**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 9 Residents (Resident #53) reviewed for quality of care. The facility failed to provide needed care or services by failing to communicate to staff Resident #53's need for supervision while taking medications as stated in his Psych NP note dated 04/22/25, remain in room and ask to open mouth to check to see he swallowed his medication. This resulted in Resident #53 being able to pocket 21 pills that he planned to use to commit suicide and caused him to be sent to a psychiatric hospital on [DATE]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 06/12/25 at 07:09 PM and an IJ template was given. While the IJ was removed on 06/15/25 the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for hospitalization and death. The findings included: Review of Resident #53's Face Sheet dated 06/12/25 reflected a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included Schizophrenia (mental health condition that affects how people think, feel, behave and can result in hallucinations, delusions, disorganized thinking and behavior), cognitive communication deficit (condition that affects how individuals think, remember, and communicate), other specified depressive episodes (condition that can include persistent sadness or low mood, fatigue or loss of energy, irritability, and thoughts of death or suicide), unspecified dementia (group of symptoms affecting memory, thinking, and social abilities), and anxiety disorder (characterized by fear or worry that is both intense and excessive). The Face Sheet reflected Resident #53 was discharged on 06/09/25 to a psychiatric hospital. Review of Resident #53's Annual MDS assessment dated [DATE] reflected a BIMS score of 15 indicating his cognition intact. Section D Mood reflected a resident mood interview that revealed over the last two weeks have you been bothered by any of the following problems? and reflected little interest or pleasure in doing things was marked yes for symptom presence and 2-6 days (several days) for frequency. Feeling down, depressed, or hopeless was also marked as a symptom present and 2-6 days (several days) for frequency. Section I of the MDS assessment reflected Resident #53 was marked for having a diagnosis of Anxiety Disorder, Depression, and Schizophrenia. Section N of the MDS assessment reflected Resident #53 was taking an antipsychotic, antianxiety, and antidepressant. Review of resident #53's care plan last revised 06/11/25 reflected a focus on risk for complications, injury, infection, and ineffective protection related to resisting care and refusal of medications with interventions that included refer to psychology/psychiatry as needed. A focus for I am receiving antidepressant medication with interventions that included, monitor/document/report adverse reactions to antidepressant therapy: suicidal thoughts. A focus was seen for , I am currently receiving anti-anxiety medication related to anxiety disorder with interventions that included, monitor/document/report any adverse reactions to anti-anxiety therapy: depression, impaired thinking and judgement, impulsive behavior and a focus for I am currently receiving psychotropic medications related to Schizophrenia with interventions that included administer psychotropic medications as ordered by physician, monitor/document/report adverse reactions to psychotropic medications: depression, suicidal ideations, social isolation and behavior symptoms not usual to the person. Review of Resident #53's Psych NP progress note dated 04/22/25 reflected, resident seen today for psychiatric visit for Schizophrenia, anxiety, dementia with behavioral disturbance .review report received from staff. Reports patient is pocketing his medication and not taking it, plan in place now, staff remain in room and ask patient to open his mouth to check and see he swallowed his medications. Review of Resident #53's physician's orders reflected an order dated 05/22/25 Make sure resident takes his medications before leaving the room. Every shift monitoring of taking medication **Make sure resident swallows his medications before leaving his room. Review of Resident #53's progress note revealed a progress note dated 06/09/25 entered by the SW that reflected, SW was sitting with resident when he stated he wasn't feeling well. SW asked resident to elaborate- he stated can I be honest with you? SW stated of course. Resident began telling this writer that he wanted to kill himself. He stated he has hoarded his medications in his locked bedside table and planned to take all at once and overdose. SW proceeded to inform ADM and DON about the situation. ADM and DON stated resident needed to be sent out and be on a 1:1 until he was sent out. SW gave resident two options to be sent to emergency room or psychiatric hospital. Resident agreed to go to psychiatric hospital to stabilize. SW called psychiatric hospital inpatient and received authorization for resident to admit to an inpatient stay. SW then collected all medications from bedroom and handed them over to DON. SW stayed 1:1 with resident, listening to music, coloring, until psychiatric hospital was ready to admit him. At 03:15 PM resident boarded onto facility van voluntarily with staff to transport to psychiatric hospital. IDT aware, PASRR aware. SW was with resident from 01:50 PM to 03:15 PM. Review of an email to