put in the bathroom doorway. She said she helped him pivot and put him on the stool. She said if something was put in place for CR #229, he could carry out that plan. She said sometimes his cognition would be better than it would at other times. She said he was able to communicate his needs to her. She said she would ask CR #229 if he was in pain and needed assistance to the bathroom and he would answer her appropriately. She said she was surprised he had a BIMs score of 06. Interview on [DATE] at 1:27 p.m. with MDS Coordinator A, said she has been the MDS nurse at the facility for 21 years. She said she is responsible for doing the MDS assessments, LTC's, MI's, and she also does PASSAR's for the residents. She said the DON and the ADON are responsible for the care plans and care plan meetings. She said whatever triggers are from the MDS, they are added to the care plan. She said on the MDS assessment if it says limited assistance for toilet use, it means that resident needs assistance to go to the bathroom. She said extensive assistance means he needs someone to help him all the time. She said she knows that CR #229 used his walker, and he would say different words or wrote them down. She said he could articulate his words. She said limited toilet use means moderate assist which means someone might need to watch him but not assist or they can help clean him. She said it is a difference when it comes to extensive assistance and limited assistance. She said if there is a care plan that says limited assistance and a MDS that says extensive assistance in a certain care area, it is a problem because it can affect the proper guidance or care that is needed for the resident. She said she cannot answer why the MDS assessment does not match the care plan. She said CR #229 was not on a toileting program. She said CR #229 was able to move around, and he was able to go leave his bed and go to the bathroom. She said when she did the MDS assessment for CR #229, he seemed to need extensive assistance. She said on [DATE], she said did not do the intervention process on the care plan because she does not create the care plans. She said the nurses and the ADON are responsible for completing the fall risk assessments. Interview on [DATE] at 1:51 p.m. with the ADON, said is the Interim Assistant DON, till they find someone permanently. She said she checks the resident's admission assessments, and she does what is needed at the facility. She said she also review the resident's orders. She said she has also written care plans. She said she looks at the resident's diagnosis and their assessments, and their history. She said she does not receive information from the MDS on how to write the care plan. She said she has spoken to CR #229 when she needed to get consent on a vaccine. She said she called his family member for that information as well. She said MDS assessments are done quarterly or if there was a significant change. She said the MDS, and the care plan should correlate. She said she is responsible for the baseline care plan. She said the baseline care plan is done upon admission, which is what she had assessed on the resident. She said the comprehensive care plan is more detailed and is pulls more data on the resident. She said the importance of the care plan is so staff can establish a plan of care for the resident. She said the importance of an MDS assessment is to show what service is needed for the resident. She said CR #229 was able to move around on his own. She said he went to the restroom on his own. She said when she went to ask him about a vaccine, he was coming out of the restroom with his wheelchair. She said on [DATE], she was told he had a fall and was bleeding from his head and was sent to the hospital. She said she was aware that CR #229 had fall on [DATE] as well. She said he was able to understand what was being care planned. She said CR #229 could use the call light and moving the bed up and down. Interview on [DATE] at 2:15 p.m., with the DON, said she is responsible for everything. She said she oversees the nursing department. She said she is responsible for the comprehensive care plan. She said she has been the DON since [DATE] and was the interim during February of 2022. She said the care plan comes from the trigger assessment that was on the MDS. She said the MDS assessment can trigger certain problems a resident has, and their diagnosis and she would create the care plan. She said CR #229 was alert and oriented. She said he could speak, but it was not that clear. She said he was also able to write. She said he could walk but it was a scary walk. She said he was able to tell you when he needed to go to the bathroom. She said a BIM's score of 06 means it is a low score and that the person is not cognitively inclined. She said staff would tell CR #229 to call for assistance and to use the call light when he needed to use the restroom, but he would go on his own. She said extensive assistance means the staff is doing the work 75 percent of the time. She said limited assistance means the resident is doing 75 percent of the work. She said it would not be an issue if the MDS and the care plan had something different. She said if she goes into a resident's room and they can make their needs known, she will document what they can relate to, and that would be it was resident centered. She said CR #229 was not always verbal, but he can write things down. She said what she was told by LVN D, was that CR #229 was on the ground, and he had a head injury. She said she told her to see if CR #229 could write it down. She said she was not sure if CR #229 ever wrote anything down. She said CR #229 could walk and staff would sometimes help him. She said the MDS extensive assistance, and two-person assist doesn't really mean that is what he needs. When the DON was asked to explain what she meant by her last statement, she said she did not know how to explain what she meant. Interview on [DATE] at 2:35 p.m., with the Administrator, said he has been the administrator at the facility for 31 years. He said he is a hands-on administrator, and he goes to resident council meetings when asked. He said the residents and the resident's family members has his personal phone number. He said his first interaction with CR #229 was when he first came to him and introduced himself. He said the second time was after his first fall. He said the first fall that occurred on [DATE] was not investigated and it was not reported to the state. He said it was a fall without injury, so he did not feel there was a reason to report it. He said he does not know why there wasn't an intervention completed. He said he has told staff to be more cautious about the residents having falls. He said there was a morning meeting about CR #229's fall. He said if there was a fall in the facility, they would have a follow up in a morning meeting. He said if a resident has a fall and there is no updated assessment, or a prevention put in place, a resident can have another fall with an injury. He said it is not a problem to have a care plan that is different from the MDS. He said when he first met CR #229, he was not total assist. He said CR #229 showed no difference in how he moved after he fell on [DATE]. He said he was the same on [DATE]. He said he was able to do things on his own. He said does not help with the MDS assessments. He said if a resident has a fall, an assessment should be updated. He said the care plan should be updated as well. He said the care plan should reflect the needs of the resident, so staff would know how to care for the resident. He said he did not receive CR #229's death certificate. He said medical records could ask for it, but they do not automatically receive that information. He said when CR #229 had his second fall on [DATE], he was told he had a fall and had a gash. He said they called the doctor, and CR #229 was sent out to the hospital. He said he does not know how long after CR #229 left the facility, that he expired. Telephone Interview on [DATE] at 10:07 a.m., with LVN D, said when CNA G was doing rounds, she let her know she observed CR #229 on the floor. She said when she went into the room, his bed was in a low position. She said he was near the bathroom. She said it looked like he hit his head. She said he was on his back, and it looked like he was trying to get up. She said CNA G got another nurse to help. She said she cannot remember the nurse's name who came to help her with CR #229. She said she called 911. She said she tried to ask CR #229 what happened and what he was doing, and she said he was pointing towards the bathroom and couldn't really speak. She said he used a communication board to communicate daily. She said she did not have much communication with him during the night. She said CR #229 had a roommate as well. She said he could walk on his own, unsteadily. She said she CR #229 did not always try to get up through the night to use the restroom. She said he always made gestures and never really spoke to her. She said she does not remember if she worked with him in the past. She said the night CR #229 had fall on [DATE], he did not say he was in pain. She said when she assessed him, he had a laceration on his head. She said CR #229 was not moaning. She said the bathroom is no more than 10 feet away from his bed. She said she did a risk management report. She said she does not recall if she did a change of condition report. She said she contacted the on-call service (physician) for the facility. She said she left a voice mail for whomever was listed under his contacts. She said when CR #229 went to the hospital, she called the DON. She said she did not think the fall was suspicious. She said the facility made sure she included a witness statement inside the risk assessment. She said it is in the risk management portion. Interview on [DATE] at 10:52 a.m., with family member, said she was told by the facility that CR #229 accident happened in the middle of the night. She said they told her he fell, and he had to go to the hospital. She said they told her he had a gash on his head, and he was conscious. She said she did not hear from the facility once her brother arrived at Hospital A because they l took over. She said she went by the facility to pick up CR #229's belongings and she was able to retrieve everything except his necklace and hearing aid. She said CR #229 passed away on [DATE]. She said at the hospital, they did a full body MRI on CR #229, and it showed that the gash was more than 5 inches. She said it went straight up from his head to his eyebrow. She said