**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident was free from abuse, neglect and exploitation for 2 of 5 (Resident #1 and CR#2) residents reviewed for abuse. The facility failed to ensure Resident #1 was free from sexual abuse when CR #2 told Resident #1 to hold his (CR#2's) penis and touch his body on 3/14/2025. The noncompliance was identified as Past Non-Compliance. The PNC IJ began on 03/14/2025 and ended on 3/17/2025. The facility corrected the noncompliance before the survey began. This failure placed all residents in the facility at risk of abuse and neglect that could result in emotional and mental trauma. Findings included: Record review of Resident #1's admission face sheet dated 4/8/2025 revealed he was a [AGE] year-old male, who admitted to the facility on [DATE] with primary diagnoses of cerebral palsy (disorder of movement and muscle tone), lobar pneumonia (a type of pneumonia that affects and inflames one or more lung lobes), acute respiratory failure with hypoxia (a serious condition where the lungs fail to adequately oxygenate the blood leading to low oxygen levels, epilepsy (nerve activity in the brain causing seizure), muscular atrophy(a condition that causes the muscles to lose mass and strength), asthma (condition where the airways become inflamed), muscle wasting (loss of muscle mass and strength), and intellectual disabilities (significant limitations in both intellectual functioning and adaptive behavior). Record review of Resident #1's admission MDS assessment dated [DATE] revealed he has a BIMS score of 8 indicating he was moderately impaired for cognition; For behavior he was coded as having no behavior. For ADL activities he was dependent on staff for toileting, shower/bathe, lower body dressing, putting on and taking off shoes and personal hygiene, he was partial/moderate assist for eating, and required substantial/maximal assistance for oral hygiene and upper body dress. The resident was coded as always incontinent of bowel and bladder. Record review of Resident #1's care plan revised 01/21/2025 revealed the following areas of concern: COGNITIVE IMPAIRMENT: Resident #1's has impaired cognition r/t Congenital Mental Retardation, and is at risk for further decline and injury. o Resident #1's needs will be met and dignity maintained over the next 90 days. o Allow time for tasks and responses o Explain all procedures using terms/gestures the resident can understand o Involve in care to maintain or increase level of independence o Praise for tasks that the resident completes o Repeat information PRN Record review of Resident #1's care plan revised 01/29/2024 revealed the following areas of concern: Record review of nurse's notes 3/15/2025 at 9:30pm COMMUNICATION- with Resident Assistant Administrator was physically in room. Resident In bed comfortably, stated that he feels safe and not upset about situation that occurred earlier in the day. Supportive Care Psychologist will see him 3/16/2025. 3/15/2025 4:06 Incident Note: Resident informed this writer that he had been touched all over his body by another resident. Also states that he was asked to touch the other resident's private parts after the resident came into his room. Resident immediately taken to room and head-to-toe assessment performed without any significant findings. Enhanced supervision began with the alleged perpetrator for resident's safety. Police department, MD and family notified. Observation on 3/17/2025 at 9:25am Resident #1 observed in a low bed. He appeared to have limited ROM. A camera was observed in the room and the resident did not have a roommate. In an interview on 3/17/2025 at 9:25am Resident #1 said CR #2 told him to touch him everywhere. He said he wanted him to touch his crack, his butt, his behind and he did, but he didn't want to touch CR #2's private body parts. He said he told Activity Director A CR #2 wanted him to touch him all over and making him do bad things by touching him. He said Activity Director A told him CR #2 should not have told him to do that, and he (Resident #1) did not do anything wrong. In an interview on 3/17/2025 at 1:13pm Resident #1's family member said CR #2 was not Resident #1's roommate. She said she had video evidence on her computer from the camera past Friday. The camera was accidently moved or disconnected on Saturday, and she thought something happened on Saturday but there was no video evidence. She said Resident #1 reported it to Activity Director A. She said she was not aware until she was told on Saturday. She said she felt the facility responded appropriately. I don't think this was an easy thing to deal with and they reacted in a few hours. They called at 4 pm on Saturday and when she got to the facility there was an officer at the facility. In an interview on 3/17/2025 at 2:15pm the Assistant Administrator said on Saturday afternoon, the 15th of March 2025, Activity Director A witnessed CR #2-wheeling Resident #1 back to his room and Resident #1 was calling CR #2 'Daddy. Activity Director A told Resident #1 not to call CR #2 daddy because he was not his father. After the meal, CR #2 wheeled Resident #1 to his room, then came back about an hour later to Bingo. She said she was surprised because Resident #1 did not like Bingo. When Resident #1 got to the table he told Activity Director A that CR #2 (Daddy) made me touch his private parts and I didn't like it. The Administrator said, Resident #1 was usually truthful when he spoke. She called the supervisor over and got statements from the CNA, 2 charge nurses, and Activity Director A. She said both residents were immediately placed on enhanced supervision, she reported the incident to both families, and she called the police. She said Resident #1's family was here when the police arrived. She said no camera footage found on Saturday because the camera was unplugged, the camera footage was from Friday. She said Resident #1 did not have a roommate, both residents were living on separate halls. She said CR #2 was a new admit, he was admitted a few days before the incident. She said he would wander down different halls. She said CR #2 was ambulatory, very friendly, and did not exhibit any behaviors that indicated aggression or sexual behavior. She said CR #2 complained of headache, and CR#2's behaviors of acting drowsy etc. during the interview. She said she called CR #2's family and she was told to send him to the hospital. She said CR #2 was sent to the hospital on Saturday on 3/15/2025 at 9:30 pm. Record review of CR #2's admission face sheet dated 3/20/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] and was discharged on 3/15/2025 to a local hospital. His diagnoses included chronic kidney disease (inability to filter waste and excess fluid from the blood), type II diabetes (high blood sugar), altered mental status (a state where a person's alertness and awareness are changed), dementia (memory loss), hypertension (high blood pressure), and hyperlipidemia (high fat in blood). Record review of CR#2's care plan dated 3/13/2025 revealed the following: CR#2 was at risk of elopement, risk/wanderer r/t, resident wanders aimlessly. -wanders from hall to hall throughout the day. - safety will be maintained through the review date. - will not leave facility unattended through the review date. - was Assess for fall risk. o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: o Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. o Monitor for fatigue and weight loss. o Monitor location. Document wandering behavior and attempted diversional In an interview on 3/17/2025 at 2:33pm CNA A said she was in-serviced that morning on stopping abuse. She said if she witnessed abuse to report it to the DON and let everyone know. CNA A was able to verbalize understanding of the different forms of abuse. In an interview on 3/17/2025 at 1:35 CNA B said she was in-serviced on the different forms of abuse. If abuse was witnessed between two residents, she was to separate the residents and report to the charge nurse immediately. CNA B was able to verbalize understanding of the different forms of abuse and training. In an interview on 3/17/2025 at 1:45pm CNA C said she was in-serviced on abuse/neglect and if she witnessed any resident-to-resident abuse she would separate the residents, call the charge nurse, and report it to the Administrator. She said she did not know much about the two residents because she normally did not work the halls the residents were on. In an interview on 3/17/2025 at 1:48 pm Resident #4 said he had no problems with any staff or residents. He said if he was abused, he would tell the people at the front desk. He was never abused by any staff or residents. In an interview on 3/17/2025 at 1:48 pm Resident #5 said she had no problems with any staff or residents. She said she was treated well by the staff. She said no resident came to her room. She said if she was abused, she would report it to the charge nurse. In an interview on 3/17/2025 at 1:50 pm Resident #6 said he had no problems with staff or residents. He said the staff treatment was good and he had no problems with other residents. He said if he was abused, he would tell the nurse. In an interview on 3/17/2025 at 1:53pm Resident#7 said he had no problems with other residents. He said if he was abused, he would report it to the charge nurse. In an interview on 3/17/2025 at 1:50pm LVN F said he was recently in-serviced on abuse and neglect, resident rights, and resident to resident abuse. He said if he witnessed resident to resident abuse, he would separate the residents, make sure they were safe, and notify the Administrator. He said no one has reported abuse to him. In an interview on 3/17/2025 at 1:52pm LVN G said she was in-serviced recently on abuse/neglect, resident rights, enhanced supervision, and resident to resident abuse. She said if she witnessed resident to resident abuse she would separate them, monitor them. She said she would interview the staff and residents to find out was going on and she would report to the Administrator or the DON. In an interview on 04/04/2025 at 1:13 pm Activity Director A said CR #2 was pushing Resident #1's wheelchair to the dining room. She said she asked CR #2 if he was going to play bingo and he wheeled Resident #1 back to his room. She said prior to the incident, she heard Resident #1 calling CR #2 daddy when they were in activities. She said she told Resident #1 not to call CR #2 daddy because he was not his daddy. She said after the meal, on 3/15/2025 she noticed CR #2 taking Resident #1 back to Resident #1's room. She said about an hour later they came to bingo, and she was surprised because Resident #1 did not like bingo. Activity Director A said when they got to the table, Resident #1 told her Daddy made me touch his private parts and all over his body and he did not like it. She said she looked for the Weekend Supervisor and told her. She said Resident #1 did not seem afraid, but he looked uncomfortable. In an interview with the Weekend Supervisor on 4/4/2025 at 3:00pm she said she was working the day the incident took place. She said Activity Director A took Resident #1 to her and said Resident #1 told her CR #2 had him touched his private parts and other parts of his body. She said she took Resident #1 to his room and did a head-to-toe evaluation and there were no marks or bruises. She said CR #2 was also evaluated and there were no marks or bruises. She said when she interviewed CR #2, he denied at first that he had Resident #1 touch his private parts but later said Resident #1 only touched his private parts one time. She said they started to monitor both residents in their different rooms. She said CR #2 started complaining of a headache and said he wanted to go to the hospital, and he was later transferred to the hospital. Interview on 4/4/2025 at 3:20pm with the Administrator revealed Activity Director A told her Resident #1 told her CR #2 had him to do something he did not want to do. She said Activity Director A told her that Resident#1 came to her and told CR #2 (Daddy) let him touch his private part, and he did not like it. She said Resident #1 was brought back to his room, head to toe assessment done and enhanced supervision and monitoring started. CR #2 was brought to his room and a head to toe assessment done and enhanced supervision and monitoring put in place. She said she immediately launched an investigation. She said after the assessment CR#2 started complaining of a headache and said he wanted to go to the hospital. She said Resident#1 and CR #2 were not roommates but were meeting at lunch. She said CR #2 would push Resident #1's wheelchair to his room and he never displayed any inappropriate behaviors. She said they were thinking of elopement as CR #2, wandered in the facility, so being inappropriate was a surprise for them. He said they were always redirecting him because he at times was confused and walked up and down the hallway. She said there was no witness to the inappropriate touching but Resident #1 said CR #2 let him touch his body part. The Administrator said during the interview CR #2 first said Resident #1 fell and he picked him up and might have touched his bottom in the process. She said at that point she knew CR #2 was not telling the truth. She said if Resident #1 fell CR #2 could not pick him up by himself. She continued to ask him questions and he finally said that he let him touch his private part, but he only did it once. She said CR #2's family was notified, and permission given for the resident to be sent to the hospital. She said he was discharged to the hospital and would not be re-admitted to the facility. She said in-services were done on abuse/neglect, enhanced supervision, and resident rights. Observation on 4/4/2025 at 12:20pm Resident #1 was observed in bed, he was alert and oriented with some confusion. He was clean and groomed with no offensive odor. The call light was observed to be within reached. No visible marks or bruises noted. CR #2 was not interviewed on 4/4/2025 because he was not at the facility. He was sent to the hospital and did not return. In an interview with Resident #1 on 4/4/2025 at 12:20pm, Resident #1 said he was treated well at the facility. He stated CR #2 abused him. He was asked at that time, what CR #2 did. He said CR #2 made him touch his private body parts all over and he did not like it. He said the man who touched him was living in another room. He stated he did not have a roommate. In a telephone interview with Resident #1's family on 04/04/2025 at 2:00pm she said the family was notified of the abuse regarding Resident #1 and CR #2. She said she was satisfied with the fact it was addressed in a timely manner. She said by the time she arrived, the police was in the building and the investigation was in progress. In an interview on 04/04/2025 at 12:17pm Medication Aide H said she had been working at the facility for about a year and she said she was trained on abuse, neglect, resident to resident abuse, and resident rights. She said if she witnessed two residents fighting, she would separate them and call the nurse. She said she would report any abuse or neglect to the DON, and the Administrator. In an interview on 04/04/2025 at 3:15pm Medication Aide L said she had been working at the facility for the last 19 years. She said she was trained on abuse, neglect, resident to resident abuse, and resident rights. She said if she witnessed two residents in a fight or any other altercation, she would separate them and call the nurse. She said she would report any abuse to the nurses, the DON, and the Administrator. In an interview on 04/04/2025 at 2:17pm CNA K said she was trained on abuse and neglect. She said she had never seen anyone being abusive to Resident#1. She said they were trained on not having residents pushing residents, resident to resident abuse, and resident rights. In an interview on 04/04/2025 at 3:40 pm RN E said she had been working at the facility for almost one year and she was recently trained on abuse, neglect, resident to resident abuse, and resident rights. She said if she witnessed two residents in a fight or other altercation, she would separate them, call the nurse, and notify the family. She said she would report any form of abuse to the nurses, the DON, and the Administrator. On 04/08/2025 at 2:50pm, the facility's Administrator, DON, and Regional Nurse were notified of the past noncompliance IJ. A plan of removal was not requested. An IJ template was provided to the Administrator on 04/08/2025 at 2:58 p.m. In an interview on 04/08/2025 at 3:50pm CNA I said she had been working at the facility for the last three weeks. She said she was trained on abuse, neglect, resident to resident abuse, resident rights, and residents who wandered in other resident's room. She said if she witnessed two residents in a fight, she would separate them and call the nurse. She said she would report any abuse to the nurses, the DON, and the Administrator. In an interview on 04/08/2025 at 4:04pm Medication Aide H said she was in-serviced on abuse and neglect, resident to resident abuse, and resident rights. She said if she witnessed resident to resident abuse, she would separate them and call the nurse. She said if she witnessed abuse, she would report it to the nurse and the administrator. In an interview on 4/08/2025 at 4:10pm CNA J said he was in-serviced recently on abuse and neglect, resident rights, and resident to resident abuse. He said if he witnessed resident to resident abuse he would separate them, call the nurse, and report the incident to the charge nurse and administrator. Record review of Resident #1's clinical records revealed that the resident was seen by psychiatric services on 3/18/2025 and they would be following the resident. Further review revealed Resident #1 said he felt safe at the facility. Record review of the in-service dated 3/15/2025 revealed all staff were in-serviced on abuse and neglect, reporting of abuse and neglect, signs of abuse and neglect, exploitation , enhanced supervision, resident rights safety, and supervision to prevent abuse and neglect of resident. Staff sign in sheets were also reviewed. Record review revealed safe survey was done with residents on 3/15/2025 and residents verbalized that they felt safe at the facility. Interviews were conducted with facility staff, and they confirmed they were in-serviced. Staff were able to recall the incident that triggered the in-serviced. Record review of the facility's document date 07/17/2021 titled, Abuse read in part . POLICY It is the policy of this center to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. DEFINITIONS Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The noncompliance was identified as Past Non-Compliance. The IJ began on 03/14/2025 and ended on 04/08/2025. The facility corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing care to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 8 of 10 residents (Resident #34, Resident #65, Resident #87, Resident #91, Resident #19, Resident #41, Resident #50 and Resident #59) reviewed for sufficient staffing. -The facility failed to ensure there were sufficient staff per the facility assessment, and failed to provide care for residents including blood pressure and blood sugar monitoring, medicaiton administration, repositioning, and incontinent care. - Resident #34, Resident #65, Resident #87, and Resident #91 did not receive their morning and/or afternoon medications. -The facility failed to provide ADL care to residents with bowel/bladder incontinence during the night shift (11pm-7am) on 4/21/24 and 4/22/24. An Immediate Jeopardy (IJ) was identified on 04/24/24. The IJ template was provided to the facility on [DATE] at 5:35 p.m. While the IJ was removed on 04/28/24 at 12:35 p.m., the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that was not immediate jeopardy, because all staff had not been trained on medication administration and chain of command. These failures could place residents at risk of their needs not being met, injury, skin breakdown, low self-esteem, depression, embarrassment, and psychological harm. Findings included: Record review of the Facility Assessment Tool updated 04/24/2024 revealed the average daily census was 94 residents. The facility had 18 residents with behavioral needs, 11 residents required injections. Tracheostomy care 18 residents and ventilator or Respirator 7 residents. The facility residents break down of ADL care was 32 dependent on bathing, 30 dependent on bed mobility, 20 dependent on eating, 25 dependent on personal hygiene, 24 dependent on toilet use, 26 dependent on transfer. The average number suggested for licensed nurses providing direct care was 5 licensed nurses (Days & Evening), 4 licensed nurses (Nights). Nurse Aides was 7 CNAs on Days and Evenings, 2 Restorative CNA split shift, 7 CNA/CMAs (Days & Evenings), 8 CNAs on Nights. Record review of facility map revealed [NAME] zone 1 was room [ROOM NUMBER] through 112, Dove zone 2 was114 through 125, Flamingo zone 5 was 126 through 137, Swan zone 6 was 139 through 150, South east wing zone 11 was 201 through 206, and south west wing zone 12 was 207 through 224. Record review of the facility resident roster dated 04/23/24 revealed [NAME] station rooms 101-112, revealed 17 residents, Dove station rooms [PHONE NUMBER] revealed 13 residents, Flamingo station rooms 126-137 revealed 16 residents, Swan station rooms 138-149 revealed 17 residents and South station rooms 201-224 revealed 33. Resident #34 Record review of the admission Record for Resident #34 (dated 04/25/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, cerebral palsy (a group of movement disorders), type 2 diabetes mellitus, gastrostomy status (has feeding tube), and epilepsy (seizure disorder). Record review of the MDS (ARD 04/11/24) for Resident #34 revealed she had a BIMS score of 0/15, indicative of severe cognitive impairment. Record review of the Care Plan (revised 03/30/24) for Resident #34 revealed she was receiving anticoagulant therapy (Eliquis) and was at risk for increased bleeding or bruising. One of the Interventions read Give medications as ordered. The Care Plan reflected Resident #34 had diabetes. Corresponding Interventions were to monitor blood glucose levels as ordered, and to give medications as ordered. Record review of the April 2024 Order Summary Report for Resident #34 revealed she was to receive Eliquis (anticoagulant) 5 mg twice daily for prevention of pulmonary embolism (blood clot in an artery of the lung). The orders reflected she was to have her blood glucose checked every six hours, with insulin to be administered per sliding scale. The orders reflected Metoprolol Tartrate (Toprol) tablet, 12.5 mg was to be administered twice daily for high blood pressure. The orders reflected the Toprol was to be held if the resident's systolic blood pressure was less than 100 mmhg. The orders reflected Trileptal Oral suspension (300 mg/5 ml) 10 ml was to be administered twice daily for epilepsy. Record review of the April 2024 MAR/TAR for Resident #34 revealed the following medications were not administered on 04/22/24 at 9:00 a.m.: -Eliquis 5 mg -Toprol 12.5 mg (blood pressure not documented) -Trileptal Oral suspension (300 mg/5 ml) 10 ml Resident #34's blood glucose levels were not checked at noon or 6:00 p.m. No sliding scale insulin was administered. Record review of the April 2024 Order Summary report revealed Resident #34 was to receive the following Fiasp (100 u/ml) insulin amounts based on her blood glucose level: -150 - 200 mg/dl administer 2 units -201 - 250 mg/dl administer 4 units -251 - 300 mg/dl administer 6 units -301 - 350 mg/dl administer 8 units -351 - 400 mg/dl administer 10 units If Resident #34's blood glucose level was greater than 400 mg/dl, the nurse was to administer 12 units and notify the NP. Observation on 04/23/24 at 9:00 a.m. revealed Resident #34 was in her room, lying in bed. She did not respond to a verbal greeting. She was receiving enteral nutrition via her g-tube. Resident #65 Record review of the admission Record for Resident #65 (dated 04/25/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus, schizophrenia, seizures, stage 4 pressure ulcer of the sacrum, and atherosclerotic heart disease of coronary artery without angina pectoris (chest pain). The resident had a gastrostomy tube (g-tube) for nutrition and medications. Record review of the MDS (ARD 01/24/24) revealed she had memory deficits and moderately impaired cognition . Record review of the April 2024 Order Summary Report for Resident #65 revealed she was to receive the IV antibiotic Ertapenem Sodium Solution reconstituted 1 gm for an infection of the pressure ulcer of her sacrum. The orders also reflected Resident #65 was to have her blood glucose checked at 8:00 a.m., and Glargine insulin (100units/ml) 40 units administered. The orders reflected she was to have her blood glucose checked every six hours, with insulin to be administered per sliding scale, and she was to receive Levetiracetam solution (100 mg/ml) 5 ml twice daily for seizures, Oxcarbazepine 300 mg twice daily for seizures, and Haldol 2 mg twice daily for schizophrenia. Record review of the April 2024 MAR for Resident #65 revealed the following medications with corresponding times were not administered on 04/22/2024: -IV Ertapenem Sodium Solution reconstituted 1 gm scheduled for 8:00 a.m. -Haldol 2 mg scheduled for 8:00 a.m. -Levetiracetam solution (100 mg/ml) 5 ml scheduled for 9:00 a.m. -Oxcarbazepine 300 mg scheduled for 9:00 a.m. Resident #65's blood glucose was not checked as ordered on 04/22/2024 at 8:00 a.m. and 40 units of Insulin Glargine was not given. Resident #65's blood glucose was not checked as ordered at 6:00 a.m., noon, or 6:00 p.m. on 04/22/2024, and sliding-scale insulin was not given. Record review of the April 2024 Order Summary report revealed Resident #65 was to receive the following Lispro (200 u/ml) insulin amounts based on her blood glucose level: -150 - 200 mg/dl administer 2 units -201 - 250 mg/dl administer 4 units -251 - 300 mg/dl administer 6 units -301 - 350 mg/dl administer 8 units -351 - 400 mg/dl administer 10 units If Resident #65's blood glucose level was greater than 400 mg/dl, the nurse was to administer 12 units and notify the physician. Observation and interview on 04/23/24 at 9:13 a.m. revealed Resident #65 was in her room, sitting in her wheelchair. She said she had received her medications today but was unable to recall yesterday (04/22/24). Resident #87 Record review of the admission Record for Resident #87 (dated 04/24/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus, atrial fibrillation, congestive heart failure, hypertension, and history of pulmonary embolism (obstruction of the pulmonary artery by a blood clot or other foreign matter). Record review of the MDS (ARD 03/25/24) revealed she scored 0 of 15 on the BIMS, indicative of severely impaired cognition . Record review of the April 2024 Order Summary Report for Resident #87 revealed she was to receive Apixaban (blood thinner/anticoagulant) 5 mg twice daily to prevent blood clots, Metoprolol Tartrate 12.5 mg twice daily for blood pressure, Amiodarone 200 mg for atrial fibrillation, and she was to have her blood glucose checked before meals, with insulin to be administered per sliding scale. Resident #87 was to recieve Mtotoprolol Tartrate 12.5 mg., which had blood pressure parameters instructing to hold the medication if the resident's systolic blood pressure was less than 100 mmHg. Record review of Resident #87's April 2024 MAR revealed she was not administered the 9:00 a.m. doses of Apixaban 5 mg, Amiodarone 200 mg, or the Metoprolol Tartrate 12.5 mg. on 04/22/24. Resident #87's blood pressure was not documented as been checked. Resident #87's blood glucose was not checked as ordered at 11:00 a.m. and 4:00 p.m. on 04/22/2024 and sliding-scale insulin was not administered. Record review of the April 2024 Order Summary report revealed Resident #87 was to receive the following Lispro insulin (100 u/ml) sliding scale amounts based on her blood glucose level: -150 - 200 mg/dl administer 1 unit -201 - 250 mg/dl administer 2 units -251 - 300 mg/dl administer 3 units -301 - 350 mg/dl administer 4 units -351 - 400 mg/dl administer 5 units If Resident #87's blood glucose level was greater than 400 mg/dl, the nurse was to administer 6 units and notify the NP. Resident #91 Record review of the admission Record for Resident #91 (dated 04/24/24) revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, diabetes mellitus, combined systolic and diastolic congestive heart failure, and long-term use of anticoagulants. Record review of the MDS (ARD 04/08/24) revealed Resident #91 scored 15 of 15 on the BIMS, indicative of intact cognition . Record review of the April 2024 Order Summary Report for Resident #91 revealed he had a LVAD (left ventricular assist device). A LVAD is a mechanical pump that is implanted in the chest to assist the resident's heart to pump blood. The orders read, in part, .Please place parameters to hold for SBP less than 110 and hr [heart rate] less than 60 on bp [blood pressure] meds . Record review Resident #91's Care Plan (initiated 04/10/24) revealed, in part, ._____ [Resident #91] requires the use of an LVAD r/t Cardiomyopathy [disorder of the heart muscle], Acute/Chronic CHF, . An 'Intervention' was for the resident to receive all medications as ordered. Record review of the April 2024 MAR for Resident #91, for Monday 04/22/24, revealed he was not administered Coumadin (blood thinner/anticoagulant) 3 mg at 5:00 p.m. as ordered. The resident was to have a PT/INR lab drawn to monitor the Coumadin. The lab was not initialed as drawn. The MAR revealed his blood glucose was not checked as ordered at 7:00 a.m. or 11:00 a.m. and sliding-scale insulin was not given. The resident was not administered Hydralazine HCl (for high blood pressure) 50 mg at 6:00 a.m. or 2:00 p.m. The resident's blood pressure was not documented for 6:00 a.m. or 2:00 p.m. Resident #91 was not administered Carvedilol (for CHF) 6.25 mg at 9:00 a.m. Observation on 04/23/24 at 3:00 p.m. revealed there were three nurses on the South Hall. In an interview on 04/23/24 at 3:30 p.m., RN M revealed the nurses on the South Hall work 12-hour shifts, from 7:00 a.m. to 7:00 p.m. She said the South Hall was usually divided for three nurses; South 1 was from room [ROOM NUMBER] to room [ROOM NUMBER]. South 2 was from room [ROOM NUMBER] to room [ROOM NUMBER]. South 3 was from room [ROOM NUMBER] to room [ROOM NUMBER]. RN M said she worked on 04/22/24, and there were two nurses. RN M said LVN N was assigned to South 1, and she was assigned South 2. She said there was supposed to be a third nurse, but one had called off. She said she and LVN N did not redistribute care of the South 3 residents because there were two admissions. She said since they were short-handed, they did not complete the medication administration. RN M presented a text dated 04/22/24 at 11:00 a.m. to the DON that reflected she informed the DON there was no nurse for South 3. The DON replied that South 3 should be divided between the two nurses. RN M had responded that she could not handle the additional residents. RN M said neither the DON, ADON, or any other nurses came in to assist. In an interview via telephone on 04/23/24 at 3:50 p.m. LVN N said she worked on 04/22/24 on the South Hall. She said she worked on South 1 and RN M worked on South 2. She said they did not notice until 11:00 a.m. that there was no third nurse. In an interview on 04/23/24 at 4:05 p.m., the DON said there had been some issues with staffing. She said there were three nurses scheduled for the South Hall on 04/22/24, but one had called off. She said the hall should have been split between the two nurses. She said she was responsible for finding replacement staffing. She said the nurse who canceled texted her at 4:22 a.m. and she did not see it until 6:50 a.m. She said she called the facility and told a nurse to adjust the schedule but did not recall who she spoke with. She said 'WNBI' should have been scribed next to the name of the nurse who called off. She said she found out fifteen minutes ago that residents missed their medications on 04/22/24 . In an interview on 04/23/24 at 4:20 p.m., the Administrator said a staffing coordinator had recently resigned, so the DON was currently responsible for staffing. She said the two nurses should have split the hall on 04/22/24. She said she was at the facility from 8:00 a.m. to 6:00 p.m., and no one informed her they were 'struggling' on the South Hall. She said she was not aware residents missed their medications. In an interview on 04/23/24 at 4:40 p.m., the DON said that if a resident missed a dose of Coumadin (Resident #91) the PT/INR lab result could change. It would place the resident at higher risk for blood clots. She said if a resident missed a dose of Levetiracetam and/or Oxcarbazepine (Resident #65) they would be at greater risk for seizures. She said she had not informed the doctor because NP Q was at the facility on 04/22/24. In an interview on 04/23/24 at 4:55 p.m., RN M said NP Q was at the facility on 04/22/24. She said she told NP Q they were short of staff, but did not tell the NP that residents missed medications. She said she had not spoken with the NP or physician regarding the medications. In an interview on 04/24/24 at 9:35 a.m., the Corporate RN said she called the physician and received orders to monitor the residents. She said RN M should have divided the residents between her and LVN N. She said she provided 1:1 education for RN M, and that she would be making a referral to the Board of Nursing. In an interview on 04/24/24 at 11:50 a.m., NP Q said she was not made aware the residents missed their medications on 04/22/24 until yesterday (04/23/24). She said she was told only the evening medications were missed. The surveyor informed her that residents missed their morning medications as well. She said the resident on Coumadin would need to have his next PT/INR lab watched. She said the facility would need to make sure vital signs and blood sugars were monitored. She said a missed dose of Keppra (Levetiracetam) or Oxcarbazepine would make the resident more prone to have a seizure, but missing a dose would probably not cause a seizure. She said Resident #91 was in the transitioning phase of attaining a therapeutic range for Coumadin, and he was not there yet. Missing the dose was a setback. She said Resident #91 has a LVAD device, and if he had a clot, it could be fatal. Resident#19 Record review of the admission sheet (undated) for Resident #19 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia (a group of thinking and social symptoms that interferes with daily functioning), other abnormalities of gait and mobility (weakness of the hip and lower extremity muscles commonly cause gait disturbances) and other lack of coordination (impaired balance or coordination). Record review of Resident #19's Quarterly MDS, dated [DATE], revealed she had a BIMS score of 12 out of 15, indicative of moderately impaired cognitively. She required partial/moderate assistance from staff with toileting hygiene, shower/bathe, upper/lower body dressing and personal hygiene. Further review of section H0300 and H0400 coded always incontinent of bladder and bowel. Record review of Resident #19's care plan, initiated 01/27/2023 and revised on 02/21/2023 revealed the following: Focus: ADL FUNCTIONAL DEFICITS: [Resident#19] is at risk for decline in ADL functions and injury r/t age related osteoporosis Polyosteoarthritis abnormalities of gait mobility malaise lack of coordination muscle wasting. Goal: [Resident#19] will be well dressed, groomed, clean, odor free and will have no decline in ADL functioning over the next 90 days. Target Date: 02/14/2024. Interventions: Toileting: Provide extensive assistance of 2 persons for toileting Observation and interview on 04/23/24 at 9:32 a.m., revealed Resident #19 was sitting on the side of the bed. The fitted sheet and the towel used as a draw sheet were soaking wet. Resident #19 mumbled for about 5 minutes while being interviewed and could not respond appropriately to the questions asked. In an interview on 04/23/24 at 10:54 a.m., CNA I said she came to work late at 7:45 a.m, and did not have a chance to change residents from last night (4/22/24) because she was busy passing out breakfast trays. Resident #41 Record review of the admission sheet (undated) for Resident #41 revealed a [AGE] year old male admitted to the facility on [DATE] with diagnoses which included sleep terrors (episodes of screaming, intense fear, and flailing while still asleep, often paired with sleepwalking) and restless legs syndrome (a condition characterized by a nearly irresistible urge to move the legs, typically in the evenings). Record review of Resident #41's Quarterly MDS, dated [DATE], revealed he had a BIMS score of 15 out of 15, indicative of intact cognitively. He required partial/moderate assistance from staff with toileting hygiene, shower/bathe, upper/lower body dressing and personal hygiene. Further review of section H0300 and H0400 coded always incontinent of bladder and bowel. Record review of Resident #41's care plan, initiated 08/09/2022 and revised on 04/03/2023 revealed the following: Focus: ADL FUNCTIONAL DEFICITS: [Resident#41] is at risk for decline in ADL functions and injury r/t Parkinson disease, Restless Leg syndrome, Muscle weakness, repeated falls, Unwitnessed fall-3/31/23 per resident Goal: [Resident#41] will be well dressed, groomed, clean, odor free and will have no decline in ADL functioning over the next 90 days. Target Date: 05/04/2024 Interventions: Toileting: Provide extensive assistance of 2 persons for toileting. In an interview on 4/23/24 at 9:23 a.m., Resident #41 said there was no CNA last night (4/22/24) and the night before (4/21/24) on 11-7am shift. He said he was incontinent of bowel and bladder. He said his bed had been soaking wet when morning shift CNA changed him. He said, I can have skin breakdown and pressure ulcer from laying in urine. Resident #50 Record review of the admission sheet (undated) for Resident #50 revealed an [AGE] year old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body), congestive heart failure(a chronic condition in which the heart doesn't pump blood as well as it should) and functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord). Record review of Resident #50's Quarterly MDS, dated [DATE], revealed he had a BIMS score of 15 out of 15, indicative of intact cognitively. He required Substantial/maximal assistance from staff with toileting hygiene, shower/bathe, upper/lower body dressing and personal hygiene. Further review of section H0300 and H0400 coded always incontinent of bladder and bowel. Record review of Resident #50's care plan, initiated 04/21/2023 and revised on 05/29/2023 revealed the following: Focus: ADL FUNCTIONAL DEFICITS: [Resident#50] is at risk for decline in ADL functions and injury r/t resp failure. Goal: [Resident#50] will be well dressed, groomed, clean, odor free and will have no decline in ADL functioning over the next 90days. Interventions: Toileting: Provide total assistance of (1) person(s) for toileting In an interview on 4/23/24 at 9:28 a.m., Resident #50 said there was no can last night (4/22/24) and the night before (4/21/24) on 11-7 a.m. shift. He said he had a bowel movement around 10 p.m. and he pressed his call light. He said no one came to the room to change him till 8 a.m. the next day (4/23/24). He said he had a heart attack in 2005 and knows the symptoms. He said, what if I was having a heart attack; nobody came to check on me. In an interview on 4/23/24 at 9:50 a.m., LVN C said she was the nurse for Swan Hall. She said she received a report from the night nurse that Swan Hall did not have a CNA on 4/21/24 during the 11-7 a.m. shift and a CNA left at 3 am on 4/22/24 during the 11-7 am shift. When asked if the DON or the Administrator were notified. LVN C said the management was aware of short staffing with CNAs calling in last minute or no show. She said she was trying to help CNA I change residents from last night along with doing her assigned duties. In an interview on 4/24/24 at 9:01 a.m., Resident #50 said there was no CNA this morning (4/24/24). He said, I have a bowel movement and need to be changed. In an interview on 4/24/24 at 9:07 a.m., with LVN C, this surveyor notified the Nurse in charge of Swan Hall that Resident #50 was requesting to be changed. LVN C said Resident #50 told her he needed to be changed but she was in the middle of passing meds and there was no CNA on the hall. Resident #59 Record review of the admission sheet (undated) for Resident #59 revealed a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord). Record review of Resident #59's Quarterly MDS, dated [DATE], revealed she had a BIMS score of 15 out of 15, indicative of intact cognitively. She was dependent on staff with toileting hygiene, shower/bathe, upper/lower body dressing and personal hygiene. Further review of section H coded having indwelling catheter and section H0400 coded always incontinent of bowel. Record review of Resident #59's care plan, initiated 02/24/2023 and revised on 03/07/2023 revealed the following: Focus: ADL FUNCTIONAL DEFICITS [Resident #59] is at risk for decline in ADL functions and injury r/t Quadriplegia Max assist to 1-2 persons with ADL'S W/C mobility. Goal: [Resident #59] will be well dressed, groomed, clean, odor free and will have no decline in ADL functioning over the next 90 days. Interventions: Toileting: Provide extensive assistance of 1 person for toileting. Observation and interview on 4/23/24 at 11:35 a.m., Resident #59's hair was oily, and she had dry flaky skin. She had food stains on her shirt. Her nails were about 3/4-inch-long with brown substance in between. Resident #59 said she had not received a shower in 6 days due to short staff. She said she required 2 people assist with showers. She said the facility was short staffed especially during the 11-7 am shift. She said she had to call the fire department to come turn and reposition her. She said the Administrator was aware of her missing showers. Resident #59 showed this Surveyor the text she had sent to the Administrator. Record review and interview on 4/24/24 at 2:14 p.m., with ADON A this surveyor request ADLs/shower sheets for Resident #59 for the month of April 2024. ADON A returned after few minutes and said she was unable to find the shower sheets for the Resident #59. In an interview on 4/24/24 at 1:05 p.m., the Administrator said Resident #59 had texted her regarding not receiving showers. The Administrator said, I made sure she received a shower yesterday (4/23/24). In an interview on 4/24/24 at 11:10 a.m., during a confidential resident group meeting 11 out of 11 residents complained about short staffing, not getting changed, nor receiving showers on their assigned days. In an interview on 4/24/24 at 1:05 p.m., the Administrator said staffing was determined by skill level of the hall. There were 5 CNAs (7-3pm), 4 CNAs (3-11pm) and 4 CNAs night shift (11-7am). She said she found out on Monday morning (4/21/24) that there was no CNAs during the night shift. She said the facility did not use agency staff that was corporate decision. She said the risk of staff shortage was high risk fall, residents not taken care of. She said nurses were allowing CNAs to leave. She said she came to the facility at night and the CNAs were scheduled but she was unable to find them. The Administrator said she was new and was trying to hire more staff. In an interview on 04/24/24 at 1:22 p.m., the DON said she was unaware the facility was short staffed on 4/21/24 and 4/22/24 during 11pm-7am shift. She said if CNA was late or no show the charge nurse needed to notify her by calling the staffing phone. She said she had the staffing phone, but she did not receive any calls. In an interview on 04/25/2024 at 4:10 p.m., with [NAME] A, she said the facility used disposable dishes and plasticware a lot last week for the resident's for some lunches, but mostly for their dinners. She said she had worked 11 days straight because the kitchen staff was short and they were unable to wash dishes to reuse again for the residents. Record review of facility's Staffing policy dated (Revised October 2017) revealed read in part: .Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Policy Interpretation and Implementation: 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident ' s plan of care . It was determined an Immediate Jeopardy (IJ) existed on 04/24/24 at 5:35 p.m., the Administrator was notified and the IJ template was provided. The following Plan of Removal was submitted by the facility was accepted on 04/25/26 at 6:47 p.m. and indicated the following: _____ [Facility name] Plan of Removal Immediate Jeopardy On 04/24/2024 the HHSC Health and Human Services Commission surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy of resident health and safety. The notification of Immediate Jeopardy states as follows: F725 - Sufficient Nursing Staffing: The facility failed to a). ensure there were sufficient staff per the facility assessment; b). the facility failed to provide sufficient nursing staffing to ensure residents received their medications; and c). the facility failed to provide ADL care to residents with bowel/bladder incontinence during the night shift (11 pm - 7 am). All facility residents have the potential to be affected by deficient practice. 1). Action: Medication Error Reports were completed for R#91, R#65, R#87, R#34, and R#37 were assessed for adverse events. There were no adverse events observed. The assessment results were shared with the nurse practitioner, and facility staff consulted the nurse practitioner to address the care needs of residents identified in the identified deficient practice. The Nurse Practitioner gave instructions to monitor residents' vital signs, including blood sugar, for residents as ordered and to call for concerns. An audit was completed to determine if other residents missed medications due to staffing shortages; a Medication Error Report will be completed, residents assessed, and medical provider notification will be completed for those resident identified and interventions as per medical provider instructions. Start Date: 04/24/2024 Completion Date: 04/24/2024 Responsible: Director of Nursing 2). Action: Skin checks were completed for R#19, R#41, R#50, and R#59. No skin breakdown and/or pressure ulcers were assessed. The facility's Chief Nursing Officer (CNO) completed Safe Surveys with cognitively intact facility residents; survey questions included the following questions: Do you feel there is sufficient staffing to meet your needs?; Do you receive your medication timely?; Does staff answer call lights timely? Do the employees appropriately help you with activities of daily living?; Does the facility help you feel safe and secure in your home?; Do you feel comfortable reporting any concerns to the proper staff member?; Do you have any concerns to report at this time? All facility residents verbalized they felt safe; no change in demeanor was observed in cognitively impaired residents. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Director of Nursing and Chief Nursing Officer 3). Action: The facility Administrator reviewed the Facility Assessment as it relates to staffing needs for medication administration and direct care. The facility Assessment has been updated. Comprehension will be assessed via completing the staffing matrix to demonstrate an understanding of minimum staffing needs. The staffing matrix will be reviewed daily by the facility administrator and nursing director during the Monday- Friday morning meeting for actual and potential needs; and by the Weekend Supervisor on Saturdays and Sundays. The facility Administrator will provide additional education as deemed necessary to maintain ongoing compliance. Compliance checks will be completed during the monthly Quality Assurance and Performance Improvement (QAPI) process. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Administrator 4). Action: Additionally, the Director of Nursing educated nursing staff (Licensed Nurses (RNs/LVNs), Certified Medication Aides (CMAs), and Certified Nursing Assistants (CNAs) on duty on the facility policy as it relates to a). Supporting Activities of Daily Living (ADLs) and b). Peri Care. The Director of Nursing emphasized the importance of timely response to 1). Residents call for assistance, 2). Provision of assistance with ADLS to include turning and repositioning, timely incontinent care, and showering per facility-established showering schedule to ensure residents are provided with care, treatment, and services as appropriate to maintain good personal hygiene and to prevent skin irritation. Licensed Nurses (RNs/LVNs) not[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including dispensing and administering of all drugs and biologicals, to meet the needs of 4 residents (Residents #34, #65, #87, and #91) of 10 residents reviewed for medication administration. -Facility staff did not redistribute assignments of residents when one of three nurses assigned to the South Hall called off from her shift. -Resident #34, Resident #65, and Resident #87 did not have their blood glucose levels checked as ordered, which determined if sliding scale insulin was to be administered on 04/22/24. -Resident #34, Resident #65, Resident #87, and Resident #91 did not receive their morning and/or afternoon medications as ordered by their physician on 04/22/24. -Resident #34, Resident #65, and Resident #87 had parameters for administering blood pressure medications. Blood pressures were not documented, and the blood pressure medications were not administered. -Missed medications included, but were not limited to, insulin, anticoagulants (blood thinners), and one IV antibiotic. -The DON was not aware of the residents missing their medications prior to surveyor notification. -The Physician was not notified until after the surveyor notified the DON. An Immediate Jeopardy (IJ) was identified on 04/24/24. The IJ template was provided to the facility on [DATE] at 5:35 p.m. While the IJ was removed on 04/28/24 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy, because all staff had not been trained on medication administration and chain of command. The failure could place the residents at risk for not having their medication needs met as ordered by their physician. Missed insulin could result in the resident becoming hyperglycemic (high blood sugar). Missed anticoagulants could result in blood clots, which could be fatal for Resident #91, who had a LVAD (left ventricle assist device). Missed antibiotics could result in a resident's infection not healing, or the resident becoming septic Findings include: Resident #34 Record review of the admission Record for Resident #34 (dated 04/25/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, cerebral palsy (a group of movement disorders), type 2 diabetes mellitus, gastrostomy status (has feeding tube), and epilepsy (seizure disorder). Record review of the MDS (ARD 04/11/24) for Resident #34 revealed she had a BIMS score of 0/15, indicative of severe cognitive impairment. Record review of the Care Plan (revised 03/30/24) for Resident #34 revealed she was receiving anticoagulant therapy (Eliquis) and was at risk for increased bleeding or bruising. One of the Interventions read Give medications as ordered. The Care Plan reflected Resident #34 had diabetes. Corresponding Interventions were to monitor blood glucose levels as ordered, and to give medications as ordered. Record review of the April 2024 Order Summary Report for Resident #34 revealed she was to receive Eliquis (anticoagulant) 5 mg twice daily for prevention of pulmonary embolism (blood clot in an artery of the lung). The orders reflected she was to have her blood glucose checked every six hours, with insulin to be administered per sliding scale. The orders reflected Metoprolol Tartrate (Toprol) tablet, 12.5 mg was to be administered twice daily for high blood pressure. The orders reflected the Toprol was to be held if the resident's systolic blood pressure was less than 100 mmhg. The orders reflected Trileptal Oral suspension (300 mg/5 ml) 10 ml was to be administered twice daily for epilepsy. Record review of the April 2024 MAR/TAR for Resident #34 revealed the following medications were not administered on 04/22/24 at 9:00 a.m.: -Eliquis 5 mg -Toprol 12.5 mg (blood pressure not documented) -Trileptal Oral suspension (300 mg/5 ml) 10 ml Resident #34's blood glucose levels were not checked at noon or 6:00 p.m. No sliding scale insulin was administered. Record review of the April 2024 Order Summary report revealed Resident #34 was to receive the following Fiasp (100 u/ml) insulin amounts based on her blood glucose level: -150 - 200 mg/dl administer 2 units -201 - 250 mg/dl administer 4 units -251 - 300 mg/dl administer 6 units -301 - 350 mg/dl administer 8 units -351 - 400 mg/dl administer 10 units If Resident #34's blood glucose level was greater than 400 mg/dl, the nurse was to administer 12 units and notify the NP. Observation on 04/23/24 at 9:00 a.m. revealed Resident #34 was in her room, lying in bed. She did not respond to a verbal greeting. She was receiving enteral nutrition via her g-tube. Resident #65 Record review of the admission Record for Resident #65 (dated 04/25/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus, schizophrenia, seizures, stage 4 pressure ulcer of the sacrum, and atherosclerotic heart disease of coronary artery without angina pectoris (chest pain). The resident had a gastrostomy tube (g-tube) for nutrition and medications. Record review of the MDS (ARD 01/24/24) revealed she had memory deficits and moderately impaired cognition . Record review of the April 2024 Order Summary Report for Resident #65 revealed she was to receive the IV antibiotic Ertapenem Sodium Solution reconstituted 1 gm for an infection of the pressure ulcer of her sacrum. The orders also reflected Resident #65 was to have her blood glucose checked at 8:00 a.m., and Glargine insulin (100units/ml) 40 units administered. The orders reflected she was to have her blood glucose checked every six hours, with insulin to be administered per sliding scale, and she was to receive Levetiracetam solution (100 mg/ml) 5 ml twice daily for seizures, Oxcarbazepine 300 mg twice daily for seizures, and Haldol 2 mg twice daily for schizophrenia. Record review of the April 2024 MAR for Resident #65 revealed the following medications with corresponding times were not administered on 04/22/2024: -IV Ertapenem Sodium Solution reconstituted 1 gm scheduled for 8:00 a.m. -Haldol 2 mg scheduled for 8:00 a.m. -Levetiracetam solution (100 mg/ml) 5 ml scheduled for 9:00 a.m. -Oxcarbazepine 300 mg scheduled for 9:00 a.m. Resident #65's blood glucose was not checked as ordered on 04/22/2024 at 8:00 a.m. and 40 units of Insulin Glargine was not given. Resident #65's blood glucose was not checked as ordered at 6:00 a.m., noon, or 6:00 p.m. on 04/22/2024, and sliding-scale insulin was not given. Record review of the April 2024 Order Summary report revealed Resident #65 was to receive the following Lispro (200 u/ml) insulin amounts based on her blood glucose level: -150 - 200 mg/dl administer 2 units -201 - 250 mg/dl administer 4 units -251 - 300 mg/dl administer 6 units -301 - 350 mg/dl administer 8 units -351 - 400 mg/dl administer 10 units If Resident #65's blood glucose level was greater than 400 mg/dl, the nurse was to administer 12 units and notify the physician. Observation and interview on 04/23/24 at 9:13 a.m. revealed Resident #65 was in her room, sitting in her wheelchair. She said she had received her medications today but was unable to recall yesterday (04/22/24). Resident #87 Record review of the admission Record for Resident #87 (dated 04/24/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus, atrial fibrillation, congestive heart failure, hypertension, and history of pulmonary embolism (obstruction of the pulmonary artery by a blood clot or other foreign matter). Record review of the MDS (ARD 03/25/24) revealed she scored 0 of 15 on the BIMS, indicative of severely impaired cognition . Record review of the April 2024 Order Summary Report for Resident #87 revealed she was to receive Apixaban (blood thinner/anticoagulant) 5 mg twice daily to prevent blood clots, Metoprolol Tartrate 12.5 mg twice daily for blood pressure, Amiodarone 200 mg for atrial fibrillation, and she was to have her blood glucose checked before meals, with insulin to be administered per sliding scale. Resident #87 was to recieve Mtotoprolol Tartrate 12.5 mg., which had blood pressure parameters instructing to hold the medication if the resident's systolic blood pressure was less than 100 mmHg. Record review of Resident #87's April 2024 MAR revealed she was not administered the 9:00 a.m. doses of Apixaban 5 mg, Amiodarone 200 mg, or the Metoprolol Tartrate 12.5 mg. on 04/22/24. Resident #87's blood pressure was not documented as been checked. Resident #87's blood glucose was not checked as ordered at 11:00 a.m. and 4:00 p.m. on 04/22/2024 and sliding-scale insulin was not administered. Record review of the April 2024 Order Summary report revealed Resident #87 was to receive the following Lispro insulin (100 u/ml) sliding scale amounts based on her blood glucose level: -150 - 200 mg/dl administer 1 unit -201 - 250 mg/dl administer 2 units -251 - 300 mg/dl administer 3 units -301 - 350 mg/dl administer 4 units -351 - 400 mg/dl administer 5 units If Resident #87's blood glucose level was greater than 400 mg/dl, the nurse was to administer 6 units and notify the NP. Resident #91 Record review of the admission Record for Resident #91 (dated 04/24/24) revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, diabetes mellitus, combined systolic and diastolic congestive heart failure, and long-term use of anticoagulants. Record review of the MDS (ARD 04/08/24) revealed Resident #91 scored 15 of 15 on the BIMS, indicative of intact cognition . Record review of the April 2024 Order Summary Report for Resident #91 revealed he had a LVAD (left ventricular assist device). A LVAD is a mechanical pump that is implanted in the chest to assist the resident's heart to pump blood. The orders read, in part, .Please place parameters to hold for SBP less than 110 and hr [heart rate] less than 60 on bp [blood pressure] meds . Record review Resident #91's Care Plan (initiated 04/10/24) revealed, in part, ._____ [Resident #91] requires the use of an LVAD r/t Cardiomyopathy [disorder of the heart muscle], Acute/Chronic CHF, . An 'Intervention' was for the resident to receive all medications as ordered. Record review of the April 2024 MAR for Resident #91, for Monday 04/22/24, revealed he was not administered Coumadin (blood thinner/anticoagulant) 3 mg at 5:00 p.m. as ordered. The resident was to have a PT/INR lab drawn to monitor the Coumadin. The lab was not initialed as drawn. The MAR revealed his blood glucose was not checked as ordered at 7:00 a.m. or 11:00 a.m. and sliding-scale insulin was not given. The resident was not administered Hydralazine HCl (for high blood pressure) 50 mg at 6:00 a.m. or 2:00 p.m. The resident's blood pressure was not documented for 6:00 a.m. or 2:00 p.m. Resident #91 was not administered Carvedilol (for CHF) 6.25 mg at 9:00 a.m. Observation on 04/23/24 at 3:00 p.m. revealed there were three nurses on the South Hall. In an interview on 04/23/24 at 3:30 p.m. RN M revealed the nurses on the South Hall work 12 hour shifts, from 7:00 a.m. to 7:00 p.m. She said the South Hall was usually divided for three nurses; South 1 was from room [ROOM NUMBER] to room [ROOM NUMBER]. South 2 was from room [ROOM NUMBER] to room [ROOM NUMBER]. South 3 was from room [ROOM NUMBER] to room [ROOM NUMBER]. RN M said she worked on 04/22/24, and there were two nurses. RN M said LVN N was assigned to South 1, and she was assigned South 2. She said there was supposed to be a third nurse, but one had called off. She said she and LVN N did not redistribute care of the South 3 residents because there were two admissions. She said since they were short-handed, they did not complete the medication administration. RN M presented a text dated 04/22/24 at 11:00 a.m. to the DON that reflected she informed the DON there was no nurse for South 3. The DON replied that South 3 should be divided between the two nurses. RN M had responded that she could not handle the additional residents. RN M said neither the DON, ADON, or any other nurses came in to assist. In an interview via telephone on 04/23/24 at 3:50 p.m. LVN N said she worked on 04/22/24 on the South Hall. She said she worked on South 1 and RN M worked on South 2. She said they did not notice until 11:00 a.m. that there was no third nurse. In an interview on 04/23/24 at 4:05 p.m., the DON said there has been some issues with staffing. She said there were three nurses scheduled for the South Hall on 04/22/24, but one had called off. She said the hall should have been split between the two nurses. She said she was responsible for finding replacement staffing. She said the nurse who canceled texted her at 4:22 a.m. and she did not see it until 6:50 a.m. She said she called the facility and told a nurse to adjust the schedule but did not recall who she spoke with. She said 'WNBI' should have been scribed next to the name of the nurse who called off. She said she found out fifteen minutes ago that residents missed their medications on 04/22/24. In an interview on 04/23/24 at 4:20 p.m. the Administrator said a staffing coordinator had recently resigned, so the DON was currently responsible for staffing. She said the two nurses should have split the hall on 04/22/24. She said she was at the facility from 8:00 a.m. to 6:00 p.m., and no one informed her they were 'struggling' on the South Hall. She said she was not aware residents missed their medications. In an interview on 04/23/24 at 4:40 p.m. the DON said that if a resident missed a dose of Coumadin (Resident #91) the PT/INR lab result could change. It would place the resident at higher risk for blood clots. She said if a resident missed a dose of Levetiracetam and/or Oxcarbazepine (Resident #65) they would be at greater risk for seizures. She said she has not informed the doctor because NP Q was at the facility on 04/22/24. In an interview on 04/23/24 at 4:55 p.m. RN M said NP Q was at the facility on 04/22/24. She said she told NP Q they were short of staff, but did not tell the NP that residents missed medications. She said she has not spoken with the NP or physician regarding the medications. In an interview on 04/24/24 at 9:35 a.m. the Corporate RN said she called the physician and received orders to monitor the residents. She said RN M should have divided the residents between her and LVN N. In an interview on 04/24/24 at 11:50 a.m., NP Q said she was not made aware the residents missed their medications on 04/22/24 until yesterday (04/23/24). She said she was told only the evening medications were missed. The surveyor informed her that residents missed their morning medications as well. She said the resident on Coumadin would need to have his next PT/INR lab watched. She said the facility would need to make sure vital signs and blood sugars were monitored. She said a missed dose of Keppra (Levetiracetam) or Oxcarbazepine would make the resident more prone to have a seizure, but missing a dose would probably not cause a seizure. She said Resident #91 was in the transitioning phase of attaining a therapeutic range for Coumadin, and he was not there yet. Missing the dose was a setback. She said Resident #91 has a LVAD device, and if he had a clot, it could be fatal . It was determined an Immediate Jeopardy (IJ) existed on 04/24/24 at 5:35 p.m. The Administrator was notified at that time. The Administrator was provided with the IJ template on 04/24/24 at 5:35 p.m. The following Plan of Removal submitted by the facility was accepted on 04/25/26 at 6:47 p.m.: _____[Facility Name] Plan of Removal Immediate Jeopardy On 04/24/2024 the HHSC Health and Human Services Commission surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy of resident health and safety. The notification of Immediate Jeopardy states as follows: F755 - Pharmaceutical Services: The facility failed to administer medications (Coumadin, Insulin, and Seizure medications) to 5 residents residing in South Hall 3. All facility residents have the potential to be affected by deficient practice. 