the surveyor dated 06/12/25 at 01:30 PM from the DON identifying Resident #53's hoarded medications confiscated on 06/09/25, email reflected: After reviewing the picture and auditing his medications, I was able to determine that the cup of meds appeared to have: (8) Depakote (anticonvulsant), (2) gabapentin (anticonvulsant), (2) zenpep (pancreatic/digestive enzyme), (1) ½ tab [NAME] (opiate antagonist), (2) metoprolol (beta blocker), (4) fluoxetine (antidepressant), (1)Loratadine (antihistamine), (1)memantine (NMDA, N-methyl-D-aspartate receptor antagonist, used to treat symptoms of Alzheimer's disease). Review of the facility reported incidents for the month of June 2025 revealed there was no self-report to the state agency for the event concerning Resident #53 on 06/09/25. Review of the facility staff in-services for the month of June 2025 revealed there was no in-services for medication administration related to remaining with residents to ensure medication was swallowed. In an interview and observation on 06/12/25 at 02:56 PM with the DON, she stated Resident #53 was feeling different and there were reports of behavior/mood changes during a care conference that occurred on 05/21/25. She stated to her knowledge that was why the order was placed in the system on 05/22/25 to make sure staff were watching Resident #53 take his medications . She stated that to her knowledge they did not know Resident #53 was having behavior changes or required supervision with med administration prior to the 05/21/25 care conference. The DON was observed reviewing Resident #53's chart and stated the last uploaded Psych NP visit in the system was for the month of March 2025. In an interview and observation on 06/12/25 at 03:47 PM the MR/FD entered the DON's office and in an interview with both staff MR/FD stated the Psych NP notes from visits were provided one of two ways, by being left at the nurse's station or sent via fax. The MR/FD stated that if the notes arrived via fax machine, they came to the attention of the ADON, and she was to review the notes and update the resident's chart as needed. The MR/FD stated that the ADON would just know that if there was a Psych NP visit, notes should be on the fax by the next day. The MR/FD stated there was only one fax machine that was used by everyone and there was the potential for communication issues if pages slipped out, or the machine could skip a page and notes would go missing. At this time the MR/FD provided the surveyor with copies of the Psych NP notes for Resident #53's visits dated 04/22/25 and 05/19/25 that she stated were not yet scanned into Resident #53's medical record . The visit for 04/22/25 reflected, Reports patient is pocketing his medication and not taking it, plan in place now, staff remain in room and ask patient to open his mouth to check and see he swallowed his medications. At this time the DON stated she was not aware of the Psych NP visit notes for 04/22/25 or 05/19/25 and was not sure how they were missed because it was before she took the position of DON. The DON stated that if notes came in via fax, they were not able to verify who saw the notes since it's a fax used by the whole facility. The DON stated there's the potential for missed communication because pages of notes or orders could go missing or end up somewhere else without being reviewed by nursing. In an interview on 06/12/25 at 04:24 PM with the Psych NP, he stated that he first became aware of Resident #53 pocketing medication during his visit on 04/22/25 and was notified by the ADON. He stated he was told on that day that there was already a system in place to ensure staff were supervising Resident #53 and ensuring he swallowed his medication before leaving the room due to reports of pocketing medications. He stated he did not review the resident's EMR that day to confirm that the orders were in place and took the ADON at her word. The Psych NP stated that it was his expectation that there was an order in place and staff were implementing supervision of Resident #53's medication administration since 04/22/25 and he stated that he also followed up on it with ADON on 05/19/25 and was told it was still in place . The Psych NP stated that based on the 21 medications Resident #53 had hoarded there was concern for a negative outcome. He stated, Anyone on its own would not have been a concern but all together would have had the potential for a negative outcome. In an interview on 06/12/25 at 05:19 PM with the ADON, she stated she put the order in for supervision of Resident #53's medication administration as soon as she was made aware of the resident pocketing his medications. She stated she could not say why the order was not implemented in April 2025 and said, It was always known to monitor him. She stated the Psych NP notes were either faxed into the facility or left at the nurse's station. She stated the facility's way of communication was through orders so that everyone is on board and knows what to do. In an interview on 06/13/25 at 01:30 PM with the ADM, he stated when the incident was reported to him on 06/09/25 of Resident #53 pocketing medication in order to commit suicide he did not believe it was a reportable incident. He stated the SW remained with Resident #53 until he was transferred out to a psychiatric hospital after he admitted to suicidal ideation and was found to have