the MRI also showed a brain bleed. She said CR #229 seemed disoriented and was acting up and being erratic and trying to get out of his bed. She said CR #229 was transferred on a Sunday from Hospital A, to a specialized trauma hospital. She said once she arrived at the main hospital, CR #229 couldn't open his eyes or do anything. She said she flew out again on [DATE] and his lungs started to fail. She said her mom was in rehab and she took her out of rehab because she is the legal guardian of CR #229. She said her mom talked to the brain surgeon, but he could not say if CR #229 would wake up again. She said CR #229 was on a breathing machine and was not breathing on his own. She said he was intubated. She said CR #229 death certificate said the cause of death was blunt force trauma to the brain and a hematoma in the brain. She said when she went to the facility on [DATE] to pick up CR #229 things, staff told her the night her brother fell, he was using a walker. She said she was not notified by staff when he fell on [DATE]. Interview on [DATE] at 11:44 a.m. with PT A said, CR #229 was evaluated for physical therapy on [DATE] and for occupational therapy on [DATE] as well as speech therapy. He said he was not evaluated upon admission on [DATE] because he was a Hospital C resident and they do not come into the facility with approvals for therapy, which means if he came to the facility on the [DATE] he would be evaluated the following week. He said he submitted documentation to Hospital C on a Monday. He said CR #229 never participated in therapy. He said he is not sure why he wasn't evaluated after the first week. He said CR #229 might not have been feeling well. He said it was reported to the therapy department on [DATE] about a resident with a recent fall during transfers. He said he evaluates a resident, depending on when they fall, if they don't normally fall, and he will screen and evaluate a resident and recommend therapy. He said residents that fall and don't move around a lot will be screened. He said CR #229 was using a rolling walker. He said he had been evaluated for the safety of the walker. Followed-up interview on [DATE] at 1:18 p.m., with the DON and the Administrator. The DON said, the root cause was that CR #229 was impulsive and was not asking for help as suggested. She said she discussed the IDT fall in the morning meetings. She said she removed some of the things that was in the room and straightened up the clutter. The Administrator said he did not document the clutter, that he just rearranged the clutter. The DON said staff assigned to therapy evaluated CR #229 on using a rolling walker and determined if it was safe to be used or not. She said she knew right away if it was safe or not. She said she is not sure if anyone took the walker away. The Administrator said he could not force CR #229 to not use the walker because that would be taking away his rights. He said when they asked him not to get up, CR #299 would listen. Followed-up interview on [DATE] at 1:25 p.m., with the Administrator, said CR #229 was able to verbalize the things he needed. He said when he received CR #229's medical record, he did not think to report it. He said he thought CR #229 was coming back to the facility. He said he had a conversation with staff from Hospital C, and he never thought the blame would be put on him regarding CR #229. Followed-up interview on [DATE] at 2:11 p.m., with the DON said, MDS Coordinator A, social services, activity services, and the dietary manager assist with completing the MDS assessment. She said section G of the MDS assessment is completed by the MDS Coordinator A. She said she and MDS Coordinator A, used to be responsible for the comprehensive care plan. She said she was responsible for the comprehensive care plan while CR #229 was present at the facility. She said MDS Coordinator A was responsible for the admission MDS assessment. She said she cannot speak on the discrepancy of the care plan and the MDS assessment because she did not see it as a big discrepancy. She said she did not check to see if there was a discrepancy because she did not see what the surveyors were seeing. She said she did the care plan based on what staff was telling her and not what was documented. She said she did not realize that certain care areas regarding CR #229 was not documented. She said CR #229 could ambulate because he could move. She said if he had a significant change, she has 14 days to update the assessment. She said she did not think the fall could have been prevented. She said he was put bed in the low position. She said CR #229 wanted to be independent. She said she would not do an SBAR or MDS assessment, only a fall risk assessment. She said no one told her that CR #229 had a walker the night he fell, on [DATE]. She said the walker was in his room and she cannot take the walker away. She said a Hospital C resident does not come into the facility with orders for rehab. She said something must happen for a Hospital C resident to receive rehab. She said it is difficult for a Hospital C resident to receive rehab. She said there are some residents who come on admission with rehab orders. She said it does not always happen. She said the facility will have to push for it, not Hospital C. Interview on [DATE] at 12:09 p.m., with the Medical Director, said he has been sharing his responsibility with Physician B. He said at the nursing facility, the meetings are usually once a month. He said he often attends the meetings virtually. He said he goes to the meetings in person when the issues are more complex. He will go over the issues with MDS Coordinator A, and the Administrator. He said in the meetings if there was an unwitnessed fall or a serious injury occurred, it will be discussed well before QAPI comes up. He said if a major fall happened that caused a brain bleed, it would be something that you would immediately report to the state. He said regardless of if the resident could communicate or not, it will still need to be reported to the state. Interview on [DATE] at 12:38 p.m., with Physician B said she was only at the facility once a week. She said her last day working at the nursing facility was on [DATE]. She said when she was working at the facility, she participated in QAPI once a month. She said she attended in person, and they discussed falls, who fell and followed up on plans after the falls. She said she will look at CR #229's medical history, and what happened with the fall. She said she would ask questions about medication before making a [NAME] to report an incident to the state. She said if the resident is deemed by therapy not safe to use different devices to keep them safe and they still want to use them, she said it is their right and they cannot hold a resident down or retrain them. She said if a resident takes a walker even after he's been redirected it will put them in an interesting position. She said some residents have tried to hit her and other staff members. Record Review of the facility's policy titled Fall and Post-Fall Management, undated, read in part, . Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for the resident as well as staff safety. Identify residents at risk for falls during ADL execution by resident individually or with staff assistance. Initiate preventative approaches. Provide appropriate strategies and interventions directed to resident, environmental factors, and staff. Provide learning opportunities. Monitor and evaluate resident outcome . This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 3:09 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy template on [DATE] at 3:10 PM. The following Plan of Removal was submitted and accepted on [DATE] at 1:29 PM. Plan of Removal [DATE] Submission #3 Immediate action: Other residents affected: o Forty-three (43) current facility residents have been identified and assessed by the DON, ADON, MDS Coordinator and Rehab Director as having the potential to be affected by the deficient practice on [DATE]. o The DON, ADON, MDS Coordinator and Rehab Director will review the Plans of Care and Kardex of the 43 residents at risk for falls to ensure universal fall precautions, appropriate and adequate assistive devices and interventions are in place to prevent unnecessary falls and accidents to be completed on [DATE]. The DON, ADON, MDS Coordinator and Rehab Director will investigate all new falls and ensure interventions are in placed within 24 hours during the daily Stand-Up meeting utilizing the Post Huddle Fall Worksheet. The Administrator will monitor the IDT Team to ensure all falls are appropriately investigated and correct interventions are updated and in place to prevent falls. o The DON and Nurse Managers will in-service Direct Care Staff regarding universal fall precautions, the Kardex system and the importance of residents having appropriate and adequate assistive devices, fall interventions and needed assistance with transfer and toileting. In-services began on [DATE] and will be completed with current Direct Care Staff on [DATE]. All other nursing staff not currently on shift or on leave will be in-serviced upon return to work prior to providing care. Facilities Plan to Ensure Compliance: o A Quality Assurance and Performance Improvement meeting was held on [DATE] with the Medical Director, Administrator, DON, ADON, Rehab Director, and MDS Coordinator to review the allegations surrounding F689 tag and the plan moving forward related to the IJ Plan of Removal. It was determined by the committee that the DON, ADON, Rehab Director and MDS Coordinator will review fall policy(s), implementation of fall interventions within 24 hours, assessment of high fall risk residents in regards to inappropriate durable medical equipment usage and provide a care plan meeting with the resident and/or responsible party to discuss unsafe practices and resolution, such as removal of equipment, upon admission and as needed. o Facility process on how to access the Kardex in Point Click Care - In-services performed by DON and ADON began on [DATE] and will be completed with current nursing staff by [DATE]. All other nursing staff not currently on shift will be in-serviced and a post- test administered by [DATE]. All new hires will receive training on the same topics during new employee orientation and prior to providing care. Agency staff will also receive training on the same topics at start of their shift prior to providing care. A posttest will be provided for understanding and competency. If in-house and agency staff members don't achieve 100%, they will be re-ed[TRUNCATED]