1). Action: Medication Error Reports were completed for R#91, R#65, R#87, R#34, and R#37 were assessed for adverse events. There were no adverse events observed. The assessment results were shared with the nurse practitioner, and facility staff consulted the nurse practitioner to address the care needs of residents identified in the identified deficient practice. The Nurse Practitioner gave instructions to monitor residents' vital signs, including blood sugar, for residents as ordered and to call for concerns. An audit was completed to determine if other residents missed medications due to staffing shortages; a Medication Error Report will be completed, residents assessed, and medical provider notification will be completed for those resident identified and interventions as per medical provider instructions. Start Date: 04/24/2024 Completion Date: 04/24/2024 Responsible: Director of Nursing 2). Action: The Chief Nursing Officer (CNO) reviewed facility policy related to Staffing on 04/24/2024; no revisions were deemed necessary. As such, The CNO educated the facility Administrator and Director of Nursing on the facility policy as it relates to Staffing, which reads Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Emphasis was placed on the need to ensure the facility had a sufficient number of Licensed Nurses (RNs/LVNs), Certified Medication Aides (CMAs), and Certified Nursing Assistants (CNAs) available 24 hours a day to provide direct resident care services and the need to ensure staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. The mode of education was a memo in the form of a copy of the policy and procedure and occurred in a face-to-face meeting on 04/24/2024. Comprehension was assessed via the teach-back methods and a one-sentence summary of actions to be taken in the event of staff shortages on 04/25/2024. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Chief Nursing Officer 3). Action: The facility Administrator and Director of Nursing educated the facility staff on duty of the facility Chain of Command when presented with staffing challenges. A copy of the facility Chain of Command - Organizational Chart - was posted on the employee bulletin board. The facility Leadership Team - Administrator and the Director of Nursing - directed the facility Licensed Nurses (RNs/LVNs) to contact the on-call staffing phone within the first fifteen (15) minutes of the start of each shift when call-ins and no-calls/no-shows were noted so that additional staff could be called to ensure sufficient number of Licensed nurses and certified nursing assistants available to provide direct resident care services and the need to ensure staffing numbers and the skill requirements of direct care staff as determined by the needs of the residents based on each resident's plan of care. If at any time a Licensed Nurses (RNs/LVNs) or Certified Medication Aide (CMAs) feel they cannot administer mediations as prescribed, he/she should follow the Chain of Command - contact the Assistance Director of nursing and then the Director of Nursing for assistance and further direction. Licensed Nurses (RNs/LVNs) will not be allowed to return to work until they receive this in-service. Licensed Nurses (RNs/LVNs) who do not physically attend the in-service training in person will be in-serviced via phone. During the in-service training and phone in-service, there will be a discussion (Question and Answering) to ensure understanding and competency. A post-test will measure learning. A demonstrable competency of 90% accuracy must be demonstrated before the start of their next shift.; those scoring less than 90% will receive immediate reeducation before being allowed to work. The mode of education was a memo in the form of a copy of the policy and procedure, which occurred in a face-to-face meeting that started on 04/24/2024. The education was added as part of the orientation for ongoing training of new hires, agency, and PRN (as needed) staff through a combination of employee training, employee monitoring, and reporting processes. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Administrator and Director of Nursing 4). Action: The facility Administrator reviewed the Facility Assessment as it relates to staffing needs for medication administration and direct care. The facility Assessment has been updated. Comprehension will be assessed via completing the staffing matrix to demonstrate an understanding of minimum staffing needs. The staffing matrix will be reviewed daily by the facility administrator and nursing director during the Monday- Friday morning meeting for actual and potential needs; and by the Weekend Supervisor on Saturdays and Sundays. The facility Administrator will provide additional education as deemed necessary to maintain ongoing compliance. Compliance checks will be completed during the monthly Quality Assurance and Performance Improvement (QAPI) process. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Administrator 5) Action: The facility Administrator Contracted with a Supplemental Staffing agency to provide Licensed Nurses (RNs/LVNs), Certified Medication Aides (CMAs), and Certified Nursing Assistants (CNAs) to ensure a contingency staffing plan is in place when the facility has call-ins and no-call/no-shows, and the facility staff cannot cover sufficient staffing needs. The facility Administrator educated the Director of Nursing on the need to call and request supplemental staff when there are call-ins and/or no-call/no-shows to ensure a sufficient number of Licensed Nurses RNs/LVNs), Certified Medication Aides (CMAs), Certified Nursing Assistants (CNAs) available 24 hours a day to provide direct resident care services - medication administration. The mode of education was in the form of a memo indicating when supplemental staffing should be requested. Comprehension will be assessed via completing the staffing matrix to demonstrate an understanding of minimum staffing needs. The staffing matrix will be reviewed daily by the facility administrator and nursing director during the Monday- Friday morning meeting for actual and potential needs; and by the Weekend Supervisor on Saturdays and Sundays. The facility Administrator will provide additional education as deemed necessary to maintain ongoing compliance. Compliance checks will be completed during the monthly Quality Assurance and Performance Improvement (QAPI) process. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Administrator and Director of Nursing 6). Action: The Chief Nursing Officer (CNO) educated the facility Director of Nursing on the facility policy and procedure as it relates to Administering Medications, which reads, Medications shall be administered in a safe and timely manner, and as prescribed. The emphasis was stressed that medication must be administered in accordance with the required time frame - within one (1) hour of their prescribed time. If a medication is not given at the prescribed time, the medical provider (Physician/Nurse Practitioner/Physician Assistant) must be contacted and consulted for further directions. The mode of education was a memo in the form of a copy of the policy and procedure, which occurred in a face-to-face meeting on 04/24/2024. Comprehension was assessed via the teach-back methods on 04/25/2024 Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Chief Nursing Officer 7). Action: The facility Director of Nursing educated Licensed Nurses (RNs/LVNs) and Certified Medication Aides (CMAs) on the facility policy and procedure as it relates to Administering Medications, which reads, Medications shall be administered in a safe and timely manner, and as prescribed. The emphasis was stressed that medication must be administered in accordance with the required time frame - within one (1) hour of their prescribed time. If a medication is not given at the prescribed time, the medical provider (Physician/Nurse Practitioner/Physician Assistant) must be contacted and consulted for further directions. The mode of education was a memo in the form of a copy of the policy and procedure and occurred in a face-to-face meeting on 04/24/2024 and 04/25/2024. Licensed Nurses (RNs/LVNs) and Certified Medication Aides (CMAs) not present will be in-serviced via phone. During the face-to-face in-service training and phone in-service, there will be a discussion (Question and Answering) to ensure understanding and competency. A post-test will measure learning. All nurses in-serviced, face-to-face or over the phone will not be allowed to work until they complete the post-test and demonstrate competency. A demonstrable competency of 90% accuracy must be demonstrated before the start of their next shift.; those scoring less than 90% will receive immediate reeducation before being allowed to work. The mode of education was a memo in the form of a copy of the policy and procedure, which occurred in a face-to-face meeting started on 04/24/2024. The education is added as part of the orientation for ongoing training of new hires, agency, and PRN (as needed) staff through a combination of employee training, employee monitoring, and reporting processes. Contact the Physician. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Director of Nursing and Facility Administrator 8). Action: The Director of Nursing (DON) will review the Point of Care (PCC) Medication Administration Dashboard daily Monday - Friday and the Weekend Supervisor on Saturdays and Sundays to ensure Licensed Nurses (RNs/LVNs) and Certified Medication Aides (CMAs) have administered and documented medication administration timely and proper notification of medical providers have been completed when any deviation from the facility policy and procedures. Discrepancies noted during reviews will be immediately addressed. Progressive disciplinary actions, which include additional training and leading to termination, will be taken as deemed appropriate. The facility administrator will review the QA audit tool on a weekly basis to ensure that the nurse managers (DON and Weekend Supervisor) follow the correction plan for four weeks. reviewed monthly during the QAPI meetings for the next three (3) months and will be ongoing as needed. Meeting minutes will be taken and maintained for twelve (12) months. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Director of Nursing, Weekend Supervisor and Facility Administrator 9). Action: The facility Administrator conducted an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) to discuss the deficient practice identified and to review the Plan of Removal (POR) was completed on 04/25/2024 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Action items will be reviewed monthly during the QAPI meetings for the next three (3) months and will be ongoing as needed. Meeting minutes will be taken and maintained for twelve (12) months. Start Date: 04/25/2024 Completion Date: 04/25/2024 Responsible: Facility Administrator Surveyors monitored the Plan of Removal for effectiveness as follows: On 04/26/24 the facility was monitored. Not all staff had been in-serviced. In an interview on 04/27/24 at 9:45 a.m. LVN O said she was assigned to South 1 Rooms 201 to 209. She said she still had three residents to give medications to in room [ROOM NUMBER] A and B, and room [ROOM NUMBER]. In an interview on 04/27/24 at 09:51 a.m. RN P said she was with a staffing agency. She said she was assigned Rooms 210 to 214. In an interview on 04/27/24 at 09:55 a.m. LVN R said he had one more resident to administer medications to, but would be finished on time. In an interview on 04/27/24 at 10:15 a.m., RN S said he was finished with the morning medication administration for the Flamingo Hall. In an interview on 04/27/24 at 10:17 a.m. LVN T said she had completed the morning medication pass for Swan Hall and Dove Hall. In an interview on 04/27/24 at 10:19 a.m. MA U said she has been in-serviced regarding medication administration and Chain of Command. She said if medications were going to be late she was to tell the charge nurse. Record review 'spot checks' of the MARs for each hall were conducted. Three random residents from each hall were reviewed. There were no concerns for the following halls: [NAME] Hall, Dove Hall, Flamingo Hall, Swan Hall, South 2 Hall, and South 3 Hall. Three residents on South 1 had their medications administered late. In an interview on 04/27/24 at 11:30 a.m. the DON was asked if any medications were administered late. She said she would check. At 1:31 p.m. she said three residents' medications were late, and the physician had been notified. In an interview on 04/27/2024 at 1:31 p.m. the DON said she had provided in-services for the agency nurses and the staff who came in today. She said the book (envelope) was at the north nurses' station. On 04/27/24 at 1:36 p.m. the surveyor picked up the two manila envelopes at the north nurses' station labelled in-service. Copies of the staff attendance sheet were made at that time. Record review of the envelopes revealed one contained in-service training for medication administration, protocol for calling off a shift, Physician notification for missed/late medications, chain of command, and general staffing policy review. Observation and interview on 04/28/24 at 6:40 a.m. revealed LVN Z and LVN L were at the north nurses' station. Both nurses said they had the in-services. Both nurses were able to explain what the in-services were about. In an interview on 04/28/24 at 7:25 a.m. LVN K said she had the in-services on Thursday. She was able to tell what the in-services were about. In an interview on 04/28/24 at 7:41 a.m. RN S said the north was short two CNAs. He said the nurses and the MA would fill in. In an interview on 04/28/24 at 10:05 a.m. LVN R said he had the in-services. He was able to tell what the in-services were about. In an interview on 04/28/24 at 10:10 a.m. LVN O said she has had the in-services. She was able to tell what the in-services were about. Record review of the binder entitled State Workbook 2024 Binder for POR revealed the following: Medication error reports for the four residents were completed. Safe Survey Questionnaires for all halls were completed. In-services for: Med Administration - Nurses, MA Notify MD - Nurses, MA Attendance/call off - all staff Chain of Command - all staff Staffing - Nursing mgt and Administrator A/N - all staff Contacting Administrator and/or DON - all staff Facility Assessment Tool updated 2 Staff agency contracts EMR Audit sheet - up to date Review of the binder revealed the facility was effectively implimenting the components of the POR. Record review of an Agency contract revealed the facility had contracted with the agency to provide nurses in case of staffing shortages. The contract was signed on 04/25/24. An Immediate Jeopardy (IJ) was identified on 04/24/24. The IJ template was provided to the faci[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 4 residents (Residents #34, #65, #87, and #91) of 10 residents reviewed for medication administration were free of significant medication errors. -Resident #91 did not receive Coumadin (anticoagulant) as ordered by the physician in the afternoon of 04/22/24, placing him at risk for a blood clot. -Resident #34, Resident #65, and Resident #87 did not have their blood glucose levels checked as ordered, which determined if sliding scale insulin was to be administered on 04/22/24. -Resident #34 did not receive Metoprolol Tartrate (for high blood pressure) as ordered by the physician, and her blood sugar was not checked, resulting in not having blood sugar levels to determine amounts of insulin to be administered. -Resident #65 did not receive a dose of IV antibiotic for a sacral pressure ulcer infection. -Resident #87 did not receive Metoprolol Tartrate as ordered by the physician, and her blood sugar was not checked, resulting in not having blood sugar levels to determine amounts of insulin to be administered. -Missed medications included, but were not limited to, insulin, anticoagulants (blood thinners), and one IV antibiotic. -The DON was not aware of the residents missing their medications prior to surveyor notification. -The Physician was not notified until after the surveyor notified the DON. An Immediate Jeopardy (IJ) was identified on 04/24/24. The IJ template was provided to the facility on [DATE] at 5:35 p.m. While the IJ was removed on 04/28/24 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy, because all staff had not been trained on medication administration and chain of command. The failure placed the residents at higher risk for hyperglycemia (high blood sugar), blood clots, and sepsis. In an interveiw with the NP revealed a blood clot could be fatal for Resident #91. Findings include: Resident #34 Record review of the admission Record for Resident #34 (dated 04/25/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, cerebral palsy (a group of movement disorders), type 2 diabetes mellitus, gastrostomy status (has feeding tube), and epilepsy (seizure disorder). Record review of the MDS (ARD 04/11/24) for Resident #34 revealed she had a BIMS score of 0/15, indicative of severe cognitive impairment. Record review of the Care Plan (revised 03/30/24) for Resident #34 revealed she was receiving anticoagulant therapy (Eliquis) and was at risk for increased bleeding or bruising. One of the Interventions read Give medications as ordered. The Care Plan reflected Resident #34 had diabetes. Corresponding Interventions were to monitor blood glucose levels as ordered, and to give medications as ordered. Record review of the April 2024 Order Summary Report for Resident #34 revealed she was to receive Eliquis (anticoagulant) 5 mg twice daily for prevention of pulmonary embolism (blood clot in an artery of the lung). The orders reflected she was to have her blood glucose checked every six hours, with insulin to be administered per sliding scale. The orders reflected Metoprolol Tartrate (Toprol) tablet, 12.5 mg was to be administered twice daily for high blood pressure. The Metoprolol Tartrate was to be held if the resident's systolic blood pressure was less than 100 mmHg. The orders reflected Trileptal Oral suspension (300 mg/5 ml) 10 ml was to be administered twice daily for epilepsy. Record review of the April 2024 MAR/TAR for Resident #34 revealed the following medications were not administered on 04/22/24 at 9:00 a.m.: -Eliquis 5 mg -Toprol 12.5 mg (blood pressure was not documented) -Trileptal Oral suspension (300 mg/5 ml) 10 ml Resident #34's blood glucose levels were not checked at noon or 6:00 p.m. No sliding scale insulin was administered. Record review of the April 2024 Order Summary report revealed Resident #34 was to receive the following Fiasp (100 u/ml) insulin amounts based on her blood glucose level: -150 - 200 mg/dl administer 2 units -201 - 250 mg/dl administer 4 units -251 - 300 mg/dl administer 6 units -301 - 350 mg/dl administer 8 units -351 - 400 mg/dl administer 10 units If Resident #34's blood glucose level was greater than 400 mg/dl, the nurse was to administer 12 units and notify the NP. Observation on 04/23/24 at 9:00 a.m. revealed Resident #34 was in her room, lying in bed. She