Graham Oaks Care Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from abuse and neglect for one (Resident #1) of 8 residents reviewed for neglect. On 9/2/25 the facility allowed Hospitality Aide A to perform a transfer on Resident #1 and failed to ensure she was trained and permitted per her job description to use Resident #1's personal medical transfer equipment to perform a transfer. No staff in the facility had been trained in the use of Resident #1's personal medical transfer equipment, and the Director of Therapy had asked the former DON to ensure her staff did not use the device. The transfer resulted in a fall during which Resident #1 received a fracture in her left knee. The noncompliance was identified as PNC. The IJ began on 9/2/25 and ended on 9/3/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for serious injuries, a decline in the resident's condition, hospitalization, or death. Findings included: Record review of Resident #1's admission Sheet, not dated, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her active diagnoses included Paraplegia (paralysis that affects the legs and not the arms), muscle weakness, unsteadiness on feet, osteomyelitis of vertebrate, and pain in thoracic spine. Record review of Resident #1's Annual MDS dated [DATE] reflected Resident #1 had a BIMS score of 15 (cognitively intact) and impaired range of motion in both lower extremities and section GG documented Resident #1 required partial to moderate assistance to transfer. Record review of Resident #1's comprehensive care plan, dated 7/14/25, reflected that she had a self-care performance deficit and required 1 staff to reposition and turn in bed, and to transfer from bed to chair. A revision of the care plan on 7/15/24 indicated that she used a sit to stand device, and it was discontinued on 9/3/25 Review of the Provider Investigation report dated 9/3/25 revealed: Resident had a fall during sit to stand transfer to the bathroom, resulting in left knee fracture . The Hospitality Aide that was assisting Resident #1 in the sit to stand transfer to the toilet was not trained or oriented to the sit to stand machine. The resident was sent to the emergency room for evaluation and pain medication was administered as ordered and as needed. There were no other negative findings at this time. Record review of a radiology report for Resident #1 dated 9/3/25 documented: There is a cortical discontinuity (interruption or fracture in the hard, dense, outer layer of bone that makes up most of the skeleton) in the lateral aspect of the left medial femoral condyle (the rounded, smooth end of the thigh bone that forms part of the knee joint), suggesting a fracture. Record review of the video evidence (Clip #1) date 9/2/25 at 6:56 PM provided by Resident #1 from her personal monitoring device located in her room, revealed Resident #1 was transferred by the Hospitality Aide A on 9/2/25 using her personal transfer equipment. The hospitality aide could not be heard in the video stating to Resident #1 that she had never used the sit to stand transfer device to perform a transfer. Resident #1 could be heard stating you have to learn when you're young. The Resident #1 is seen sitting on the transfer device while Hospitality Aide A pushed her into the bathroom after which the resident could not be viewed by the camera. Video clip #2 - Resident #1 is not in view, but Hospitality Aide A is seen standing in the doorway of the bathroom and is heard stating I I can't get in there. I'm sorry. She turned toward the resident's room door which was closed, opened the door and stated: Let me get some help. She then left the room. The resident could be heard groaning and calling out help!. She was not in view of the camera and the clip ended. Record review of the nurses note dated 9/2/2025 11:34 PM reflected the following information: Note Text: BP-146/94. T-97.5. P-101. R-18.Resident had a fall. Location: Resident Bathroom Fall information: Assisted, Legs gave out, .Cognition / Behavior at Time of Event: Oriented / no problem,This nurse was notified by the Hospital Aide that she had assisted residents to the ground via a gait belt from sit to stand device. The Hospitality Aide was assisting the resident to bathroom and during the transfer to toilet, resident could not get bearings on her legs, and they gave out. No injuries noted at the time of assisted fall. The Resident #1 did not hit her head, alert and oriented x4. resident complained of left knee discomfort. Resident assisted to w/c from floor by 3 staff members and placed in bed. Will continue to monitor for delayed injuries. Appears and/or states to be in pain. Describes the pain as: Intermittent, Location of pain: left knee Pain relieving intervention used at this time: routine oxycodone.Initial Treatment/New Orders:Resident Statement: resident stated legs gave out trying to transfer from sit & stand to toiletName of MD/NP notified: Medical Director/Primary Care PhysicianDate/time of notification: 09/02/2025 9:00 PM.Name of RP notified: husband Date/time of notification: 09/02/2025 9:00 PM.Interventions in place prior to fall: Scheduled toileting program, x2 assist when toiletingInterventions initiated in response to fall: Scheduled toileting program, x2 assist with transfers9/3/2025 01:52 Transfer Notification Note Text: Resident #1 was transferred to a hospital on [DATE] 1:30 AM related to resident had assisted fall in bathroom and hurt left knee, swelling noted in left knee, unable to manage pain or get x-ray until business hours, resident request to be sent to ER. Record review of the Hospitality Aide's job