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 7 residents (CR #229) reviewed for reporting of alleged violations. - The facility failed to report to the State Agency within 2 hours of CR #229's unwitnessed fall which resulted in an injury that occurred on [DATE]. This failure could place residents at risk of death due to not reporting or completing investigations of injuries of unknown origin and falls. Findings included: Record review of CR #229's face sheet revealed he was a [AGE] year-old male who was admitted on [DATE]. His diagnosis included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), anxiety (intense excessive, and persistent worry and fear about everyday situations), and cerebrovascular disease (includes stroke, carotid stenosis, vertebral stenosis and intracranial stenosis, aneurysms, and vascular malformations). Record review of CR #229's Comprehensive MDS assessment dated [DATE] revealed CR #229 had a BIMs score of 6 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of CR #229's Progress Notes dated [DATE] at 04:39 a.m. entered by Agency Nurse, read in part, .CNA reported to this nurse that during rounds, res was observed on the floor surrounded with red drainage. Res is alert with difficulties hearing. Res is unable to tell nurse what happened. Res has a wound to left temporal region. Res able to move all extremities x4 without pain. Res BP:99/56 HR 65 RR 15 o2 97RA T: 98.9. this nurse called EMS to transport res to Hospital A . Record review of CR #229's Progress Notes dated [DATE] at 4:57 a.m. entered by Agency Nurse, read in part, .Res observed on floor in room, in front of sink, away from bed . Record review of CR #229's Patient Record-Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .DISPO: pending evals, likely return to nursing home. Patient is critically ill at risk for at least one organ failure. I spend 45 mins of critical care time . Record review of CR #229's Patient Record Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .[NAME]: #Acute traumatic subdural hemorrhage, on admission. #Acute traumatic IPH . Interview on [DATE] at 10:27 a.m. with RN A, revealed she came into work and LVN A told her CR #229 got out of bed and fell. She said during the day he stayed in his wheelchair and at night he was in the bed. She said CR #229 has not been at the facility since his fall. She said she is not sure how long CR #229 was at the facility. She said he was supposed to turn on his call light when he needed help, but he is non complaint. She said he would sometimes try to walk on his own and staff would tell him that he had to use his wheelchair. She said there are three nurses that works station one. Interview on [DATE] at 10:41a.m. with CNA D, revealed she came into work the next morning and was told CR #229 got up to go to the restroom and fell. She said she never allowed him to go to the restroom by himself. She said she did not allow him to do things on his own. She said she has been working at the facility for a year. She said there are two CNAs on each hall. Interview on [DATE] at 12:10p.m., with the Administrator, revealed he did not self-report the incident because it was not staff related . He said CR #229 was able to explain what happened to staff. He said it was an agency nurse that was working the night of the incident. He said CR #229 had a fall once before on [DATE]. He said CR #229 was discharged to the hospital. Follow-up interview on [DATE] at 2:18 p.m. with the Administrator, revealed he was in challenging times. He said he had challenges with staffing. He said some of the staff do not care. He said, trying to get staff to adhere to facility rules were overwhelming. He said he was going off the information regarding CR #229 that was given to him by some of the staff. He said he was told CR #229 was able to gesture what happened and he assumed CR #229 fell in the restroom. He said he was not sure as to why the initial fall assessment was not done. He said he does not know when they received the information that CR #229 was deceased . He said he never documented the updates on residents that they followed up on. He said they have not documented what was discussed in the morning meetings, especially when it had been documented that they discharged a resident. He said CR #229 died at the hospital. He said they do not go back in to document that kind information. He said he has never done that at any facility he had worked at. He said if a resident died outside of the facility, staff will be notified by word of mouth. He said they [facility] would have to call to receive that kind of information. He said the facility does not receive a death certificate on a resident. He said the family would call and provide information about the resident. He said the only way someone at the facility would know about a deceased resident was by asking. He said he acknowledges that there was conflicting information. Interview on [DATE] at 2:27p.m. with Marketing Admissions, revealed when she found out the information about CR #229 passing away, she informed the staff, the Administrator, and the DON. She said someone from the hospital called and gave her the information that CR #229 passed away. She said she had called three times to do a follow up. She said there was nothing clinical reported to her by the hospital about CR #229 . She said they told her CR #229's family was by his bedside, and he was stable. She said she received clinical documentation via the Care Port system that was a referral system. She said when she visited CR #229 at the hospital, he was fine. She said she did not see the family at the hospital. She said there was no documentation regarding the phone call that she received. She said she called the hospital on [DATE] and they called her back at 8:30a.m. and informed her that CR #229 was deceased . She said she was nonclinical, and she did not put information into the PCC. Record Review of the facility's policy titled Prevention and Reporting Resident Abuse and Neglect, undated, read in part, .The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged abuse and neglect. This facility has implemented the following processes in an effort to provide residents and staff a comfortable and safe environment. The Director and the Administrator will designate a person to complete an Investigative Report to: Notify Texas Department of Human Services according to state law as required by state; state specific guidelines for reporting will be followed . .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview, and record review, the facility failed to ensure allegations of abuse and neglect were thoroughly investigated and reported results of the investigation to the state agency within 5 working days of the incident for 1 of 7 residents (CR #229) reviewed for investigate, prevent, and correct alleged violation, in that: The facility did not complete an investigation report regarding CR #229. This failure placed residents at risk of injury, harm, and leaving him susceptible to repeated abuse/neglect and injury of unknown origin. Findings included: Record review of CR #229's face sheet revealed he was a [AGE] year-old male who was admitted on [DATE]. His diagnosis included dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), anxiety (intense excessive, and persistent worry and fear about everyday situations), and cerebrovascular disease (includes stroke, carotid stenosis, vertebral stenosis and intracranial stenosis, aneurysms, and vascular malformations). Record review of CR #229's Comprehensive MDS dated [DATE] revealed CR #229 had a BIMs score of 6 out of 15 which indicated he was severely cognitively impaired. He required extensive assistance with two persons physical assist with bed mobility. He required extensive assistance and one-person physical assistance for dressing, extensive assistance and one person's assistance for toilet use, supervision, and one-person physical assist for eating, and extensive assistance and two persons assistance for transfer. He also required extensive assistance and one-person assistance for personal hygiene. Record review of CR #229's Progress Notes dated [DATE] at 04:39 a.m. entered by Agency Nurse, read in part, .CNA reported to this nurse that during rounds, res was observed on the floor surrounded with red drainage. Res is alert with difficulties hearing. Res is unable to tell nurse what happened. Res has a wound to left temporal region. Res able to move all extremities x4 without pain. Res BP:99/56 HR 65 RR 15 o2 97RA T: 98.9. this nurse called EMS to transport res to Hospital A . Record review of CR #229's Progress Notes dated [DATE] at 4:57 a.m. entered by Agency Nurse, read in part, .Res observed on floor in room, in front of sink, away from bed . Record review of CR #229's Patient Record-Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .DISPO: pending evals, likely return to nursing home. Patient is critically ill at risk for at least one organ failure. I spend 45 mins of critical care time . Record review of CR #229's Patient Record Referral from Hospital A dated [DATE] at 11:34 a.m., read in part, .[NAME]: #Acute traumatic subdural hemorrhage, on admission. #Acute traumatic IPH . Interview on [DATE] at 10:27a.m., with RN A, she said during shift report LVN A told her CR #229 got out of bed and fell. She said CR #229 has not been at the facility since he fall. Interview on [DATE] at 10:30a.m. with CNA F said she used to assist CR #229 with everything. She said she would transfer him to the chair and assist him to the bathroom. She said his balance was unsteady. She said the resident would tell her he didn't need any help. She said she wasn't present when the resident fell. She said his behavior was always good towards her. She said this was the first incident of him falling. Interview on [DATE] at 10:41a.m., with CNA D said she came into work the next morning and was told CR #229 got up to go to the restroom and he fell. Interview on [DATE] at 12:10p.m. the Administrator said he did not complete a self-report or an investigation because the incident because it was not staff related . He said CR #229 was able to explain what happened to staff. He said CR #229 had a fall once before on [DATE]. He said CR #229 was discharged to the hospital. Follow-up interview on [DATE] at 2:18p.m., the Administrator said he said regarding CR #229, he was going off the information that was given to him by some of the staff. He said he was told CR #229 was able to gesture what happened and he assumed he fell in the restroom. He said he does not know when they received the information that CR #229 was deceased . He said he never documented the updates on residents that they follow up on. He said they have not documented what is discussed in the morning meetings, especially when it has been documented that they discharged a resident. He said CR #229 died at the hospital. He said they do not go back in to document that kind information. He said he has never done that at any facility he has worked at. He said if a resident dies outside of the facility, staff will be notified by word of mouth. He said they will have to call to receive that kind of information. He said the facility does not receive a death certificate on a resident. He said the family will call and give information about the resident. He said the only way someone at the facility would know about a deceased resident is by asking. He said he acknowledges that there was conflicting information. Interview on [DATE] at 2:27p.m., with Marketing Admissions, she said someone from the hospital called on [DATE] and gave her the information that the CR #229 passed away. She said after she found out, she informed the Administrator and the DON that CR #229 passed away. Interview on [DATE] at 2:40 p.m. with the DON, said CR #229 was gone from the facility when she arrived to work that morning. She said she was told he had fallen, and staff noticed he was injured, and they sent him out to Hospital A. She said staff did not know how or where he hit his head . She said they wanted to get CR #229 assessed. She said she did not report the incident because he was discharged to the Hospital A, and no one witnessed the incident. Record Review of the facility's policy titled Prevention and Reporting Resident Abuse and Neglect, (revision date not listed) read in part . The Director and the Administrator will designate a person to complete an Investigative Report to: Notify Texas Department of Human Services according to state law as required by state; state specific guidelines for reporting will be followed. The Administrator and Director of Nursing are responsible for investigation and reporting: Investigation of all alleged violations will be done under the direction of the DON and/or Administrator. This may utilize a Complaint Form, initial Investigation for Possible Abuse Violations form, or other written documentation. .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