did not respond to a verbal greeting. She was receiving enteral nutrition via her g-tube. Resident #65 Record review of the admission Record for Resident #65 (dated 04/25/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus, schizophrenia, seizures, stage 4 pressure ulcer of the sacrum, and atherosclerotic heart disease of coronary artery without angina pectoris (chest pain). The resident had a gastrostomy tube (g-tube) for nutrition and medications. Record review of the MDS (ARD 01/24/24) revealed she had memory deficits and moderately impaired cognition . Record review of the April 2024 Order Summary Report for Resident #65 revealed she was to receive the IV antibiotic Ertapenem Sodium Solution reconstituted 1 gm for an infection of the pressure ulcer of her sacrum. The orders also reflected Resident #65 was to have her blood glucose checked at 8:00 a.m., and Glargine insulin (100units/ml) 40 units administered. The orders reflected she was to have her blood glucose checked every six hours, with insulin to be administered per sliding scale, and she was to receive Levetiracetam solution (100 mg/ml) 5 ml twice daily for seizures, Oxcarbazepine 300 mg twice daily for seizures, and Haldol 2 mg twice daily for schizophrenia. Record review of the April 2024 MAR for Resident #65 revealed the following medications with corresponding times were not administered on 04/22/2024: -IV Ertapenem Sodium Solution reconstituted 1 gm scheduled for 8:00 a.m. -Haldol 2 mg scheduled for 8:00 a.m. -Levetiracetam solution (100 mg/ml) 5 ml scheduled for 9:00 a.m. -Oxcarbazepine 300 mg scheduled for 9:00 a.m. Resident #65's blood glucose was not checked as ordered on 04/22/2024 at 8:00 a.m. and 40 units of Insulin Glargine was not given. Resident #65's blood glucose was not checked as ordered at 6:00 a.m., noon, or 6:00 p.m. on 04/22/2024, and sliding-scale insulin was not given. Record review of the April 2024 Order Summary report revealed Resident #65 was to receive the following Lispro (200 u/ml) insulin amounts based on her blood glucose level: -150 - 200 mg/dl administer 2 units -201 - 250 mg/dl administer 4 units -251 - 300 mg/dl administer 6 units -301 - 350 mg/dl administer 8 units -351 - 400 mg/dl administer 10 units If Resident #65's blood glucose level was greater than 400 mg/dl, the nurse was to administer 12 units and notify the physician. Observation and interview on 04/23/24 at 9:13 a.m. revealed Resident #65 was in her room, sitting in her wheelchair. She said she had received her medications today but was unable to recall yesterday (04/22/24). Resident #87 Record review of the admission Record for Resident #87 (dated 04/24/24) revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, type 2 diabetes mellitus, atrial fibrillation, congestive heart failure, hypertension, and history of pulmonary embolism (obstruction of the pulmonary artery by a blood clot or other foreign matter). Record review of the MDS (ARD 03/25/24) revealed she scored 0 of 15 on the BIMS, indicative of severely impaired cognition . Record review of the April 2024 Order Summary Report for Resident #87 revealed she was to receive Apixaban (blood thinner/anticoagulant) 5 mg twice daily to prevent blood clots, Metoprolol Tartrate 12.5 mg twice daily for blood pressure, Amiodarone 200 mg for atrial fibrillation. The Metoprolol Tartrate was to be held if the resident's systolic blood pressure was less than 100 mmHg. She was to have her blood glucose checked before meals, with insulin to be administered per sliding scale. Record review of Resident #87's April 2024 MAR revealed she was not administered the 9:00 a.m. doses of Apixaban 5 mg, Amiodarone 200 mg, or the Metoprolol Tartrate 12.5 mg. on 04/22/24. Her blood pressure was not documented as been checked. Resident #87's blood glucose was not checked as ordered at 11:00 a.m. and 4:00 p.m. on 04/22/2024 and sliding-scale insulin was not administered. Record review of the April 2024 Order Summary report revealed Resident #87 was to receive the following Lispro insulin (100 u/ml) sliding scale amounts based on her blood glucose level: -150 - 200 mg/dl administer 1 unit -201 - 250 mg/dl administer 2 units -251 - 300 mg/dl administer 3 units -301 - 350 mg/dl administer 4 units -351 - 400 mg/dl administer 5 units If Resident #87's blood glucose level was greater than 400 mg/dl, the nurse was to administer 6 units and notify the NP. Resident #91 Record review of the admission Record for Resident #91 (dated 04/24/24) revealed he was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, diabetes mellitus, combined systolic and diastolic congestive heart failure, and long-term use of anticoagulants. Record review of the MDS (ARD 04/08/24) revealed Resident #91 scored 15 of 15 on the BIMS, indicative of intact cognition . Record review of the April 2024 Order Summary Report for Resident #91 revealed he had a LVAD (left ventricular assist device). A LVAD is a mechanical pump that is implanted in the chest to assist the resident's heart to pump blood. The orders read, in part, .Please place parameters to hold for SBP less than 110 and hr [heart rate] less than 60 on bp [blood pressure] meds . Record review Resident #91's Care Plan (initiated 04/10/24) revealed, in part, ._____ [Resident #91] requires the use of an LVAD r/t Cardiomyopathy [disorder of the heart muscle], Acute/Chronic CHF, . An 'Intervention' was for the resident to receive all medications as ordered. Record review of the April 2024 MAR for Resident #91, for Monday 04/22/24, revealed he was not administered Coumadin (blood thinner/anticoagulant) 3 mg at 5:00 p.m. as ordered. The resident was to have a PT/INR lab drawn to monitor the Coumadin. The lab was not initialed as drawn. The MAR revealed his blood glucose was not checked as ordered at 7:00 a.m. or 11:00 a.m. and sliding-scale insulin was not given. The resident was not administered Hydralazine HCl (for high blood pressure) 50 mg at 6:00 a.m. or 2:00 p.m. Resident #91's blood pressure was not documented for either dose. Resident #91 was not administered Carvedilol (for CHF) 6.25 mg at 9:00 a.m. Observation on 04/23/24 at 3:00 p.m. revealed there were three nurses on the South Hall. In an interview on 04/23/24 at 3:30 p.m. RN M revealed the nurses on the South Hall work 12 hour shifts, from 7:00 a.m. to 7:00 p.m. She said the South Hall was usually divided for three nurses; South 1 was from room [ROOM NUMBER] to room [ROOM NUMBER]. South 2 was from room [ROOM NUMBER] to room [ROOM NUMBER]. South 3 was from room [ROOM NUMBER] to room [ROOM NUMBER]. RN M said she worked on 04/22/24, and there were two nurses. RN M said LVN N was assigned to South 1, and she was assigned South 2. She said there was supposed to be a third nurse, but one had called off. She said she and LVN N did not redistribute care of the South 3 residents because there were two admissions. She said since they were short-handed, they did not complete the medication administration. RN M presented a text dated 04/22/24 at 11:00 a.m. to the DON that reflected she informed the DON there was no nurse for South 3. The DON replied that South 3 should be divided between the two nurses. RN M had responded that she could not handle the additional residents. RN M said neither the DON, ADON, or any other nurses came in to assist. In an interview via telephone on 04/23/24 at 3:50 p.m. LVN N said she worked on 04/22/24 on the South Hall. She said she worked on South 1 and RN M worked on South 2. She said they did not notice until 11:00 a.m. that there was no third nurse. In an interview on 04/23/24 at 4:05 p.m., the DON said there has been some issues with staffing. She said there were three nurses scheduled for the South Hall on 04/22/24, but one had called off. She said the hall should have been split between the two nurses. She said she was responsible for finding replacement staffing. She said the nurse who canceled texted her at 4:22 a.m. and she did not see it until 6:50 a.m. She said she called the facility and told a nurse to adjust the schedule but did not recall who she spoke with. She said 'WNBI' should have been scribed next to the name of the nurse who called off. She said she found out fifteen minutes ago that residents missed their medications on 04/22/24. In an interview on 04/23/24 at 4:20 p.m. the Administrator said a staffing coordinator had recently resigned, so the DON was currently responsible for staffing. She said the two nurses should have split the hall on 04/22/24. She said she was at the facility from 8:00 a.m. to 6:00 p.m., and no one informed her they were 'struggling' on the South Hall. She said she was not aware residents missed their medications. In an interview on 04/23/24 at 4:40 p.m. the DON said that if a resident missed a dose of Coumadin (Resident #91) the PT/INR lab result could change. It would place the resident at higher risk for blood clots. She said if a resident missed a dose of Levetiracetam and/or Oxcarbazepine (Resident #65) they would be at greater risk for seizures. She said she has not informed the doctor because NP Q was at the facility on 04/22/24. In an interview on 04/23/24 at 4:55 p.m. RN M said NP Q was at the facility on 04/22/24. She said she told NP Q they were short of staff, but did not tell the NP that residents missed medications. She said she has not spoken with the NP or physician regarding the medications. In an interview on 04/24/24 at 9:35 a.m. the Corporate RN said she called the physician and received orders to monitor the residents. She said RN M should have divided the residents between her and LVN N. In an interview on 04/24/24 at 11:50 a.m., NP Q said she was not made aware the residents missed their medications on 04/22/24 until yesterday (04/23/24). She said she was told only the evening medications were missed. The surveyor informed her that residents missed their morning medications as well. She said the resident on Coumadin would need to have his next PT/INR lab watched. She said the facility would need to make sure vital signs and blood sugars were monitored. She said a missed dose of Keppra (Levetiracetam) or Oxcarbazepine would make the resident more prone to have a seizure, but missing a dose would probably not cause a seizure. She said Resident #91 was in the transitioning phase of attaining a therapeutic range for Coumadin, and he was not there yet. Missing the dose was a setback. She said Resident #91 has a LVAD device, and if he had a clot, it could be fatal . It was determined an Immediate Jeopardy (IJ) existed on 04/24/24 at 5:35 p.m. The Administrator was notified at that time. The Administrator was provided with the IJ template on 04/24/24 at 5:35 p.m. The following Plan of Removal submitted by the facility was accepted on 04/25/26 at 6:47 p.m.: _____[Facility Name] Plan of Removal Immediate Jeopardy On 04/24/2024 the HHSC Health and Human Services Commission surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy of resident health and safety. The notification of Immediate Jeopardy states as follows: F755 - Pharmaceutical Services: The facility failed to administer medications (Coumadin, Insulin, and Seizure medications) to 5 residents residing in South Hall 3. All facility residents have the potential to be affected by deficient practice. 1). Action: Medication Error Reports were completed for R#91, R#65, R#87, R#34, and R#37 were assessed for adverse events. There were no adverse events observed. The assessment results were shared with the nurse practitioner, and facility staff consulted the nurse practitioner to address the care needs of residents identified in the identified deficient practice. The Nurse Practitioner gave instructions to monitor residents' vital signs, including blood sugar, for residents as ordered and to call for concerns. An audit was completed to determine if other residents missed medications due to staffing shortages; a Medication Error Report will be completed, residents assessed, and medical provider notification will be completed for those resident identified and interventions as per medical provider instructions. Start Date: 04/24/2024 Completion Date: 04/24/2024 Responsible: Director of Nursing 2). Action: The Chief Nursing Officer (CNO) reviewed facility policy related to Staffing on 04/24/2024; no revisions were deemed necessary. As such, The CNO educated the facility Administrator and Director of Nursing on the facility policy as it relates to Staffing, which reads Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. Emphasis was placed on the need to ensure the facility had a sufficient number of Licensed Nurses (RNs/LVNs), Certified Medication Aides (CMAs), and Certified Nursing Assistants (CNAs) available 24 hours a day to provide direct resident care services and the need to ensure staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. The mode of education was a memo in the form of a copy of the policy and procedure and occurred in a face-to-face meeting on 04/24/2024. Comprehension was assessed via the teach-back methods and a one-sentence summary of actions to be taken in the event of staff shortages on 04/25/2024. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Chief Nursing Officer 3). Action: The facility Administrator and Director of Nursing educated the facility staff on duty of the facility Chain of Command when presented with staffing challenges. A copy of the facility Chain of Command - Organizational Chart - was posted on the employee bulletin board. The facility Leadership Team - Administrator and the Director of Nursing - directed the facility Licensed Nurses (RNs/LVNs) to contact the on-call staffing phone within the first fifteen (15) minutes of the start of each shift when call-ins and no-calls/no-shows were noted so that additional staff could be called to ensure sufficient number of Licensed nurses and certified nursing assistants available to provide direct resident care services and the need to ensure staffing numbers and the skill requirements of direct care staff as determined by the needs of the residents based on each resident's plan of care. If at any time a Licensed Nurses (RNs/LVNs) or Certified Medication Aide (CMAs) feel they cannot administer mediations as prescribed, he/she should follow the Chain of Command - contact the Assistance Director of nursing and then the Director of Nursing for assistance and further direction. Licensed Nurses (RNs/LVNs) will not be allowed to return to work until they receive this in-service. Licensed Nurses (RNs/LVNs) who do not physically attend the in-service training in person will be in-serviced via phone. During the in-service training and phone in-service, there will be a discussion (Question and Answering) to ensure understanding and competency. A post-test will measure learning. A demonstrable competency of 90% accuracy must be demonstrated before the start of their next shift.; those scoring less than 90% will receive immediate reeducation before being allowed to work. The mode of education was a memo in the form of a copy of the policy and procedure, which occurred in a face-to-face meeting that started on 04/24/2024. The education was added as part of the orientation for ongoing training of new hires, agency, and PRN (as needed) staff through a combination of employee training, employee monitoring, and reporting processes. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Administrator and Director of Nursing 4). Action: The facility Administrator reviewed the Facility Assessment as it relates to staffing needs for medication administration and direct care. The facility Assessment has been updated. Comprehension will be assessed via completing the staffing matrix to demonstrate an understanding of minimum staffing needs. The staffing matrix will be reviewed daily by the facility administrator and nursing director during the Monday- Friday morning meeting for actual and potential needs; and by the Weekend Supervisor on Saturdays and Sundays. The facility Administrator will provide additional education as deemed necessary to maintain ongoing compliance. Compliance checks will be completed during the monthly Quality Assurance and Performance Improvement (QAPI) process. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Administrator 5) Action: The facility Administrator Contracted with a Supplemental Staffing agency to provide Licensed Nurses (RNs/LVNs), Certified Medication Aides (CMAs), and Certified Nursing Assistants (CNAs) to ensure a contingency staffing plan is in place when the facility has call-ins and no-call/no-shows, and the facility staff cannot cover sufficient staffing needs. The facility Administrator educated the Director of Nursing on the need to call and request supplemental staff when there are call-ins and/or no-call/no-shows to ensure a sufficient number of Licensed Nurses RNs/LVNs), Certified Medication Aides (CMAs), Certified Nursing Assistants (CNAs) available 24 hours a day to provide direct resident care services - medication administration. The mode of education was in the form of a memo indicating when supplemental staffing should be requested. Comprehension will be assessed via completing the staffing matrix to demonstrate an understanding of minimum staffing needs. The staffing matrix will be reviewed daily by the facility administrator and nursing director during the Monday- Friday morning meeting for actual and potential needs; and by the Weekend Supervisor on Saturdays and Sundays. The facility Administrator will provide additional education as deemed necessary to maintain ongoing compliance. Compliance checks will be completed during the monthly Quality Assurance and Performance Improvement (QAPI) process. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Administrator and Director of Nursing 6). Action: The Chief Nursing Officer (CNO) educated the facility Director of Nursing on the facility policy and procedure as it relates to Administering Medications, which reads, Medications shall be administered in a safe and timely manner, and as prescribed. The emphasis was stressed that medication must be administered in accordance with the required time frame - within one (1) hour of their prescribed time. If a medication is not given at the prescribed time, the medical provider (Physician/Nurse Practitioner/Physician Assistant) must be contacted and consulted for further directions. The mode of education was a memo in the form of a copy of the policy and procedure, which occurred in a face-to-face meeting on 04/24/2024. Comprehension was assessed via the teach-back methods on 04/25/2024 Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Chief Nursing Officer 7). Action: The facility Director of Nursing educated Licensed Nurses (RNs/LVNs) and Certified Medication Aides (CMAs) on the facility policy and procedure as it relates to Administering Medications, which reads, Medications shall be administered in a safe and timely manner, and as prescribed. The emphasis was stressed that medication must be administered in accordance with the required time frame - within one (1) hour of their prescribed time. If a medication is not given at the prescribed time, the medical provider (Physician/Nurse Practitioner/Physician Assistant) must be contacted and consulted for further directions. The mode of education was a memo in the form of a copy of the policy and procedure and occurred in a face-to-face meeting on 04/24/2024 and 04/25/2024. Licensed Nurses (RNs/LVNs) and Certified Medication Aides (CMAs) not present will be in-serviced via phone. During the face-to-face in-service training and phone in-service, there will be a discussion (Question and Answering) to ensure understanding and competency. A post-test will measure learning. All nurses in-serviced, face-to-face or over the phone will not be allowed to work until they complete the post-test and demonstrate competency. A demonstrable competency of 90% accuracy must be demonstrated before the start of their next shift.; those scoring less than 90% will receive immediate reeducation before being allowed to work. The mode of education was a memo in the form of a copy of the policy and procedure, which occurred in a face-to-face meeting started on 04/24/2024. The education is added as part of the orientation for ongoing training of new hires, agency, and PRN (as needed) staff through a combination of employee training, employee monitoring, and reporting processes. Contact the Physician. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Director of Nursing and Facility Administrator 8). Action: The Director of Nursing (DON) will review the Point of Care (PCC) Medication Administration Dashboard daily Monday - Friday and the Weekend Supervisor on Saturdays and Sundays to ensure Licensed Nurses (RNs/LVNs) and Certified Medication Aides (CMAs) have administered and documented medication administration timely and proper notification of medical providers have been completed when any deviation from the facility policy and procedures. Discrepancies noted during reviews will be immediately addressed. Progressive disciplinary actions, which include additional training and leading to termination, will be taken as deemed appropriate. The facility administrator will review the QA audit tool on a weekly basis to ensure that the nurse managers (DON and Weekend Supervisor) follow the correction plan for four weeks. reviewed monthly during the QAPI meetings for the next three (3) months and will be ongoing as needed. Meeting minutes will be taken and maintained for twelve (12) months. Start Date: 04/24/2024 Completion Date: 04/25/2024 Responsible: Director of Nursing, Weekend Supervisor and Facility Administrator 9). Action: The facility Administrator conducted an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) to discuss the deficient practice identified and to review the Plan of Removal (POR) was completed on 04/25/2024 with the Medical Director. The Medical Director has reviewed and agrees with this plan. Action items will be reviewed monthly during the QAPI meetings for the next three (3) months and will be ongoing as needed. Meeting minutes will be taken and maintained for twelve (12) months. Start Date: 04/25/2024 Completion Date: 04/25/2024 Responsible: Facility Administrator Surveyors monitored the Plan of Removal for effectiveness as follows: On 04/26/24 the facility was monitored. Not all staff had been in-serviced. In an interview on 04/27/24 at 9:45 a.m. LVN O said she was assigned to South 1 Rooms 201 to 209. She said she still had three residents to give medications to in room [ROOM NUMBER] A and B, and room [ROOM NUMBER]. In an interview on 04/27/24 at 09:51 a.m. RN P said she was with a staffing agency. She said she was assigned Rooms 210 to 214. In an interview on 04/27/24 at 09:55 a.m. LVN R said he had one more resident to administer medications to, but would be finished on time. In an interview on 04/27/24 at 10:15 a.m., RN S said he was finished with the morning medication administration for the Flamingo Hall. In an interview on 04/27/24 at 10:17 a.m. LVN T said she had completed the morning medication pass for Swan Hall and Dove Hall. In an interview on 04/27/24 at 10:19 a.m. MA U said she has been in-serviced regarding medication administration and Chain of Command. She said if medications were going to be late she was to tell the charge nurse. Record review 'spot checks' of the MARs for each hall were conducted. Three random residents from each hall were reviewed. There were no concerns for the following halls: [NAME] Hall, Dove Hall, Flamingo Hall, Swan Hall, South 2 Hall, and South 3 Hall. Three residents on South 1 had their medications administered late. In an interview on 04/27/24 at 11:30 a.m. the DON was asked if any medications were administered late. She said she would check. At 1:31 p.m. she said three residents' medications were late, and the physician had been notified. In an interview on 04/27/2024 at 1:31 p.m. the DON said she had provided in-services for the agency nurses and the staff who came in today. She said the book (envelope) was at the north nurses' station. On 04/27/24 at 1:36 p.m. the surveyor picked up the two manila envelopes at the north nurses' station labelled in-service. Copies of the staff attendance sheet were made at that time. Record review of the envelopes revealed one contained in-service training for medication administration, protocol for calling off a shift, Physician notification for missed/late medications, chain of command, and general staffing policy review. Observation and interview on 04/28/24 at 6:40 a.m. revealed LVN Z and LVN L were at the north nurses' station. Both nurses said they had the in-services. Both nurses were able to explain what the in-services were about. In an interview on 04/28/24 at 7:25 a.m. LVN K said she had the in-services on Thursday. She was able to tell what the in-services were about. In an interview on 04/28/24 at 7:41 a.m. RN S said the north was short two CNAs. He said the nurses and the MA would fill in. In an interview on 04/28/24 at 10:05 a.m. LVN R said he had the in-services. He was able to tell what the in-services were about. In an interview on 04/28/24 at 10:10 a.m. LVN O said she has had the in-services. She was able to tell what the in-services were about. Record review of the binder entitled State Workbook 2024 Binder for POR revealed the following: Medication error reports for the four residents were completed. Safe Survey Questionnaires for all halls were completed. In-services for: Med Administration - Nurses, MA Notify MD - Nurses, MA Attendance/call off - all staff Chain of Command - all staff Staffing - Nursing mgt and Administrator A/N - all staff Contacting Administrator and/or DON - all staff Facility Assessment Tool updated 2 Staff agency contracts EMR Audit sheet - up to date Review of the binder revealed the facility was effectively implimenting the components of the POR. Record review of an Agency contract revealed the facility had contracted with the agency to provide nurses in case of staffing shortages. The contract was signed on 04/25/24. An Immediate Jeopardy (IJ) was identified on 04/24/24. The IJ template was provided to the facility on [DATE] at 5:35 p.m. While the IJ was removed on 04/28/24 the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy, because[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent falls for 1 (CR#1) of six residents reviewed for accidents, hazards, and supervision. - The facility failed to provide adequate supervision and proper bed mobility for CR#1 when the facility wound care doctor and wound care nurse failed to supervise resident while doing wound care causing CR#1 to fall from the bed and hit her head on 7/18/23 and be rushed to the hospital and life flighted to another local hospital by helicopter for an emergency procedure. -The facility failed to care plan and put additional services in place for CR #1 when she had her 1st fall on 7/18/23.CR #1 had a 2nd fall on 10/28/23 causing her additional pain and suffering. An Immediate Jeopardy (IJ) was identified on 11/7/23 at 2:39 p.m. While the IJ was removed on 11/11/23, the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of pattern as the facility continued to monitor the implementation and effectiveness of their plan of removal. These failures placed residents who are totally dependent on Staff for activities of daily living, supervision, and bed mobility at risk of not being adequately supervised, no adequate intervention, improper bed mobility, worsening of existing wounds, decline in quality of care, experiencing pain and death. Findings include: CR #1 Record review of CR #1's face sheet revealed original admission date to facility was 4/11/23 and was admitted on [DATE] and she died on [DATE]. Resident was diagnosed with pressure ulcer of sacral region, hypertension (high blood pressure), acute kidney failure (kidneys unable to filter waste products from the blood), anemia (a disorder in which red blood cells are destroyed faster than they can be made), end stage renal disease (kidneys stop functioning permanently leading to the need for dialysis or a kidney transplant to maintain life), legal blindness, hearing loss, major depressive disorder, seizures (a burst of uncontrolled electrical activity between brain cells (also called neurons or nerve cells) that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness) and insomnia (a sleep disorder characterized by difficulty falling asleep, or staying asleep). Record review of CR #1's undated care plan revealed resident was at risk for falls and injuries dated 4/22/23 and the interventions were to anticipate needs, provide prompt assistance, assure lighting is adequate and areas are free of clutter, encourage resident to ask for assistance of staff, encourage socialization and activity attendance as tolerated, ensure call light is in reach and answer promptly, therapy to screen resident and to evaluate/treat as indicated, and send to ER for evaluation on 7/19/23. Record review of CR #1's undated care plan did not reveal any additional significant interventions after fall on 7/18/23 and 10/28/23. Record review of CR #1's MDS signed on 10/31/23 revealed resident had a BIMS Summary score of 0 meaning severe cognitive impairment and she was dependent on staff and the helper does all of the effort. CR #1's bed mobility, transfer, walking, dressing, eating and/or swallowing score was 0 for the number of days restorative programs were performed. CR #1 did not have use of bed rails, trunk and limb restraint and no bed or chair alarms were used. Record review of Admission/readmission Tool effective date 7/26/23 revealed most recent admission 7/26/23 admitted from hospital with admitting diagnosis of fall, resident bedbound, bed mobility and transfers were total assistance and required 2-person assistance. Record review of CR #1's Side Rail Safety Evaluation effective date 7/26/23 revealed CR#1 requesting to have side rails raised while in bed for either comfort or safety, no cognitive impairments or change in level of consciousness, visually impaired, resident no able to get in and out of bed unassisted in a safe manner, has a history of falls, resident does not experience difficult with balance or trunk control, no reason to believe the resident may attempt to climb over the rails, rails are not being used as a restraint to prevent from getting out of bed, no diagnosis of seizures or experienced seizures in last 90 days, resident takes medication that would require safety precautions, resident able to demonstrate safe technique when using the side rail for positioning and mobility. Record review of CR #1's Local Hospital emergency room Records dated 7 /18/23 revealed, Call log 2:41 p.m., transfer center 7/18/23 at 2:53 p.m. and 7/18/23 at 3:14 p.m. Patient [CR#1] accepted to local hospital Neuro ICU .Chief complaint from nursing facility fall forward hitting face on floor while doing therapy. Patient [CR#1] awake and alert x3, Contusions to face, no altered level of consciousness per nursing home. Pain to left side of face, tenderness, pattern constant, confused times 4, distance of fall 0-3 feet from bed, hard floor, accidental, left face Trauma Secondary Assessment: Head/Neck general findings: Hematoma, swelling, abrasion, left upper and right upper extremity decreased motor function and left and right lower extremity decreased motor function, Trauma documentation respiratory rate 10-29 breaths per minute, Glasgow coma scale revised score 12. Neurological Assessment: not oriented to situation, not oriented to time, consciousness level: Alert, history of blindness in right and left eye, neurovascular check was poor 2 in all areas. Reexamination /Reevaluation : .interpretation of capillary transit time heterogeneity (CTH), patient has diffuse vasogenic edema results from disruption of the blood-brain barrier, allowing protein-rich fluid to accumulate in the extracellular space and hydrocephalus (a neurological disorder caused by an abnormal buildup of cerebrospinal fluid in the ventricles (cavities) deep within the brain) .Procedure; Critical Care Time: [40 ] minutes. The patient presents with an illness or injury that acutely impaired one or more vital organ systems. There was a high probability of imminent or life-threatening deterioration in the patient's condition during their evaluation in the ED. This is the total time spent evaluating, coordinating, managing, and providing care to the critical patient, as well as time spent in documenting such activities. This time is exclusive of time required to perform procedures required during patient management. Impression and Plan Diagnosis Vasogenic brain edema Working, Medical) Hydrocephalus, Working, Medical) Hypertensive emergency, Working, Medical) Accidental fall, Working, Medical) Plan Condition: Critical. Disposition: Transfer to other location: Time: 07/18/2023 3:12 p.m., Facility name: local hospital neuro ICU accepted by: Doctor. Transfer on 7/18/23 at 3:59 p.m.: Reason for transfer: higher level of care. Service Needed: Neurosurgery, patient in system to another local Hospital, condition on Transfer: Stable, Transported: ID bands in place, on Cardiac monitor, via helicopter. Record review of Local Hospital emergency room Records dated 10/29/23 at 6:59 a.m. revealed: Check in time 10/28/23 at 8:46 p.m., Chief complaint: Patient from Nursing home fall out of bed per staff at around 4:30 p.m., Patient was found on the floor by staff, no visible injuries, patient on hospice at this time and is DNR, family wanted patient checked out- no thinners, patient at baseline mentation. Trauma scores: Respiratory Rate: 10-29 breaths per minute, systolic blood pressure is greater than 89, Glasgow Coma Revised Score: 12, Mechanism of injury: fall from bed, distance of fall: 0-3 feet, fall impact: hard floor. Diagnosis from visit: fall, head injury and hyperkalemia. Medical history: blindness, hypertension, seizures, vasogenic brain edema and acquired hydrocephalus, aphasia at baseline, Posterior reversible encephalopathy syndrome, healthcare associated pneumonia, and chronic arterial ischemic cerebrovascular accident (stroke). Record review of facility incidents from 8/1/23 to 11/1/23 dated 11/1/23 revealed CR #1's fall was not listed. Record review of CR #1's progress notes dated 7/18/23 at 12:05 p.m. revealed, at 11:10 a.m., during rounds with NP, treatment nurse reports that resident [CR#1] fell off bed and hit head on nightstand. Resident [cr#1] is immediately assessed, bruising noted to left eyes .Resident [CR#1] denies pain and due to dx of legal blindness, resident only reports that she fell out of bed and hit head. Resident denies pain at this time. Alert and oriented x 3. 11:16 a.m. NP orders to send resident out via emergency transport. 911 called at 11:18 a.m. and arrived at 11:22 a.m. Resident [CR#1] is transported to local hospital via stretcher 11:29 a.m. [CR#1's family member] is contacted at approximately 11:30 a.m. of condition and transfer to hospital for CT scan. During this time [CR#1's family member] states while crying, I am looking at recording, oh my god, whoever is in white coat is just standing there not holding mom to make sure she does not fall. this nurse apologizes for any wrong doings on that person behalf. Don, ADON, administrator made aware. Record review of CR#1's progress notes dated 07/26/2023 at 6:49 p.m., written by RN B for Admit/Readmit resident returned to the facility from local hospital at 3:40 pm. She arrived on a stretcher with 2 EMS attendants. She is Alert and oriented x3 and legally blind. She receives Hemodialysis (a treatment to filter wastes and water from your blood) in house Monday thru Friday through her right. subclavian access. She was placed in a new bed with air mattress and 1/4 side rails for safety. Fall precautions are in place. Bed in low position and call light in reach. In an interview on 11/1/23 at 10:25 a.m. with CR #1's family member she stated she had 2 videos' where the facility dropped CR #1. CR #1's family member stated she did not want to disclose the video's. She stated the first time the facility dropped CR#1 was when they were doing wound care and the Wound Care Nurse saw CR#1 was hanging off the side of the bed and the Wound Care Doctor walked away from CR#1 while CR#1 did not have bed railing. She stated the Wound Care Nurse turned around to do something and CR#1 fell out of the bed on July 18, 2023. CR#1's family member stated CR#1 was sent to the emergency room at a local hospital and they life flighted her to another local hospital because there was swelling on CR#1's brain and they needed a surgeon. CR#1's family member stated the incident was not investigated by the State. CR#1's family member stated when CR#1 was readmitted to the facility she requested the facility to give CR#1 a bed with rails and they said they did not have a bed with rails. CR#1's family member stated CR#1 was blind, could not feed herself, bed bound and CR#1 scoots. CR#1's family member stated the facility always had CR#1 up way to high. CR#1's family member stated for the last fall on 10/28/23 CR#1 was sitting way to high up in the bed and at this time CR#1 could not speak and the staff that was in the room left with CR#1 sitting all the way up like she was sitting upright in a recliner and CR#1 fell. She stated she had a number for a can and 2 days prior to her mom's last falling CR#1 was about to fall and CR#1's family member called the CNA, and she heard the CNA by phone drop what she was doing and ran to CR#1 and CR#1 was already hanging from the bed. CR#1's family member said then 2 days after that CR#1 was on the floor and during shift change an aide (unknown name) came in and found CR#1 on the floor. In an interview on 11/1/23 at 12:20 p.m. with the Administrator she stated she received a call from the facility staff saying CR#1 fell out of bed on 10/28/23 and that CR#1's family was at the facility, and they were threatening the nurse saying that if the nurse walked in the room, they (CR#1's family) would end up in jail. The police were in the building, and they had the nurse in a room by herself for her protection until CR#1's family left the building. The Administrator stated CR#1's family wanted CR#1 sent to the hospital even though she was hospice. She stated the nurse called hospice and let them know they were sending CR#1 out the hospital to be checked out. The facility nurse called the CR#1's family too. The Administrator stated CR#1 went to the hospital on [DATE] and they sent her right back. The Administrator stated on Sunday,10/29/23 she came to look at CR#1 and CR#1 looked bad, but CR#1 was in isolation because she had Candida auris. The Administrator stated she moved CR#1 to a private room so the family could visit, and that nurse would not have to interact with the family. The Administrator stated she saw CR#1's family again on Monday, 10/30/23 and CR#1's family stated they had it on camera that CR#1 edged herself out and fell out the bed. The Administrator stated the facility nurse was agency and she asked for the nurse not to return. She stated CR#1 passed away on Monday, 10/30/23. In an interview on 11/1/23 at 12:58 p.m., CNA A stated CR#1 was blind, and CNA A would sit with CR#1 to feed her. CNA A always wanted more food, went to dialysis every other day, then every day. CNA A stated they always had to watch CR#1 and she would scratch her face, slide and would be in the bed sideways. She stated CR#1 went to the hospital on [DATE] and when she came CR#1 was not talking anymore and then she started talking again. CNA A stated on Saturday, 10/28/23 there was a facility function, and she brought her kids to introduce her to CR#1 and she went to check on her and found CR#1 slouched over and CNA A laid CR#1's head back a little more and repositioned her and left to do the facility function. CNA A stated she heard a few hours after she left the facility CR#1 fell. CNA A stated she did not know how CR#1 fell out of the bed. In an interview on 11/1/23 at 1:10 p.m. with LVN B she stated on 10/28/23 she is an agency nurse went on break and came back and the shift was changing with the CNAs. She stated a CNA (unknown name) was doing rounds and the CNA found CR#1 on the floor and another nurse (unknown name) on South Hall responded to the fall initially and was assessing CR#1. LVN B stated she had to get her equipment and when she walked in CR#1's room the facility staff had CR#1 on the floor in supine position (face up) and they lifted her up in the bed. LVN B stated the facility staff stated CR#1 did not have injury. LVN B stated she did vitals 81/84 on most of CR#1's fingers and LVN B put the oxygen on CR#1 and monitored her. LVN B stated she made sure CR#1's oxygen came back with 97 to 98. LVN B stated she called the on-call number for hospice and said CR#1 fell and she did the vitals and Hospice said they would send out a nurse to assess CR#1 and LVN B told Hospice CR#1 needed oxygen and that she needed a concentrator in her room. LVN B stated she called CR#1's family and said CR#1 had a fall and said she had the vitals. LVN B stated CR#1's family member started yelling saying that's why she wanted side rails on CR#1's bed and CR#1's family member hung up the phone and both CR#1's family members walked in and one of them stormed past LVN B and the other family member came towards her and a cop came in and said he was here to investigate. LVN B stated the police officer asked her about how CR#1 fell out the bed and CR#1 was alert but was not verbal. LVN B stated CR#1's family member stated LVN B better not be out here because she is going to jail today so the police officer put her in a room and the whole time CR#1's family member was threatening LVN B. LVN B stated the vitals were supposed to be taken for neuro checks, but she could not do them. LVN B stated she contacted the ADON and DON and told them and they contacted the Administrator and CR#1's family was escorted