pocketed medications. The ADM stated that failure to report an incident to HHSC could result in the potential for residents to not get services they needed. He stated it was his expectation that the DON and ADON reviewed provider notes such as psychiatric NP notes and orders. He stated to his knowledge they came in through the fax and were distributed to nursing staff by either the receptionist, himself, or whoever saw it on the shared facility fax. The ADM stated 06/09/25 was the first time he became aware of Resident #53 pocketing medications. He stated it was his expectation that provider notes and recommendations were used to provide the best care possible. He stated failure to follow provider recommendations have the potential to result in residents not getting services or the potential for them to harm themselves. Review of the undated Administering Oral Medications policy reflected: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Steps in the procedure: Remain with the resident until all medications have been taken. The Administrator was notified on 06/12/25 at 07:09 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 06/13/25 at 04:01 PM and reflected the following: Re: Plan of Removal of Immediate Jeopardy The following is a plan of removal, which was immediately implemented, to remedy the Immediate Jeopardy which was imposed on 6/12/2025 at 7:09 pm. On 6/12/2025 the surveyor provided an Immediate Jeopardy (IJ) template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: Facility failed to provide needed care or services by failing to communicate to staff Resident #1's [Resident #53] need for supervision while taking meds as stated in psych notes 04/22/2025 to remain in room and ask to open mouth to check to see he swallowed his medication. As set forth by F684 - The facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. All items listed will be completed by 5:00 PM on 6/13/2025 with continued follow-up for scheduled staff. 1. Resident #1 [Resident #53] is currently in psychiatric hospital. 2. Findings were relayed to the Medical Director on 6/12/2025 7:30 PM by the DON via phone call. No new orders were received at this time. 3. Emotional Distress Assessment was completed on all 60 residents in the building at this time with no emotional distress observed. This was conducted by the charge nurses on each station and completed by 6/13/2025 at 6:00 AM and documented in each resident's clinical record. 4. Resident #1's [Resident#53] Care Plan was updated by the VP of Clinical regarding the monitoring and remaining in room to ensure resident takes all medications and does not pocket them on 6/12/2025 at 7:30 PM. All nursing staff were in-serviced including PRN, agency staff and all newly hired staff prior to their shift by the DON. Staff are to remain in resident's room to ensure medications are swallowed and not pocketed. Oral cavity to be assessed post administration of medications. 5. On 5/6/2025 at 7:30 PM the DON began medication administration competency check offs on all licensed staff and medication aides. This will be completed before the employees scheduled shift. It will include the 5 rights of medication administration and will also include staying with the resident until medications are ingested. 6. A 100% facility sweep was completed on 6/12/2025 at 7:45 PM by the Administrator and DON with no other loose medications being identified in the building. 7. All psychiatric notes will be e-faxed directly to the administrator and DON for review and implementation of any orders and uploaded into the medical record. 8. Administrator /DON initiated staff in-service for ALL RNs, LVNs and CMAs on Administering Oral Medications, ALL CNAs in-serviced on monitoring for loose medications and notifying the charge nurse immediately if found, ALL staff in-serviced on Abuse and Neglect. DON trained by VP of Clinical Services prior to start of in-service on 6/12/2025. If staff are unable to attend any of the in-services, they will be required to complete them before starting their assigned shift to include PRN staff, agency staff and any new hires. The Administrator/DON will monitor to ensure all in-servicing completed. The POR was monitored from 06/13/25 through 06/15/25 in the following ways : 06/13/25 In an interview and record review 06/13/25 at 05:25 the ADM provided an email confirmation for review from the company IT team letting them know an eFax setup was completed. In an interview with the ADM he stated the eFax that was set up would allow all incoming faxes to be sent in an electronic format to the ADM, DON, and ADON so that they could ensure all provider notes and orders would be reviewed. The ADM and MR/FD stated that verbal confirmation was received from the Psych NP on 06/13/25 that all notes and orders would now be sent to the eFax that was set up. 06/15/25 Resident #53 remains in the Psychiatric hospital. The facility's Medical director was notified on 6/12/25 at 07:30 PM by the DON via phone of Immediate Jeopardy. Uploaded text verification reviewed by the surveyor. Record review revealed emotional distress assessments were completed on all 60 Residents on 6/13/25 documented within the progress notes of the electronic medical record. The progress note reflected: Note Text: Upon assessment this shift, resident states that she is not having any type of emotional distress. Denies any fear and that she feels safe. Surveyor verified this through record review of 5 resident chart audits. Record review of Resident #53's Care Plan was done and revealed it was updated which reflected: Medication Administration Date Initiated: 06/12/2025 Nursing - Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away to CNA possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment, or safety awareness. The DON began medication administration competency check offs on all licensed staff and medication aides. This will be completed before the employees scheduled shift. It will include the 5 rights of medication administration and will also include staying with the resident until medications are ingested. Surveyor verification was completed for 12 of 21 nurses and medication assistants. 