MDS Data Transmission (Tag F0640)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's assessment was completed within 7 and 14 days, and electronically transmit encoded, accurate, and complete MDS data to the CMS System for a subset of items upon a resident's transfer, reentry, discharge, and death for 1 of 3 discharged residents (CR #33) reviewed for encoding and transmitting resident assessments, in that: - The Facility failed to complete and transmit a discharge MDS for CR #33. This failure could place discharged residents at risk of not having a proper discharge and not receiving services post discharge. Findings include: Record review of CR# 33's admission record dated [DATE] revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged home on [DATE]. He had a diagnoses of repeated falls and tracheostomy status (a surgically created hole (stoma) in your windpipe (trachea) that provides an alternative airway for breathing). Record review of CR #33's admission MDS assessment dated [DATE], revealed he had a BIMS of 13 of 15 which indicated he was cognitively intact. He required supervision to limited assistance with 1 person with most ADLs (Activities of Daily Living). Record review of CR #33's EMR on [DATE] revealed: he had no discharge MDS on record. Record review of CR #33's Assessment History- MDS Assessment Snapshot , revealed there was no discharge MDS on record. Record review of CR #33's Physician Discharge summary dated [DATE], revealed he was discharged home with home health care. Interview on [DATE] at 11:40am. with the MDS Coordinator A, she said that there were no discharge assessments found in the facilities EMR system for CR #33. She said she was responsible for completing the discharge MDS assessments and had not completed one for CR #33. She added that she missed this in the system. Record review of facility provided CMS's RAI Version 3.0 Manual, Chapter 5: Submission and Correction of The MDS Assessment revised 11/2019 revealed:5.1 Transmitting MDS data- All Medicare and/or Medicaid-certified nursing facilities or agents of those facilities must transmit required MDS data records to CMS. 5.2 Timeliness Criteria- completion timing . For all other comprehensive MDS assessments, Annual assessment updates . The completion may be no later than 14 days from the ARD. Upon a resident's entry, discharge to community, discharge to another facility or discharge deceased , a subset of items but be completed within 7 days of the Event Date. .