description stated in part: Knowledge base - ability to record information, good communication skills, genuine care for and interest in the elderly, ability to comply with company safety policies, provide support to the nursing department by assisting with non-nursing tasks, including but not limited to bed making, passing water and ice, answering call lights and gathering supplies. The Hospitality aide job description was signed on 8/27/25 by Hospitality Aide A. Record review of the facility incident logs for the months of July, August, and September 2025, revealed no other injuries related to transfers. Record review of the facility policy Transfers from Chair to Bed stated the following in part: .A gait belt should be used for all transfers and the resident supported by holding the gait belt. Record review of Hospitality Aide A's employee file revealed she was not trained for transfer skills and competency checked until 9/11/25 after which she was allowed to come back to work. Record review of the facility Policy titled Abuse/Neglect revealed the following in part: The resident has the right to be free from abuse and neglect, misappropriation, of resident property and exploitation as defined in this subpart. Neglect is the failure of the facility, its employees, or services providers to provide goods, and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. During an interview and an observation on 10/1/25 at 11:35 AM Resident #1 was sitting up in her electric wheelchair in her room with her left leg elevated. She stated she was non weight bearing to her left leg because of the fracture and she had to be transferred with a Hoyer lift. Resident #1 stated she did persuade Hospitality Aide A to use the transfer device despite Hospitality Aide A telling her she did not know how to us the transfer device. She stated she persuaded her to use the device because it was easier for her but stated some of the girls didn't like to use the device because it was difficult to maneuver in her small bathroom and she slid off the edge of the seat. She stated her leg was caught between the lift and the wall and it hurt. She stated they had to get the assistance of Hospitality Aide B to get her off of the floor and LVN C watched. Hospitality Aide A did not come back to the room. During an interview with Hospitality Aide A on 10/3/25 at 6:00 PM Hospitality A stated she didn't know how to use the sit to stand equipment, but she answered Resident #1's call light and Resident #1 kept telling her she needed to urinate. Hospitality Aide A stated she knew Resident #1's call light had been on for about 20 minutes before she went into the room to answer it. She then stated they were shorthanded that evening and she had been assigned by LVN C to work as a floater in 3 different halls. Hospitality Aide A stated she knew there was no one around to assist at that time because no one else answered the call light. Hospitality Aide A stated Resident # 1 asked her to use the sit to stand machine to transfer her to the toilet in the bathroom, so she did it anyway, knowing that she was not supposed to do a transfer. Hospitality Aide A stated she assisted Resident #1 to the toilet but was unable to get her lined up over the toilet seat. Hospitality Aide A stated Resident #1 then said her legs were giving way and she was unable stand. Resident #1 then fell to the floor. Hospitality Aide A stated she was unable to use a gait belt to aid in the support of Resident #1. Hospitality Aide A stated she realized after the incident that she should not have done the transfer because she had not been trained and that she had no training on the use of the transfer device before the incident. Hospitality Aide A stated the facility then told Resident #1 the device would have to be taken home because it did not belong to the facility and there was no manual for its use. Hospitality Aide A stated she was suspended after the incident and was allowed to come back after 9 days when the facility completed their investigation and that is when they had the training and check off skills for her. During an interview with Hospitality Aide B on 10/10/25 at 6:15 PM he was called to Resident #1's room after the fall on 9/2/25 to get her off the floor. He stated her leg was between the machine and the wall of the bathroom and he was unable to use a gait belt to lift her off the floor. He stated he lifted her underneath her arms and put her back into her chair. He then returned to the memory care unit where he was stationed that night. Hospitality aide B stated he had no training on use of the device by the facility. During an interview with the Administrator on 10/3/25 at 10:00 AM, she stated she was not aware that staff were not trained on the sit-to-stand machine until after the incident. She stated she thought the machine belonged to the facility; and that the DON that was no longer employed with the facility had trained them. She stated the prior DON had been in charge of training of Hospitality Aides and following through to ensure staff complete training for all equipment used for transfers and that they were tested and competency checked before using the equipment and all skills were performed. The Administrator stated that after the incident and during the time of the facilities investigation of the incident, that there was no policy manual for the use of the sit- to-stand device. The administrator stated she did not know Hospitality Aide A was performing transfers without training and competency checks. She stated that her expectation was that a Hospitality Aide does not perform transfers and duties