100% Facility sweep for loose medications was completed on 06/12/2025 verified by the DON and ADM this was verified by surveyor through interview and written statement. An eFax system was set up by the facility on June 13, 2025, to ensure all faxes with pertinent information such as physician order and visit notes are sent and reviewed by the department heads. Verified with ADM email conformation on June 13,2025. IT team contract. Training was given to the nursing staff by the ADM and DON 06/13/25-06/15/25. The staff verbalized that they had received instruction to ensure that all medications were taken. Do Not allow residents to self-administer medication. Do not leave medication at the resident's bedside. If a resident was seen not taking medication, pocketing medications, spitting out medications it must be reported to the charge nurse and DON immediately. Staff were instructed if they find medications in a cup or otherwise that have not been administered, they are to notify the charge nurse immediately. All residents were to be supervised while taking their medications and leaving medications at the bedside is never allowed. The nurses and MAs were to verify medication had been swallowed by oral assessment. Staff also verbalized they had been trained on abuse and neglect. They were able to give examples of abuse such as hitting a resident, neglecting to change resident clothes, and allowing residents to fall by not using proper equipment. Staff were able to identify the ADM as the abuse coordinator and stated all abuse is reported immediately to the abuse coordinator. Interviews reflected below. The DON's training was given by the VP of Clinical Services on 6/12/2025. The Training included policy and procedures for oral medication administrations and abuse investigating and reporting in-service record review completed for verification of the document. Interviews were completed with 3 LVNs, 1 RN, 9 CNAs, 2 MA, 1 housekeeper, 1 dietary staff and included 6-night shift and 9-day shift nursing staff. The interviews revealed the following: Interview on 6/15/25 5:45 AM with LVN BB night shift charge nurse revealed she did have an observation competency evaluation on medication pass, ensuring the right dose and resident's medication. She stated she was specifically told to ensure residents were swallowing their medications, ensure no medications were left in room, do not leave any medication cups in the room, do not allow residents to self-administer medications. She stated she had been trained on abuse and neglect to report to the ADM immediately. She gave an example of abuse as staff yelling at a resident or treating them badly. She stated she would protect the resident and report to the ADM immediately. Interview on 6/15/25 05:55 AM CNA CC stated she had been CNA here for 3 years-night shift. The aide stated she had been trained on abuse and neglect. She stated take all allegations seriously report immediately to the abuse coordinator. She stated the abuse coordinator was the ADM. She stated she had been instructed on to make sure if any medications were found in residents' rooms to report to the nurse. She stated medications were not supposed to be in residents' rooms. Interview on 6/15/25 06:15 AM with CNA DD-night shift, she said she was in-serviced regularly on abuse and neglect. She stated an example of abuse is yelling at a resident and she has never witnessed abuse in this facility. She stated if she suspected abuse, she would call and report it to the ADM who is the Abuse Coordinator. She stated medications were not supposed to be in residents' rooms. She stated if medications were found in the room she is supposed to report it to the charge nurse immediately. Interview on 6/15/25 06:24 AM with CNA EE-nightshift, she stated she had been trained on abuse and neglect, and if she were to see abuse protect the resident and report to the ADM. She stated if she were to see medications sitting around on bed side table in residents' she was instructed to remove medications and report to nurse immediately. Interview on 6/15/25 06:30 AM with CNA FF -night shift, she stated if she were to see loose pills in a residents' room, she would remove the medications and take them to the charge nurse. She stated she had been trained on abuse, example yelling at a resident. She stated the ADM was the abuse coordinator. Day shift Interview on 6/15/25 06:42 AM with RN GG -day shift, he stated he had been instructed to make sure residents take all medication prior to leaving the room. He stated he was instructed to not allow