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a person-centered comprehensive care plan for each resident, consistent with the resident rights for 1 of 5 residents (Resident #70) reviewed for develop and implement comprehensive care plan, in that: - The facility failed to address the smoking status in Resident #70's care plan. This failure could place residents at risk for receiving decreased quality of care and or not receiving the appropriate required care and services to meet their individual needs. The findings include: Record review of the facility admission record dated 5/17/2023 revealed Resident #70 was admitted on [DATE]. Resident #70 was a 64-year- old male. Resident #70 had diagnoses that included Chronic Obstructive Pulmonary Disease (group of diseases that cause airflow blockage and breathing-related problems) and pneumonia (an infection that affects one or both lungs). Record review of Resident #70's admission Minimum Data Set Assessment (MDS) dated [DATE] revealed that Resident #70 had a BIM (Brief Interview for Mental Status) score of 13 out of 15, cognition was intact. Resident #70 required supervision with ADL's (Activities of Daily Living). Record review of the smoker list, no date provided revealed that Resident #70 was a smoker at the facility. Interview on 5/19/2023 at 11:22 a.m. with the DON (Director of Nursing), revealed that Resident #70's comprehensive care plan was not completed for smoking. She said she had the responsibility to make sure this was done along with the MDS Coordinator. She said that Resident #70 had the potential to have an unsafe smoking environment without the comprehensive care plan to address smoking. She said that she was the only one who missed it. She completed Resident # 70's smoking assessment and confirmed adding smoking to his comprehensive care plan on 5/16/2023. Record review of the revised Comprehensive Care Plan dated and created on 5/16/2023 read in part . Resident #70 has been advised of the facility smoking policy. Resident #70 requires supervision with smoking . Record review of the facility policy and procedure entitled Comprehensive Care Plans, undated, read in part, . The facility will develop and implement a comprehensive person-centered care plan for each resident, to meet a resident' medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment . .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of fifteen residents (Resident #27 ) who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding, in that: -The facility did not have the supplies available to replace the Gastrostomy Tube for Resident #27 for at least 5 days and used an indwelling urinary Foley catheter for at least 5 days, instead of an actual gastrostomy tube. -The facility did not have appropriate physician orders for Resident #27's medications to be administered through the temporary indwelling urinary Foley catheter, while it was being used as a gastrostomy tube. The failure could place residents with gastrostomy tubes at risk for developing significant complications, including infections, aspiration, hospitalizations, or death. Findings included: Record review on 5/19/23 at 9:08 a.m. of Resident #27's admission Record dated 5/19/23 revealed she was a [AGE] year old female who admitted to the facility on [DATE] had some of the following diagnoses: gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), dysphagia (difficulty or discomfort in swallowing), agnosia (inability to interpret sensations and hence to recognize things, typically as a result of brain damage), flaccid hemiplegia affecting right dominant side (severe or complete loss of motor function on one side of the body), Type II diabetes mellitus, (chronic condition that affects the way the body processes blood sugar and moderate protein calorie malnutrition. Record review on 5/16/23 at 9:22 a.m. of Resident #27's admission MDS dated [DATE] revealed she had a BIMS score of 2 indicating she was severely cognitively impaired and was totally dependent on at least one staff member for eating. She was coded as having an active diagnosis of malnutrition and gastrostomy status. She was also coded as receiving 51% or more of her total calories from a tube feeding. Record review of Resident #27's physician order summary dated May 2023 revealed no orders for enteral (state of being fed through a tube) feedings to be administered through a temporary/short-term Foley catheter being used as her gastrostomy site, Record review of Resident #27's physician order summary dated May 2023 revealed no orders for medications to be administered through the temporary/short-term Foley catheter being used as her gastrostomy site. Record review on 5/18/23 at 2:12 p.m. of Resident #27's progress notes dated 5/8/23 and created by LVN A, revealed the following entry: gtube is noted to be clogged at this time. (sic)unable to flush or unclog at this time. (sic)gtube replaced by (employee initials) LVN with 16 F foley with 5 cc balloon. 5 cc of residual returned; placement verified per auscultation. No s/s of acute distress noted at this time. Gtube site care provided at this time. Stoma (artificial opening made into a hollow organ, especially one on the surface of the body leading to the gut), remain clean, dry, and free of s/s of infection at this time. There was no documentation that Resident #27's physician had been notified. There was no SBAR or change of condition report. There was no incident or accident report regarding Resident #27's gastrostomy tube becoming clogged and or dislodged. Record review of Resident #27's progress notes on 5/18/23 at 2:44 p.m. that were dated 5/13/23 and created by LVN C, revealed the following entry: CNA notified this nurse that resident had vomited. Upon entering resident's room large amount of coffee ground emesis noted on resident gown. TF was stopped and resident's head was elevated to a 90-degree angle. Resident has two more episodes of emesis while this nurse was in the room. VS-BP145/86 P 105 T 97.9 R 20. DON made aware. Pager called for NP A and RP contacted with no answer and voicemail not set up to leave message. EMS A contacted to transport resident to ER. Repeated attempts to contact LVN C during the investigation on 5/17/23, 5/18/23 and 5/19/23 went unanswered through exit. Record review of Resident #27's progress notes on 5/18/23 at 3:33 p.m. that were dated 5/14/23 and created by RN A read in part, .Late entry, Received a phone call from a physician (on 5/13/23) with Hospital A with question regarding resident's feeding tube, a Foley catheter had been inserted because there was not a gastrostomy tube, in the correct size, available. Resident was sent to hospital for vomiting, possibly coffee ground emesis per the report from the nurse who sent her to the ER, writer checked placement by auscultation and gastric aspiration the day before she went to the hospital and results indicated it was safe to use . Record review of Resident #27's hospital records on 5/18/23 at 4:08 p.m. that were dated 5/14/23 read in part, .discharge diagnoses: coffee ground emesis, PEG tube malfunction, pneumonia, constipation, protein-calorie malnutrition, moderate . Interview with LVN A on 5/17/23 at 2:08 p.m., she said that she was the author of the progress note dated 5/8/23. She said that Resident #27's gastrostomy tube became clogged, and she could not get it to function on her shift. She then said that the gastrostomy tube became dislodged. When asked if she received a physician order to change the gastrostomy tube, she said that she was uncomfortable changing the tube after it became dislodged and asked LVN B to assist her in replacing it. She said that LVN B changed the tube by inserting a 16 french foley catheter because the facility did not have Resident #27's size for the gastrostomy tube replacement catheter. LVN A said that after LVN B changed the tubing, Resident #27's gastrostomy site began working and functioning properly again. LVN A said that she was able to restart Resident #27's enteral feeding, medications and hydration at that time as previously ordered. When asked if she notified the physician, LVN A said she could not remember. LVN A said it should have been documented that Resident #27's physician had been notified but she could not recall if she had notified the physician. LVN A said that she did not remember if she was ever able to reach Resident #27's physician for any orders. LVN A said that she did not know why she did not complete an SBAR/change of condition or incident report for Resident #27. She acknowledged that a resident's G-tube becoming dislodged was a change in condition. She said she could not recall if she had been trained on gastrostomy tube care. Interview with RN A on 5/17/23 at 2:33 p.m., she said she cared for Resident #27 when she had the temporary/short-term Foley catheter used as a gastrostomy tube. She said because the site functioned properly, she used it for medications and feedings. RN A said it was not uncommon to temporarily use an indwelling urinary catheter tubing in lieu of actual gastrostomy tubing, until the actual gastrostomy tubing became available. She said she had been told via report from other nursing staff that Resident #27's actual gastrostomy tubing was on back order and would be arriving any day. When she reviewed the facility policy, she said she did not know what temporary or short-term timeframes specifically meant. When asked if she felt like 5 days was too long a period to use temporary tubing, RN A said that it was working and she did not question it. RN A said she was not sure if she had been trained by the facility on gastrostomy tubes. RN A said that she did not think that using the Foley catheter as a gastrostomy tube, for 5 days, was an issue because she thought everyone (DON, MD, RP), knew about it already. She stated she did not notify Resident #27's physician or NP because she thought it had already been done. Observation of Resident #27 on 5/18/23 during medication administration on 5/18/23 at 8:41am. The administration was performed by RN A and Resident #27 tolerated well. Observation of Resident #27's gastrostomy tube tubing intact that was patent and functioned properly throughout the medication administration. There was no drainage around the site and no signs or symptoms of infection. There were no additional surgical sites or bandages observed, indicating, the gastrostomy tubing was replaced in the hospital, using Resident #27's existing gastrostomy tube site. Resident #27 was non-verbal but waved her hand and nodded her head in affirmation that she was doing well and had no pain or concerns with the site. Interview with LVN B on 5/18/23 at 9:41 a.m., she said that she was called to Resident #27's bedside on 5/8/23 by LVN A to help her with Resident #27's gastrostomy tube. LVN B said that when she got to Resident #27's bedside the gastrostomy tube was out and laying on top of Resident #27's gown. LVN B said that there was no blood or other drainage and that Resident #27's gastrostomy tube site/opening in her abdomen appeared very small to her and she was fearful it would close, as she was not familiar with, and did not regularly work with Resident #27. She said that she replaced the tube using a 16 French Foley catheter tubing because they did not have a small enough gastrostomy catheter available in the facility stock/supply. She said that both she and LVN A looked and could not find another option. LVN B said she thought LVN A had already called and or contacted Resident #27's physician and RP. LVN B said that she had been trained by facility on gastrostomy tubes including use, changes and troubleshooting issues, but could not recall when she had the training last. LVN B said she believed it was upon hire. LVN B said she did not document on Resident #27 because it was not her resident and again, she thought LVN A was documenting everything including contacting the physician and obtaining orders. Interview with DON on 5/18/23 at 1:04 p.m., she said that there was no documentation that LVN A, LVN B, LVN C or RN A had contacted Resident #27's physician. The DON said she contacted Physician A and he said he was not sure if he had been contacted and would have to check his phone records but could not confirm or deny that he had been contacted by LVN A about Resident #27's gastrostomy tube becoming clogged or dislodged. The DON said that there was no SBAR or change of condition for Resident #27 but there was a progress note. When asked if she thought a dislodged g-tube on a resident was a change in condition, she said yes. The DON said that it was not uncommon and per facility policy and procedure to utilize a Foley catheter to temporarily keep a gastrostomy tube site open and patent. The DON said she could not find any documentation of physician notification or orders from Physician A to continue to use Resident #27's short-term Foley catheter for medications and feedings. The DON said that the Foley catheter could be used short term to administer medications and or feedings. The DON said that she did not believe 5 days was long term use and said that the facility no longer completed orders for supplies and that Corporate ordered supplies. The DON said she did not know why she had not reviewed LVN A's documentation to check if the physician had been notified. The DON said she did not know why there was no documentation of an SBAR, change in resident condition or incident report for Resident #27. The DON said she had been aware of Resident #27's need for gastrostomy tube tubing. The DON said that Corporate were the ones who notified the facility that the replacement gastrostomy tubes for Resident #27 were on back order. The DON said that she did not believe that Resident #27's hospitalization from 5/13/23 through 5/14/23 had anything to do with the use or misuse of Resident #27's temporary Foley catheter. Interview with Administrator on 5/18/23 at 1:34 p.m., he said that Corporate completed the ordering of supplies such as gastrostomy tubes, for the facilities. He said that he had no dated invoices or order slips to show as evidence for when Resident #27's gastrostomy tubing was ordered or when Corporate was notified it was on back order. He said that all residents should have the supplies they need on site and that the facility did its best to maintain the appropriate supplies for their residents. Observation on 5/18/23 at 1:44 p.m. revealed a current adequate gastrostomy tube supplies for Resident #27 and all gastrostomy tube residents for the facility. Interview with Medical Director on 5/18/23 at 2:02 p.m., he said that historically the facility has and can use a Foley catheter as temporary tubing for a gastrostomy tube. He said that they do not always send a resident to the hospital for replacement because they try to avoid unnecessary hospital transfers. He said that Resident #27 had an established gastrostomy tube for years and it was not a new gastrostomy tube site, so the Foley catheter use was not a problem. He said that he did not see an issue with the facility using a temporary Foley catheter tube for 5 days to administer Resident #27's medications and feedings. He said that he did not believe Resident #27's hospitalization on 5/13/23 was as a direct result of the Foley catheter tubing, when asked about Resident #27's hospital diagnosis of pneumonia, he said it could have been early aspiration related to her nausea and vomiting or could have been related to fluid overload. He said there was no definitive aspirate in the hospital findings and that Resident #27 could have had nausea and vomiting related to constipation. He said that staff should notify a physician with any changes in condition for a resident. Telephone interview with Resident #27's attending Physician A on 5/18/23 at 3:08 p.m., he said that he could not recall, confirm or deny if LVN A contacted him on 5/8/23 when Resident #27's gastrostomy tube became dislodged or clogged. He said that best practice was to reinsert the appropriate gastrostomy tube as soon as possible but did not feel that 5 days was too a long a period of time or would have caused Resident #27 to go to the hospital on 5/8/23. He said that he could not say what kind of orders he would have given LVN A on 5/8/23 and that he may or may not have ordered LVN A to send Resident #27 to the hospital right away. He said that he did not recall if he or his NP saw or evaluated Resident #27 during the 5 days, she had the Foley catheter used as her gastrostomy tube. He said as long as it had functioned properly, there was probably no issue with the continued use of the Foley catheter for Resident #27's medications and feedings. He said that he did not know why he had not written any orders for the use of Resident #27's medications and feeding to continue via the temporary Foley catheter. Record review of facility policy and procedure Policy: Gastrostomy Tube Replacement (G-Tube) also known as PEG tube, read in part:1. The g-tube should be replaced as soon as possible (within 4 hours) to keep the tract patent. 2. If it has been greater than 4 hours, consult your physician for further instructions regarding replacing and/or hospital transfer. 3. Tubes dislodged greater than 24 hours should not be replaced at bedside .7. A foley catheter may be used in place of g-tube for SHORT TERM Use if a g-tube is not available at time replacement is needed. When the proper g-tube arrives, the replacement should occur at this time. Record review of facility policy and procedure titled Unusual Occurrences, Guidelines for .Basic Responsibility. Licensed Nurse .To document all unusual occurrences .Documentation Guidelines .Documentation may include: the event and any surrounding circumstances .Physical assessment. Interventions provided. Notification of the physician and responsible party . Preventative measures put in place to prevent recurrence. Document occurrence . Record review of facility policy and procedure titled: Notification to Physician, Family and others, read in part: .The facility will inform the resident, consult with the resident's physician; and consistent with his or her authority, the resident representative and document in the residents medical record .A significant change in the resident's physical status .(that is deterioration .or clinical complications), Record review of facility policy and procedure titled Change in Resident Condition, revealed the following: 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff .5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical condition or status .7. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status. .