out. LVN B stated CR#1's family was upset CR#1 was not sent out to the hospital. LVN B stated the only time they send hospice patients out is because of broken bones and there was nothing she could send CR#1 out for, and she needed a Doctor's order. LVN B stated she talked to the Administrator and was told to send CR#1 out to the hospital because the family requested it. LVN B stated this all happened at 430 p.m. and by 5 p.m. she was already in contact with CR#1's family and hospice was documenting everything. She stated by 7 pm the Administrator said go ahead and send CR#1 out based on the family's request. LVN B stated when the police asked CR#1's family to see the video he said, it looked like CR#1 just popped out of bed. LVN B stated only 18 minutes had gone by since the time CR#1 hit the floor to the time they saw her do vitals. LVN B stated when she saw the video, CR#1 had just popped out the bed. LVN B stated the first text went out at 4:05 p.m. and CR#1's vitals were in progress. LVN B stated maybe hospice can get bolsters for CR#1 and the DON said the facility could not do rails. LVN B stated she was not able to do neuros at that time due to CR#1's family threatening her. She stated when she got in CR#1's room, the bed was medium low, but the bed was flat and that it may have been a 30-degree angle if that. LVN B stated she did not understand how CR#1 fell out the bed. LVN B stated she knew the CNA's were doing rounds, but she does not know how long it had been since someone went to check on CR#1. In a record review and interview on 11/1/23 at 1:50 p.m., the DON stated she saw the video of CR#1's fall on 10/28/23 and it looked like CR#1 plopped out of the bed and before the fall, CR#1 was declining she refused to eat and refused dialysis. The DON stated she was not here in July when CR#1 fell and did not come to the facility until the end of August so she could not say what happened with the fall in July. Record review of CR#1's hospital notes revealed CR#1 was in the hospital from 7/18-7/26/23 for the fall. The DON stated the hospital discharge note says CR#1 had brain swelling (hydrocephalus) and she needed an LP (Lumbar puncture) procedure. The DON stated she probably would have reported the incident to the State. In an interview on 11/1/23 at 2:15 p.m. with the Administrator she stated the Wound Care Doctor saw CR#1 falling and she stepped back and put her hands in the air and let CR#1 fall when the wound care nurse walked away. The Administrator stated she fired the Wound Care Doctor that day and she did not return to the facility. In an interview on 11/1/23 at 2:27 p.m. with the NP she stated when CR#1 was taken out in July for a fall CR#1 had sent her for a head CT. She stated the CT was negative and LP is lumbar puncture. The NP stated the CT was negative with no bleed on her brain. CR#1's hospital diagnosis was Hydrocephalus and metabolic encephalopathy. In an interview on 11/2/23 at 11:24 a.m. with the Wound Care Nurse he stated on 7/18/23 the Wound Care Doctor CR#1 on her side. The Wound Care Nurse stated when he entered CR#1's room CR#1 was laying on her right side facing the window and the Wound Care Doctor was standing on the left side of CR#1's bed at the foot of the bed facing CR#1. He stated he did wound care set up and CR#1's wound was already exposed because the Wound Care Doctor had already removed the other dressing. He stated he had to throw something into the trash, so he turned away from CR#1 to throw the trash away. The Wound Care Nurse stated when he turned, he could hear CR#1 starting to roll over and when he turned around CR#1 had already fallen from the bed and the Wound Care Doctor was still facing the patient at the foot of the bed. He stated it looked like the Wound Care Doctor just stood there and watched CR#1 fall. He stated he could not remember what she said, but he was very panicked and assessed CR#1 and called for a CNA to help to pick CR#1 up and placed her back in bed. The Wound Care Nurse stated CR#1 hollered out Awhh or Ouch. He stated the Wound Care Doctor saw CR#1 hit her head on the nightstand. The Wound Care Nurse stated CR#1 was taken out to the hospital by 911. The Wound Care Nurse stated he assessed CR#1 and so did the nurse on the floor (unknown name). He stated CR#1 did not have any visible injuries and no bleeding. In an interview on 11/2/23 with CNA B she stated on 7/18/23 she heard a loud crash while she was in the next room giving someone a bath, so she stopped what she was doing and came to assist CR#1. She stated she was agency staff and when she came into CR#1's room there were 2 people (Wound Care Doctor and Wound Care Nurse) in the room with CR#1 and CR#1 was on the floor. CNA B stated CR#1 was on the floor on the side of the bed and there was a nightstand on the side of the bed, and she did help to put CR#1 back in the bed. CNA B stated the Wound Care Nurse and Wound Care Doctor were just looking at CR#1 and no one was saying anything, and she guessed CR#1 had already been assessed. CNA B stated they used a draw sheet under CR#1 rolled her from side to side and lifted CR#1 up and after that CNA B left the room. In an interview on 11/3/23 at 11:38 a.m. with the Wound Care Doctor she stated she went in to take care of CR#1 and she had requested several times that the facility get a bed that will keep CR#1 from falling. The Wound Care Doctor stated she asked for rails several times. She stated she told the Wound Care Nurse that was working with her, and the Administrator and the Administrator said that those kinds of beds were not allowed but she saw other patients with beds like that. The Wound Care Doctor stated the Wound Care Nurse put the patient (CR #1) in a position where CR#1 could be taken care of. She stated when she came into the room CR#1 fell. The Wound Care Doctor stated the Wound Care Nurse went to call for help and she got a CNA, but she called her, and she lifted CR#1 and the CNA lifted CR#1 in the bed and they took her blood pressure and stood by her until the ambulance came. She stated CR#1 was taken to the ambulance immediately. The Wound Care Doctor stated she did not turn CR#1 and that the Wound Care Nurse turned CR#1 and went out to get the medicine to treat CR#1. The Wound Care Doctor stated the Wound Care Nurse went out of the room and CR#1 fell. She stated she went in with the Wound Care Nurse and, they turned CR#1, and the Wound Care Nurse went out to get CR#1's medicine. She stated no one assisted the Wound Care Nurse in turning CR#1 because CR#1 was very small. She stated she did not remember who removed the bandages. The Wound Care Doctor stated when CR#1 fell she was leaving the room, but she heard CR#1 fall so she turned to see what the noise was, and she had fallen. The Wound Care Doctor stated she called the NP to come and get CR#1. The Wound Care Doctor stated she did not see CR#1 going down, she just heard the noise of something hitting the floor. She stated CR#1 was turned to her side and CR#1's face was toward the right side facing the window. The Wound Care Doctor stated she was headed to the door, but this was a vague memory and she thought she was going to check on the Wound Care Nurse outside. She stated she did not remember bolsters or pillows around CR#1, and she did not think CR#1 had a fall mat. The Wound Care Doctor stated she did not remember how high CR#1's bed was. She stated she had not touched CR#1 at all and did not even do her wound that day. The Wound Care Doctor left the facility afterwards. She stated she was hired as a consulting physician and the facility asked for her training when hired as a consulting physician. She stated she knew what to do when a resident falls because doctors are trained in positioning residents. The Wound Care Doctor stated the facility asked for her medical training, but those trainings come with wound care. She stated the Administrator told her she did not want her to work at the facility and she agreed that she did not want to work at the facility. She stated the Wound Care Nurse was not in the room at all and neither was she stated no one was in the room with CR#1. The Wound Care Doctor stated she did not remember if CR#1 was at the edge of the bed. In an interview on 11/3/23 at 12:04 p.m. with the Administrator she stated because The Wound Care Doctor is a doctor the facility did not do training with them. She stated the facility got the doctor's license and their credentialing packet and that includes board certifications, etc. In an interview on 11/3/23 at 12:18 p.m. with the Wound Care Nurse he stated when he walked in CR#1's room CR#1 was already on her side and the dressing was already removed and the Wound Care Doctor was standing at the foot of the bed facing CR#1. He stated he was not there because he was gathering wound care supplies at the cart, so the Wound Care Doctor went ahead to inspect the wound. He stated the Wound Care Doctor had already looked at CR#1's wound and he was going to perform the wound care and move on to the next patient. The Wound Care Nurse stated CR#1 was laying on her right side facing the window and the brief was open and the dressing was removed, and the wound care doctor was standing at the foot of the bed facing CR#1. He stated CR#1's bed was not very high like maybe up to his elbow. The Wound Care Nurse stated CR#1 did not have a fall mat, he could not remember if CR#1 had rails or not when the incident occurred. He stated CR#1's head was on a pillow; she was laying on her side and the blankets were pulled back. He stated there were no bolsters or additional pillows for positioning. The Wound Care Nurse stated he started performing the wound care and he had his left hand on CR#1 to stabilize her and he was using his right hand to clean the wound with the gauze and he went to turn to throw the gauze away and he heard CR#1 begin to fall and the blankets were rustling and he turned and CR#1 was already on the ground and started screaming OW. He stated once he was in the room, he did not have to leave the room to do anything. The Wound Care Nurse stated after he cleaned CR#1's wound he took his hand off CR#1 and turned to his side to throw trash away and he could hear CR#1 falling. The Wound Care Nurse stated the Wound Care Doctor was standing at the side foot of CR#1's bed facing CR#1 and the Wound Care Doctor could have reached out to touch CR#1 if she wanted to. He stated he walked around CR#1's bed to assess CR#1 and the Wound Care Doctor went to get a CNA to assist with getting CR#1 into the bed. He stated they got CR#1 assessed and got her in the bed and the Wound Care Doctor talked to the NP. In an interview on 11/3/23 at 12:56 p.m. with the NP she stated the Wound Care Doctor walked down the hall with the Wound Care Nurse and the Wound Care Doctor said CR#1 would need a head CT and she said yeah she fell, hit her head and needs a head CT. The NP stated CR#1 was very confused and she sent CR#1 to the hospital right away 911 because CR#1 had a head strike. She stated she did not know the events that occurred. The NP stated CR#1's family came to her and said they saw the Wound Care Doctor in CR#1's room and the Wound Care Doctor put her hands up when CR#1 fell. The NP stated the Wound Care Doctor did not tell her what happened, but she found it odd that she did not tell the NP what happened. The NP stated the next day the Wound Care Doctor no longer worked at the facility. She stated the Wound Care Doctor specifically told her that CR#1 would need a head CT and the Wound Care nurse was standing right next to her when she said it. She stated she was a NP, and she was a bedside nurse before becoming a physician, and as a bedside nurse and was a CNA first so she has a clear understanding of bedside care. The NP stated the Medical Doctors have a vast knowledge of the body with 13 years of intense study, but their bedside manner is more like studying the disease. She stated she did not feel like Doctors [NAME] in on when they care for the patient like studying you should watch this position and do that. The NP stated in reference to wound care they are not trained specifically for bedside positioning. The NP stated CR#1 had no herniation syndrome and there were superficial injuries in the left occipital region without underlying fracture. In an observation on 11/3/23 at 2:10 p.m. of wound care with the Wound Care Nurse revealed the Wound Care Nurse raised the random resident's bed to a high position. The Wound Care Nurse turned the resident using the bedsheet and turned the resident to his side and said he should stay on his side and told him to stay that way until he came back with the wound supplies. Observation revealed the Resident was left holding on to a grab bar on the wall. The resident said alright and asked the Wound Care Nurse did he park way out in the parking lot. Observation revealed the Wound Care Nurse did not bolster or use any kind of support for the resident to prevent him from falling. Observation revealed the Wound Care Nurse left the room and went to gather all of his wound care supplies while the resident was left holding on to the grab bar and his bed was positioned up high with no support around him. The Wound care nurse came back into the room and told the resident he needed to wash his hands and grab some gloves and the resident asked him why he had to wash his hands first if he was going to get gloves. The Wound Care Nurse left the resident to wash his hands and get gloves and he was observed leaving the room again to go back to his supply cart. Observation of the Resident appeared he got tired of holding the grab bar on the wall and he let go of the bar and whispered, oh boy and grabbed the bar back again. The Wound Care Nurse was observed going back outside of the residents room again to the wound cart and came back into the room. The wound care nurse was observed performing wound care and the Resident asked him how long did he have to lay like this. The Wound Care Nurse told the resident not too much longer and he continued with wound care. Observation revealed once the Wound Care Nurse finished wound care, he left the resident in the same position and went to wash his hands and the resident asked the Wound Care Nurse if he could turn back and the Wound Care Nurse said yes, and the resident said the Wound Care Nurse did not tell him he could. Resident was observed turning himself and the Wound Care Nurse brought the bed in low position to the floor and raised the resident's head. The Resident was observed to have upper rails on his bed. In an interview on 11/7/23 at 11:15 a.m. with the ADON she stated the MDS Nurse does the comprehensive care plans, but nursing will do care plans. The ADON stated they had a care plan meeting with CR#1's family and the SW, DON, ADON, Administrator and NP were there. She stated they talked about CR#1's medical condition. She stated CR#1 was able to make her own decisions and if she did not want to do dialysis she did not have to. She stated the MDS nurse only came to the facility 2 or 3 times a week and she was here yesterday. The ADON stated whenever there is an incident or accident the DON and ADON take care of the care plan. She stated they ask daily about falls in standup and they have a sheet where they have to write down the falls and talk about the interventions and it gets care planned by the ADON or DON. The ADON stated CR#1 was sent out to the hospital on 7/18/23 so it would not have been care planned until she returned back from the hospital. She stated they talked about the 10/28/23 fall and they talked about it in the morning meeting on Monday, 10/30/23. She stated the DON was going to care plan the fall. The ADON stated on 10/28/23 she spoke with the charge nurse and told her to put 2 fall mats in place on each side of the bed. She stated she also asked her to leave the head of her bed back because when she was leaning, she would slouch up so that is why she told her to change the position of the bed and she told the charge nurse where the fall mats were. The ADON stated she could have sworn that they did have a fall mat after the first fall on 7/18/23 and then she went out to the hospital again and the fall mat left again when [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure each resident was free from abuse and neglect for 1 (CR #50) of 7 residents reviewed for abuse and neglect. -The facility failed to ensure CR #50, was free from abuse when she was grabbed and hit by CNA F, causing bruising to the face, torso, and left arm. -RN H and CNA G failed to follow appropriate procedure and notify the facility's abuse coordinator and administrator immediately of knowing an incident of abuse involving CR #50 that occurred on 07/19/2022 and reported on 07/25/2022. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 03/01/2023. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of serious harm from possible abuse and neglect. Findings included: Record review of the face sheet for CR #50 dated 02/08/2023 revealed a [AGE] year-old female admitted to the facility on [DATE] and discharged on 08/05/2022. Her diagnoses included hypersensitive, heart disease with heart failure, muscle wasting, lack of coordination, dementia, Alzheimer's disease, rheumatoid arthritis, and depression. Record Review of CR #50's Annual MDS assessment dated [DATE] revealed a BIMS score 3 out of 15; indicating residents' cognition had severe impairment. Record review of CR #50's undated care plan revealed the following: -Focus: Difficulty in making decisions due to dx of dementia. -Goal: Make a decision regarding clothing choice through review date 10/30/22. Make a decision regarding activity preference through review date of 10/30/22. -Intervention: assess and document cognitive status frequently. Notify physician of any abnormal findings. Provided consistent direct care givers on all shifts. Limit choices to minimal number. Provided opportunities for resident to make simple choices with ADL care. Interact with resident in non-judgmental manner at all times. -Focus: resident can get resistant and combative at times. -Goal: resident will not show any increased episodes of combative behavior 10/30/22. -Intervention: approach resident warmly and positively. Provided consistency with direct care providers on all shifts. All resident opportunity to make choices and participate in cares. Do not argue with resident. Do not offer assistance for activity before resident attempts activity on own. Activities to evaluate and provide appropriate activities recommendations for resident. Praise resident for demonstration desired behavior. Administer behavior medications as ordered by physician. Record Review completed of the SSA Intake ID 366245 dated 07/25/2022 alleged that CNA F admitted she hit CR #50 in the face after resident acted out on 07/19/2022 at 9:00pm. The incident was witnessed by CNA G who reported the incident to RN H. Record Review completed of the SSA Intake ID 367563 dated 07/30/2022 alleged that unknown staff (CNA F) assaulted CR #50 on 07/25/2022 leaving bruises on the resident's face, chest, and arms. Law enforcement was called, and the incident was assigned to a detective. Record review of PIR associated with Intake ID 366245 dated 07/25/2022 revealed that CNA G witnessed CNA F hit CR #50 on 07/19/2022. CNA G reported the incident to RN H on 07/19/2022. RN H assessed CR #50 on 07/19/2022 to have no injuries or pain. SBAR completed on 07/19/2022 with notifications to physician and responsible party. Neither RN H or CNA G reported the incident to ADMIN B, and ADMIN B was not made aware of the incident until 07/25/2022. CNA F was contracted staff and did not return to the facility after the incident on 07/19/2022. On 07/25/2022 resident safety checks were completed with no concerns for abuse/neglect. On 07/25/2022 resident received skin assessment, met with social worker, and referred for psychological consult. On 07/25/2022 residents on the hall of CR#50 received safety checks with no concerns for abuse/neglect. On 07/25/2023 staffing agency was notified of the incident. On 07/25/2022 facility completed in-service on abuse/neglect, reporting, and dementia care. Record review of CR#50 head to toe assessment dated [DATE] with bruising to right side of the face, torso, upper left arm, and left wrist. Record review of social work progress note dated 07/25/2022 that revealed that social worker met with resident who was not able to communicate what happened. Social Worker referred for psychological consult. Record review of CR# 50 psychological evaluation dated 07/26/2022 with conclusion that resident did not appear to be experience trauma related to the incident. Record review on 02/09/2023 at 10:00am of local police report 22-007400 obtained by SSA dated 07/25/2022 completed by Officer I revealed that local police responded to the facility on [DATE] read in part I could not ask CR #50 any questions due to her mental capabilities. CNA F gave me a verbal and