residents to self-administer medications. He stated he had been observed performing a medication pass by the DON. He stated he had been trained on abuse and neglect by the ADM. He stated the ADM is the abuse coordinator. He stated an example of abuse was neglecting to change a resident. He stated if he were to see abuse, he would protect the resident and report it immediately. Interview on 6/15/25 06:55 AM with LVN HH -agency nurse, she stated she had been observed performing a medication pass by the DON. She stated she had been in-serviced on medication administration including review of resident rights, staying with residents to make sure they are not pocketing medications. She stated she was instructed do not leave room until all medications are taken. She stated she was instructed to perform and oral check to ensure residents swallowed their medications. She stated she had been in-serviced on abuse and neglect. She stated abuse and neglect should be reported immediately to ADM and DON. Interview on 6/15/25 07:05 AM with MA II - day shift, she stated she had been trained to ensure residents swallowed medications, and to talk to the resident and make sure their mouth is clear, she had been checked off on medication pass, and did complete a medication pass with the DON she stated she reviewed resident rights, medications storage, types of medications routes. She stated she had been trained on abuse, and said an example was yelling at a resident. She gave an example of abuse such as hitting a resident. She stated the ADM was the abuse coordinator. Interview on 6/15/25 07:15 AM MA JJ -day shift, she stated she had been trained to ensure residents swallowing medications, that she is to speak to residents and make sure their mouth is clear. She said she has been checked off on medication pass, did complete a medication pass with the DON she reviewed resident rights, medications storage, types of medications routes. She stated she had been trained on abuse, example yelling at a resident. She gave an example of abuse such as slapping a resident. She stated the ADM is the abuse coordinator. Interview on 6/15/25 07:25 CNA KK -day shift, she stated if she were to see loose pills in a resident's room, she would remove the medications and take them to the charge nurse. She stated she had been trained on abuse; an example was yelling at a resident. She gave an example of abuse such as leaving a resident in dirty clothing. She stated the ADM is the abuse coordinator. Interview on 6/15/25 07:35 AM CNA LL-day shift, she stated if she were to see loose pills in a resident's room, she would remove the medications and take them to the charge nurse. She stated medications were not to be in residents' rooms. She stated she had been trained on abuse, and an example would be yelling at a resident. She stated the ADM was the abuse coordinator. She stated an example of abuse would be pushing a resident. Interview on 6/15/25 07:45 AM with CNA MM -day shift, she stated if she were to see loose pills in a resident's room, she would remove the medications and take them to the charge nurse. She stated medications were not to be in residents' rooms. She stated she had been trained on abuse and provided the example yelling at a resident. She stated the ADM was the abuse coordinator. She stated an example of abuse would be yelling at a resident. Interview on 6/15/25 07:55 AM with CNA NN - day shift - She stated if she were to see loose pills in a residents' room, she would remove the medications and take them to the charge nurse if there were any loose in the resident room. She stated medications were not to be in residents' rooms unattended. She stated she had been trained on abuse, example yelling at a resident. She stated the ADM is the abuse coordinator. She stated an example of abuse would be pushing a resident. Interview on 6/15/25 08:05AM with MA OO - She stated if she were to see loose pills in a residents' room, she would remove the medications and report them to the charge nurse immediately. She stated medications were not to be left behind in residents' rooms. She stated she had been trained on abuse. She stated the ADM is the abuse coordinator. She stated an example of abuse would be hitting a resident. Interview on 6/15/25 08:15 AM interview with HK PP, he stated if he were to see loose pills in a residents' room, he would remove the medications and report them to the charge nurse. He stated medications were not to be left in residents' rooms. He stated he had been trained on abuse, example yelling at a resident. He stated the ADM is the abuse coordinator. He stated an example of abuse would be not using appropriate transferring equipment for a resident causing a fall. Interview on 6/15/25 08:25 AM interview with DA QQ, she stated examples of abuse were threating a resident, not meeting their needs, pulling on a resident. She stated she would report abuse to the ADM, he is the abuse Coordinator. She stated if she were to see any pills on a tray or lying around, she would report to the charge nurse immediately. She stated residents were not allowed to have medications in their rooms. The failures detailed above resulted in an identification of an Immediate Jeopardy (IJ) on 06/12/2025 at 07:09 PM and an IJ template was given. While the IJ was removed on 06/15/25 the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.