Apr 2022 4 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #7) reviewed for incontinent care. The facility failed to ensure CNA A and CNA B properly cleaned Resident #7 during incontinent care. This failure could place residents at risk for urinary tract infections (UTI), urethral erosions, discomfort, skin breakdown and a decreased quality of life. Findings include: Record review of Resident #7's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included down syndrome (A genetic chromosome 21 disorder causing developmental and intellectual delays); contracture, left knee, (inability to fully straighten or extend the knee) and cognitive communication deficit. Record review of Resident #7's quarterly MDS assessment, dated 4/7/22, revealed her staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. She was assessed as having short term memory problems, long term memory problems, and severely impaired cognitive skills for daily decision making. She never/rarely made decisions. She required extensive assistance from two-person physical assist for dressing, toilet use, and personal hygiene. She was always incontinent of bowel and bladder. Record review of Resident #7's care plan, initiated on 4/23/19 and revised on 2/20/2020, read in part: .Incontinence: Focus: [Resident #7] is incontinent of bowel and bladder related to impaired cognition due to Autism & impaired mobility due to history of CVA. Goal: The resident will be clean and odor free through next review date. Interventions: Check the resident every two hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. The resident will remain free from skin breakdown due to incontinence and brief use through the review date . Observation and attempted interview with Resident #7 on 4/21/22 at 9:41 a.m., revealed the resident rested in her bed. The resident did not respond to the questions asked about her stay at the facility. Observation on 4/21/22 at 9:44 a.m., revealed CNA A provided incontinent care for Resident #7 and CNA B assisted. CNA A removed Resident #7s brief and tucked it under the resident's buttocks. CNA A spread Resident #7's labia to thoroughly clean the area and the resident's urinary meatus. CNA B assisted Resident #7 to turn onto her left side to clean her buttocks. Resident #7 had a large bowel movement. CNA A wiped Resident #7's buttocks and left feces remaining on her inner buttock. CNA A was ready to place a clean brief on the resident with assistance from CNA B without cleaning the visible feces from her inner thigh, or inner buttocks. In an interview on 4/21/22 at 9:55 a.m. with CNA A and CNA B, CNA A said she received training from other CNAs on the floor upon hire. She said she should have cleaned Resident #7's skin thoroughly before she placed the clean brief on her. She said there was feces on the wipe when the state surveyor asked her to clean the resident again. She said the DON randomly checked on CNAs. CNA A said She did not remember when the DON last spot checked her. CNA B said they had not been spot checked. CNA B said Resident # 7's skin should had been cleaned and free from feces before the clean brief was applied. She said the failure placed the resident at risk for skin breakdown and infections. CNA A and CNA B said they recalled doing CNA competency checks for incontinent care at the time of hire. In an interview on 4/21/22 at 10:52 a.m., the DON said she expected staff to provide prompt and efficient incontinent care to prevent complications of infection and cross contamination. She said CNA's competency check offs/assessments were completed upon hire. She said the ADON did spot checks on CNAs. She said she would do spot check if there were UTIs on a certain hall. In an interview on 4/21/22 at 12:28 p.m., with the ADON, she said she spot checked staff randomly. She said, she could not tell the exact date when she last spot checked the staff. Record review of the facility's, undated, Peri-Care performance criteria read in part: .Female: 18. Cleanses area first by wiping fecal material with toilet paper (as required). 19. Cleanses by wiping from vagina toward anus with one stroke. Use clean area of cloth for each stroke. 20. Continues until skin is clean . Record review of the facility's, undated, Perineal Care policy read in part: .Purpose: To clean the perineum. To prevent infection and odor . 9. Female perineal care: a. If resident is soiled with feces, place resident on side and clean perineum and rectal area . e. Ask resident to separate her legs and flex knees. If she is unable to spread her legs and flex knees, the perineal area can be washed with the resident on the side with legs flexed .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 4-20-22 at 9:45 am, with the Dietary Supervisor revealed the facility's dumpster area, was in the lot behind the dietary department had a commercial -size dumpster ¾ full of garbage and the lids and doors were open. Interview on 4-20-22 at 9:45 am, with the Dietary Supervisor she stated that the dumpster lids always must be closed to keep vermin, pests and insects out of the dumpster and from entering the facility. She further stated that if dumpster door is open, pests, insects and vermin will be attracted to feed on the garbage and could gain entry in the facility and infestation could result. The Dietary Supervisor said that she is responsible to make sure that the dumpster lids always must be closed. Record review of facility's, undated policy and procedure on Trash Dumpster revealed. 5. Garbage and rubbish containing food wastes will be stored in such a way that it is inaccessible to vermin. 8. Outside dumpster provided by garbage pickup services will be kept closed and the surrounding area will be free of litter.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of five Residents (Residents #27 and #52) reviewed for infection control. 1. The facility failed to ensure the Wound Care Nurse followed infection control techniques while she performed wound care for Resident #27. The Wound Care Nurse kept gloves, used for care, in her pockets and hand sanitizer in her pocket. Cross contaminated clean hand with dirty pocket when placing hand sanitizer back in pocket. 2. The facility failed to ensure the Wound Care Nurse followed infection control technique while she performed foley Cather care on Resident#52. The Wound Care Nurse kept gloves, used for care, in her pockets. These failures could place residents at risk of cross contamination, infection and hospitalization. Finding include: 1. Record review of Resident #27's admission face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included urinary tract infection (An infection in any part of the urinary system, the kidneys, bladder, or urethra), type 1 diabetes mellitus without complications (A chronic condition in which the pancreas produces little or no insulin), hemiplegia and hemiparesis following other cerebrovascular disease affecting the left non-dominant side (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Record review of Resident #27's quarterly MDS assessment, dated 2/22/2022, revealed her staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. She was assessed as having short term memory problems, long term memory problems, and severely impaired cognitive skills for daily decision making. She never/rarely made decisions. She required extensive assistance from two-person physical assist for dressing, toilet use, and personal hygiene. She was always incontinent of bowel and bladder. Record review of Resident #27's physician's order, dated 6/2/21, revealed an order to cleanse sacral wound with NS, pat dry, apply cal. alg. and cover with dry dressing Q day until healed everyday shift for wound healing. Record review of Resident #27's physician's order, dated 2/15/22, revealed an order to skin prep right heel and lota Q day until healed everyday shift for wound healing. Record review of Resident #27's care plan, initiated 2/3/2018 and revised on 3/14/2021, read in part: .Pressure Ulcer Risk: Focus: [Resident #27] has the potential for the development of a pressure ulcer related to incontinent episodes. Goal-Resident will have no reports of preventable skin breakdown through next review date. Interventions: Follow facility policies & protocols for the prevention and treatment of skin breakdown . Observation and interview on 4/21/22 at 9:12a.m., revealed Resident #27 rested on her air mattress. She was alert and well groomed. The resident did not respond to the questions asked about her pressure ulcer/wounds. Observation on 4/21/22 at 9:13 a.m., the Wound Care Nurse provided wound care for Resident #27 assisted by CNA A. The Wound Care Nurse performed hand hygiene, applied clean gloves (pulled from her scrub pocket) to remove the soiled dressing from the coccyx wound, dated 4/20/22. The Wound Care Nurse threw the soiled dressing into the biohazard bag. an open area of approximately 0.7 centimeters in diameter on the coccyx was observed. The Wound care Nurse removed soiled gloves. Pulled sanitizer bottle from the scrub pocket. Sanitized her hands. Placed the sanitizer bottle back in her pocket. Applied clean gloves (pulled from her pocket), the Wound Care Nurse cleansed the wounds with normal saline x2, patted dry with a clean dry gauze. The Wound care Nurse removed soiled gloves. Pulled sanitizer bottle from the scrub pocket. Sanitized her hands. Placed the sanitizer bottle back in her pocket. Applied clean gloves (pulled from her pocket) applied Calcium Alginate and covered it with clean dry dressing on the coccyx wound. The Wound Care Nurse removed the residents prevalon boat from Resident's Right foot. The Wound care Nurse removed soiled gloves. Pulled sanitizer bottle from the scrub pocket. Sanitized her hands. Placed the sanitizer bottle back in her pocket. Applied clean gloves (pulled from her pocket) applied skin prep on the right heel and placed the residents prevalon boat back on the resident. 2. Record review of Resident #52's admission face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included epilepsy (A disorder in which nerve cell activity in the brain is disturbed, causing seizures), paraplegia (Paralysis that affects all or part of the trunk, legs, and pelvic organs) and acute kidney failure (A condition in which the kidneys suddenly can't filter waste from the blood). Record review of Resident #52's Comprehensive MDS assessment, dated 3/17/22, revealed BIMS score of 01 out of 15, which indicated severely impaired cognitively. He required total dependence from two-person physical assist for dressing, toilet use, and personal hygiene. He was coded for having an indwelling catheter. Record review of Resident #52's care plan, initiated 4/16/21 and revised on 2/11/22, read in part: .Urinary Catheter: Focus: [Resident #52] has a urinary catheter and is at risk for urinary tract infections and injury. Urinary catheter related to Pressure Ulcer. Goal: The resident will show no signs or symptoms of a urinary tract infection through next review date. Interventions: Monitor for s/sx of discomfort on urination and frequency . Observation on 4/21/22 at 9:27 a.m., revealed the Wound Care Nurse provided foley care to Resident #52. The Wound Care Nurse performed hand hygiene, applied clean gloves (pulled from her scrub pocket). The Wound Care Nurse unfasten the resident's brief performed the catheter care. The Wound Care Nurse removed soiled gloves. Pulled sanitizer bottle from the scrub pocket (sanitizer was in the same pocket as the gloves). Sanitized her hands. Placed the sanitizer bottle back in her pocket. Applied clean gloves (pulled from her pocket) and fasten the same soiled brief. In an interview on 4/21/22 at 9:55 a.m. with CNA A, she said the Wound Care Nurse pulled gloves from her pocket while she provided the wound care on Resident # 27. She said staff were not allowed to keep gloves inside their pockets as it placed residents at risk for infection. In an interview on 4/21/22 at 10:00 a.m. with the Wound Care Nurse, The Wound Care Nurse asked, what was wrong with keeping gloves in the pocket. I have done wound care with 2 other state Surveyors in the past and they haven't said anything to me. Never had a problem. State Surveyor asked what the facility's protocol/policy regarding gloves and what had the facility trained her on infection control/keeping gloves in the pocket. Wound Care Nurse said, why would the administration tell me about that. There is nothing wrong with keeping gloves in the pocket. She said the ADON periodically checked on her. She said she received training on infection control sometime last week. In an interview on 4/21/22 at 10:52 a.m. with the DON, The DON said staff were not supposed to have gloves in the pocket, it was risk for infection. Germs from the pocket could transfer to the resident. She said once the gloves were out of the box it needed to be placed on a clean surface. She said she would in-service the Wound Care Nurse. Record review of the facility's, undated, Infection Control Plan: Overview read in part: .In order to prevent the spread of communicable disease within the Long Term Care Facility and provide each resident with an optimal living environment, we have established a comprehensive infection control program for the surveillance, prevention, and control of infection. Goals: 6. Provide regular and ongoing education of all healthcare workers in the theory and practice of infection control and prevention. 7. Ensure compliance with all local, state and federal regulations and standards related to infection control and prevention .