written statement. CNA F stated this incident occurred on Tuesday 07/19/2022 The patient got combative and hit CNA F on the right arm and her right breast. I CNA F had a reflex and pushed her hand back to her face and told her to stop. CNA G stated that CR #50 can be combative and they were starting to change CR #50, and CR#50 hit her partner CNA F and CNA F slapped the resident after. CNA G was shocked and asked why would you do that? After that, CNA G reported the incident to the nurse, which was RN H . Officer I spoke with the County District Attorney office who advised to forward the report to CID for further investigation. Interview on 02/09/2023 at 2:13pm with the DON, she said that she could not remember all the details of the incident involving CR #50. She said that one CNA (CNA G) witnessed a contractor CNA(CNA F) hit the resident. She said that the CNA (CNA G) that witnessed the incident reported it to Nurse(RN H). She said CR # 50 was observed with a bruise on her face by staff whose name she did not remember(CNA J and RN I), and it was believed the contactor CNA (CNA F) caused the bruise. She said that staff involved (CNA G and RN H) did not report the incident timely, so the investigation was delayed. She said that staff who observed the bruising after the incident (CNA J and RN I) reported the information timely, but they did not see the bruising until days later. She said that staff(CNA G and RN H) should have reported the incident immediately to ADMIN B or her. She said that ADMIN B completed the investigation once the incident was made known to her. She said that staff were in-serviced on abuse, neglect, and reporting. She said that the CNA (CNA F) did not return to the facility after the incident. She said that if staff do not report abuse timely it could put residents at risk of the abuse continuing. Interview on 02/09/2023 at 2:26pm with Restorative Aid, he said that he vaguely remembered incident with CR#50. He said a CNA whose name he did not remember saw a contractor CNA whose name he did not remember hit a resident on date that he did not remember. He said that all staff that provided care to the resident after the incident were interviewed by the Admin B because it was not reported to the DON or Administrator at the time. He said that when he provided care the day after the incident the resident did not have a bruise to her face but later developed bruising to her face. He said that all staff received training for abuse/neglect to include reporting before and after the incident. He said that he has not observed abuse/neglect while working at the facility, but if he did it would be reported to the administrator immediately. In a phone interview with CR #50's Responsible Party on 02/09/2023 at 02:40PM, she said that CR #50 was taken out of the facility after a contractor employee beat the shit out of CR #50. She said that CR #50 got combative with a CNA, and the CNA assaulted CR#50. She said that CR #50 has dementia and that was no excuse for the CNA to assault CR #50. She said that the last time that she spoke with the local police department she was told that they were waiting to see if the district attorney would accept charges against the CNA. She said that she did not feel the facility acted fast enough when investigating the abuse of CR #50. In a phone interview on 02/09/2023 at 2:50pm with ADMIN B, she said that she has not worked at the facility since 12/09/2022. She said that she was not notified of the incident with CR #50 until days after the incident took place because the staff involved did not report it to her timely. She said that as the Administrator and Abuse Coordinator she should have known about the incident immediately, and if she was not present the DON should have been notified. She said that other staff (CNA J and RN I) saw CR #50 with a bruise to the face that was fading days after the incident, she was notified immediately, and she started an investigation. She said that CR #50 had a skin assessment and there were fading bruises to other parts of her body that she did not remember the location. She said that during the investigation she found out that a contractor CNA (CNA F) hit the resident in the face, the incident was witnessed by another CNA (CNA G), and then the incident was reported to a nurse (RN H). She said that when she did get the information she started the investigation, reported to SSA, and contacted the local police department. She said that staff were in-serviced on abuse, neglect, and reporting the same day she found out about the incident. She said that risk of not reporting abuse timely is the abuse could repeat and happen to other residents. She said that the contractor CNA (CNA F) worked at the facility the day of the incident did not return. She said that CNA F's license was not referred as she did not have enough identifying information since the CNA was contracted. Interview on 02/09/2023 at 3:46pm with RN H, she said that the CNA G came to her on the 07/19/2023 at the end of the shift and told her that CNA F hit CR #50. She said that CNA F was a contractor and had already left the facility. She said that she assessed the resident, and she did not have injuries, express pain, and the resident seem fine. She said that ADMIN B was the abuse coordinator at the time, and she did not report the incident to ADMIN or the DON. She said that she did not know what she was thinking that day, and she thought that because the resident was okay, she did not need to report it. She said that CR#50 developed a bruise later. She said that she had previous training on abuse, and the incident should have been reported immediately, and she felt bad afterwards. She said that the risk was that the abuse could continue and could happen to other residents. In a phone interview on 02/09/2023 at 3:55pm with CNA F, she said that in July of 2022 during care CR#50 spit on her, hit her, and grabbed her. She said that she was trying to block the resident from hitting her and she hit CR#50 in the face with the back of her hand. She said that CR#50 had a strong grasp on her arm, and she had to physically remove the resident's hand from her arm. She said that during the incident the resident had backed her up against the wall in the room, hit her multiple time, and she had to block resident from hitting her. She said that she only remembered that she hit the resident the one time, and she had to pull the residents hand from her arm. She said that she did not report the incident to anyone at the facility. She said that there was another CNA in the room that reported the incident. She said that she was trained on abuse and neglect at the start of her shift, she only worked at the facility the day of the incident, and she never returned to the facility. She said that she was contacted by law enforcement as part of their investigation. She said that she was told by law enforcement that CR#50 had multiple bruises and the bruises observed were too old to be caused by her. In an interview on 2/10/2023 at 10:49am with DON, she said that during the time of the incident contracted staff received training to include abuse/neglect on the contractor online portal prior to accepting the shift. She stated that in October of 2022 contracted staff received training on the portal prior to accepting a shift and when they arrived at the facility prior to starting the shift. She said that the staffing coordinator, night/weekend supervisor, or her complete the training with contracted staff. She said that contracted staff can not sign in for a shift at the facility until the training is completed. She stated that the training topics are kept at the nurse's station next to the sign in/out sheets. In an interview on 2/10/2023 at 10:55am with Staffing Coordinator, she said that she has worked at the facility since 2019, and she did not start her current position until October of 2022. She said she was unsure of how contracted staff were trained in July of 2022. She stated that all contracted staff received training to include abuse/neglect on the contractor online portal prior to accepting the shift. She stated that the portal will not allow her to schedule contracted until the training has been completed. She said that the DON, night/weekend supervisor, or her complete the training with contracted staff once they arrive to the facility before starting a shift. She said that contracted staff can not sign in for a shift at the facility until the training is completed. She stated that contracted staff have a K next to their name on the sign in/out sheet for KARE. She stated that the facility had contracts with Shift Key and KARE, but as of December of 2022 the facility only uses KARE for CNA's, and it is rare they contract for RN or LVN staff. She stated that the training topics are kept at the nurse's station next to the sign in/out sheets. In an observation on 02/10/2023 at 11:00am, training topics were observed at the nurse's stations next to the sign/out sheet which included topic on abuse/neglect and reporting. In an observation of the sign in/out sheet it was revealed that CNA L was the only contracted staff scheduled for the day. In an interview on 02/10/2023 at 11:05am with CNA L, she said that she was contracted staff with KARE, and started accepting shifts at the facility sometime in December of 2022. She stated that she had been trained on abuse/neglect to include reporting. She was knowledge on types of abuse/neglect, and that all abuse/neglect should be reported to the DON or ADMIN immediately. She denied that she has observed abuse/neglect of residents while working at the facility. She stated that there is training that you must complete on the contractor portal before you are scheduled which includes abuse/neglect. She stated that when she arrives to a shift, she receives training with either the DON or staffing coordinator before she can sign in for a shift. She stated that she has the same training every time she accepts a shift at the facility. Interview on 02/10/2023 at 11:53am with the ADMIN, she said that she was the current abuse prevention coordinator. She said that if staff witnessed abuse the incident should be reported immediately to the Administrator and DON. She said that the incident should be reported to the SSA within two hours no later than 24 hours. She said that the risk of not reporting abuse timely was it could expose other residents to potential abuse or harm. She said that she was unsure of how ADMIN B ensured that contracted staff were trained. She said that currently contracted staff receive training prior to accepting the shift on the contractor portal and training when they arrive to the facility with either the DON, staffing coordinator, or night/weekend supervisor. She said that the facility is only using the contractor agency KARE. She said she was not aware of QAPI Meeting to be held or PIP completed after the incident took place. In a phone interview on 02/10/2023 at 2:06pm with Officer J, he said that law enforcement case # 22-007400 was transferred from Officer I to CID an assigned to him. He said that the CNA (CNA F) involved admitted to hitting the resident once, and it was witnessed by other staff. He said that by the time the investigation started the bruises observed were old. He said that he will submit evidence to the grand jury for criminal charges. In an observation on 02/27/2023 at 12:00pm, training topics were observed at the nurse's stations next to the sign/out sheet which included topic on abuse/neglect and reporting. In an observation of the sign in/out sheet it was revealed that contracted staff CNA L, CNA M, CNA N, and CNA O were scheduled for 3:00pm-11:00pm shift. In an interview on 02/27/2023 at 12:05pm with LVN S, she said that she worked at the facility since 2019. She stated that she had been trained on abuse/neglect to include reporting. She was knowledge on types of abuse/neglect, and that all abuse/neglect should be reported to the ADMIN immediately. She denied that she has observed abuse/neglect of residents while working at the facility. She stated that the facility trains on abuse/neglect often, and she received training during the month of February of 2023. In an interview on 02/27/2023 at12:30pm with ADMIN and HR Director, both said that facility stopped using the contractor agency (Shift Key) that CNA F contracted with in December of 2022, but they could provide a copy of the invoices that would show the date and time contracted staff worked. Both indicated that CNA F is not contracted with contractor agency (KARE) the facility is currently using. ADMIN said that the contractor portal for KARE has an option to select contracted staff as do not return, but she was not sure if that was an option for Shift Key. In a phone interview on 02/27/2022 12:35pm with the General Manager, he said that he is employed by the contractor agency KARE. He said that he did not have record that CNA F was contracted with their staffing agency. In an interview on 02/27/2023 at 12:40pm with the Staffing Coordinator she said that both contractor portals for KARE and Shift Key have an option to select contract staff as do not return. In a phone interview on 02/27/2023 at 12:55pm with ADMIN B, she said that incident took place on 07/19/2022 during the 3:00pm-11pm shift toward the end of the shift. She said that CNA F did not finish the shift after the incident. She said that she could not be certain, but she believed that RN H asked CNA F to leave the facility after the incident or CNA F left on her own. She said that during her investigation she contacted that the contractor agency that CNA F worked with to inform them of the incident, and she coded in the staffing agency portal as do not return on 07/25/2022. She said that there was a risk that CNA F could have returned to the facility to work from 07/20/2022-07/25/2022 because she was unaware of the incident. She said that she interviewed all staff that worked the hall of CR#50, and all the staff believed that the incident was reported the night the incident took place. In a phone interview on 02/27/2023 at 3:25pm with CNA G, she said that she witnessed CNA F slap CR# 50 in the face on 07/19/2022 during the 3:00pm -11:00pm shift. She said that she could not remember the exact time the incident took place, but it was between 9:00pm-10:00pm. She said that she did not see CR#50 hit CNA F prior to the slap. She said that she could not remember if CNA F hit CR#50 multiple times and she could only remember the slap. She said that she asked CNA F why she slapped CR #50, CNA F did not reply back to her, and CNA F walked out of the room. She said that she made sure CR #50 was lying in the bed. She said that she followed CNA F down the hall, CNA F clocked out, and CNA F left the building. She said that she could not remember the exact time CNA F left the building but it was shortly after the incident. She said that she found RN H at the nursing station after seeing CNA F leave, and she reported the incident to RN H. She said that she had been trained on abuse/neglect and reporting prior to the incident. She said that the incident should have been reported to ADMIN B immediately. She said that she did not report the incident because it was after hours, and she thought RN H would have called ADMIN B or the DON. She said that after the incident she was trained on abuse/neglect and reporting. She said that the risk of not reporting is that the abuse could continue. In an effort to complete a phone interview on 02/27/2023 at 3:33pm with RN I it was determined that the phone number was no longer in services. In an interview on 02/27/2023 at 3:40pm with the HR Director, he said that RN I had not worked at the facility since December of 2022. In an interview on 02/27/2023 at 3:41pm with RN H, she said that the incident took place on 07/19/2022 during the 3:00pm-11:00pm shift. She said that she could not remember the exact time of the incident, but the shift was almost over. She said that she was sitting at the nursing station charting, when CNA G came to her, and told her that CNA F hit CR #50. She said that she did not have to ask CNA F to leave the facility because she was already gone. She said that she asked CNA G where was CNA F, and she was told that CNA F left the building after the incident. In a phone interview with CNA K on 02/27/2023 at 3:51pm, she said that she worked the night of the incident involving CR #50 on the 11:00pm to 7:00am shift. She said that she arrived at 10:45pm. For her shift. She said that CNA G told her that a contractor CNA hit CR #50 in the face and left the building. She said that when she arrived to her the shift the contractor CNA was not there. She said that CNA G told her that she reported the incident to RN H who contacted ADMIN B. She said that she had been trained to report abuse/neglect to the administrator immediately prior to an after the incident. She said that the risk of not reporting immediately is that the abuse could continue. In an interview with CNA J on 02/27/2023 at 4:12pm, he said that he observed CR #50 with a fading bruise to her face on date he could not remember in July of 2022. He said that he was working with CNA K, and she told him that a contractor CNA had hit CR #50 in the face, but he could not remember the date of the incident. He said that CNA K said that the incident was reported by the staff working the night of the incident. He said that he took the information to RN I who went to ADMIN B. He said that he had been trained to report abuse/neglect to the administrator or DON immediately prior to the incident an after the incident. He said that the risk of not reporting immediately is that the abuse could continue. In an interview on 02/27/2023 at 4:15pm with CNA M, she said that she was contracted staff with KARE. She stated that she had been trained on abuse/neglect to include reporting. She was knowledge on types of abuse/neglect, and that all abuse/neglect should be reported to the ADMIN immediately. She denied that she has observed abuse/neglect of residents while working at the facility. She stated that there is training that you must complete on the contractor portal before you are scheduled which includes abuse/neglect. She stated that when she arrives to a shift, she receives training with the staffing coordinator before she can sign in for a shift. In an interview on 02/27/2023 at 4:20pm with CNA N, she said that she was contracted staff with KARE. She stated that she had been trained on abuse/neglect to include reporting. She was knowledge on types of abuse/neglect, and that all abuse/neglect should be reported to the ADMIN immediately. She denied that she has observed abuse/neglect of residents while working at the facility. She stated that there is training that you must complete on the contractor portal before you are scheduled which includes abuse/neglect. She stated that when she arrives to a shift, she receives training with the staffing coordinator before she can sign in for a shift. In an interview on 02/27/2023 at 4:25pm with CNA O, she said that she was contracted staff with KARE. She stated that she had been trained on abuse/neglect to include reporting. She was knowledge on types of abuse/neglect, and that all abuse/neglect should be reported to the ADMIN immediately. She denied that she has observed abuse/neglect of residents while working at the facility. She stated that there is training that you must complete on the contractor portal before you are scheduled which includes abuse/neglect. She stated that when she arrives to a shift, she receives training with the staffing coordinator before she can sign in for a shift. Record review of contractor invoices to include time reporting from 07/12/2022-12/31/2022 revealed that CNA F worked on 07/19/2022. CNA F clocked in at 3:00pm and clocked out 10:00pm with a 30 minute break. Record review of facility in-services from June 2022 through February of 2023 revealed that the facility trains staff quarterly for abuse and neglect. All staff were in-serviced on abuse neglect to include reporting on 06/07/2022-06/10/2022, 07/25/2022, 10/04/2022 by ADMIN B. All staff were in-serviced on abuse neglect to include reporting on 01/31/2023 and 02/22/2023 by ADMIN. Record review of the facility policy titled, Abuse and Neglect, with effective date October 2022 read in part, .It is the policy of the facility to administer care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment, .VII. Reporting/Response (483.13(c)(1)(iii), 483.1 (c)(2) and 483.13 ( c )(4)): Have procedures to: All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. All allegations of abuse will be reported to HHSC immediately after the initial allegation is received This was determined to be a Past Noncompliance IJ that began on 03/01/23 and ended on 03/01/23. The Administrator was notified on 03/01/23 at 4:33 p.m and was provided with IJ template on 03/01/23 at 4:33 p.m. No plan of removal was required.