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in 1.The facility failed to ensure employees cleaned their hands in a handwashing sink. 2.The facility failed to ensure the dish machine sanitized wares. These failures could place residents at risk of foodborne illness and disease. Findings included: 1. Observation on 4/20/22 at 9:15 AM revealed Dietary [NAME] B, after racking soiled breakfast dishes, she proceeded to empty clean dishes without washing her hands. She then washed her hands in one of the utility sinks, in the dish washing area, and did not use soap. Interview with Dietary Manager on 4/20/22 at 9:20 AM revealed food employees must wash hands after racking soiled dishes and then touching clean dishes to prevent cross contamination. Utility sink does not have the proper soap for hand washing. Dietary manager was aware that the staff did not washed hands prior to touching clean dishes. 2.Observation on 4/20/22 at 9:25 AM revealed the dish machine was not properly sanitizing dishes/wares evidenced by the test strip did not change color. The test strip should have turned purple as indicating that the approved chemical/sanitizing agent containing at least 150 - 400 ppm (parts per million of quaternary ammonia. Interview with Dietary Manager on 4/20/22 at 9:30 AM revealed that she will call the service/repairman for the dish machine not sanitizing. She instructed dietary employee not to wash dishes until machine fixed. Observation on 4/20/22 at 11:00 AM revealed Service/repair representative entered the facility kitchen and stated there was not enough sanitizing agent/solution being fed in the dish machine. Representative repaired the issue by showing the staff that the container of sanitizing agent is empty. Prior to operating the dish machine, the employees must check and make sure that soap, sanitizing agent and drying agent is replenishing if it is empty.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 1 life-threatening violation(s), $36,170 in fines. Review inspection reports carefully.
• 20 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
• $36,170 in fines. Higher than 94% of Texas facilities, suggesting repeated compliance issues.
• Grade F (28/100). Below average facility with significant concerns.

Bottom line: Trust Score of 28/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Courtyard Nursing And Rehabilitation's CMS Rating?

CMS assigns COURTYARD NURSING AND REHABILITATION an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Texas, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Courtyard Nursing And Rehabilitation Staffed?

CMS rates COURTYARD NURSING AND REHABILITATION's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 70%, which is 24 percentage points above the Texas average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 83%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Courtyard Nursing And Rehabilitation?

State health inspectors documented 20 deficiencies at COURTYARD NURSING AND REHABILITATION during 2022 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 19 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Courtyard Nursing And Rehabilitation?

COURTYARD NURSING AND REHABILITATION is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by FOURCOOKS SENIOR CARE, a chain that manages multiple nursing homes. With 120 certified beds and approximately 66 residents (about 55% occupancy), it is a mid-sized facility located in HOUSTON, Texas.

How Does Courtyard Nursing And Rehabilitation Compare to Other Texas Nursing Homes?

Compared to the 100 nursing homes in Texas, COURTYARD NURSING AND REHABILITATION's overall rating (2 stars) is below the state average of 2.8, staff turnover (70%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Courtyard Nursing And Rehabilitation?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.

Is Courtyard Nursing And Rehabilitation Safe?

Based on CMS inspection data, COURTYARD NURSING AND REHABILITATION has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Courtyard Nursing And Rehabilitation Stick Around?

Staff turnover at COURTYARD NURSING AND REHABILITATION is high. At 70%, the facility is 24 percentage points above the Texas average of 46%. Registered Nurse turnover is particularly concerning at 83%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Courtyard Nursing And Rehabilitation Ever Fined?

COURTYARD NURSING AND REHABILITATION has been fined $36,170 across 1 penalty action. The Texas average is $33,441. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Courtyard Nursing And Rehabilitation on Any Federal Watch List?

COURTYARD NURSING AND REHABILITATION is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 120
Avg. Residents: 66
Occupancy: 55.5%
Ownership: For profit - Corporation
Chain: FOURCOOKS SENIOR CARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
High Turnover: -10
1 Immediate Jeopardy citation: -12
20 Deficiencies: -5
Fines ($36,170): -5
Final Score: 28/100

Nearby Alternatives

THE METHODIST HOSPITAL SNF 5-star West Janisch Health Care Cente... 5-star PARK MANOR OF CYFAIR 5-star

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 455613