that were not included in their job description and for which they had not been trained appropriately. The Administrator then stated she expected the DON to be responsible for monitoring and education of all staff. Attempted to interview LVN C on 10/8/25 and again 10/9/25 (Charge Nurse) regarding the incident with Resident #1, but she replied by text to the Administrator stating she was in the hospital, and she was unable to interview. During an interview on 10/9/25 at 11:00 AM The Administrator stated she was no longer employed by the facility effective today 10/9/25. During an interview with the Director of Therapy on 10/3/25 at 10:30 AM he stated Resident #1 was a one-person transfer prior to her fall, but she was now a 2 person Hoyer lift due to the non-weight bearing status to her left leg and her therapy had been put on hold. He stated he communicated to the former DON that the sit-to-stand lift did not belong to the facility and there was no manual for the equipment. He stated the residents had not been checked off to use the device and the staff were not trained. He stated he made it clear to the former DON that he was not qualified to do the training, because the use of the equipment was not a part of his curriculum in therapy school. He stated he assumed everyone in the facility knew the device was used by the resident because it was in her room and it was a large piece of equipment and hard to miss. He stated he did not recall the date that he relayed this information to the former DON, but he asked her to ensure staff did not use the device. During an interview with the former DON on 10/3/25 at 4:16 PM she stated her last day at the facility was 8/15/25. She stated she did not remember the Director of Therapy telling her that the staff should not use the device. She stated she did know that the device was being used by staff to do the transfers of Resident #1 without training and competency checks. During an interview with the Medical Director/Primary Physician on 10/6/25 at 4:00 PM he stated his expectation was that residents be transferred by staff that had been trained and the equipment used had been safely checked. Review of Hospitality Aide A's training record reflected that she had completed training on Position and Transfer Techniques and fall prevention on 9 /11/25. She had also signed an acknowledgment on 10/3/25 that she was to follow the resident's care plan to know who required a Hoyer lift or who was to be lifted by two people. During an interview on 10/3/25 with Hospitality Aide A, she stated if there were any questions about how a resident was to be transferred, she knew she was to clarify this with the nurse.During an Observation on 10/4/25 at 1:30 PM Hospitality Aide B and CNA 1 perform a Hoyer lift on 10/4/25 at 1:30 PM using 2 people on Resident #4 and proper procedure and all all-safety rules were followed, and no incidents were noted. In an interview with the Administrator on 10/8/25 at 9:00 A.M., she stated after the incident on 9/3/25 they immediately completed the following corrections/interventions. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. Review of the Plan reflected: 1. Self-reporting protocol initiated on 9/3/25 and dated 9/3/23.2. Reported incident to the State within 2 hours of incident 9/3/25.3. Known perpetrator (Hospitality Aide A) suspended immediately pending investigation.4. Care plan for Resident #1 updated immediately and revised for injury.5. Skin assessments on all non-verbal residents and Safe Surveys of interviewable residents on halls A, B, C, D, were completed on 9/3/25 and 9/4/25.6. Interviews with staff members regarding whether they have seen a fellow staff member act in an abusive or neglectful manner toward a resident was completed on 9/3/257. Abuse and neglect Inservices started with all staff on 9/3/258. Ad HOC QAPI meeting held 9/3/25 for Inappropriate transfer by untrained staff.6. Audited all resident's Kardex/care plan on 09/3/25 to ensure all resident's level of care was updated and accurate.7. Educated and validated all staff understood the use of the Kardex/care plan system on 09/3/258. Review plan in QAPI monthly until resolved. Completed risk management entry 9/3/259. Medical director notified of this plan on 9/3/25 by the Administrator.10. The DON and Admin will monitor for potential neglect by reviewing incidents in stand up daily 9/3/2511. Monitor at least 10 of the following ADL Actions each week to ensure that the proper number of staff is providing assistance: bathing, bed mobility, transferring, walking initiated 9/3/25All monitoring above will continue for at least 4 weeks. The QAPI committee will review the findings and make revisions to the plan, as necessary. Verification 10/9/25 :Correction #1:In an Interview on 10/9/25 at 11:00 AM the Administrator stated that she received a call from the Charge Nurse notifying her of Resident #1's fall 0n 92/25. The resident was assessed and did not complain immediately. She did begin to complain of pain and the charge nurse notified her that the resident was requesting to go to the hospital. She was sent to the hospital and diagnosed with a fracture on her left knee. During the course of the investigation the administrator discovered that the resident was transferred by Hospitality Aide A that was performing duties such as transfer, that were not in her signed job description and was doing so without appropriate training on safety and operation. She stated she immediately filed a self-report and suspended the perpetrator pending the results of the investigation. She was informed by therapy staff that the mechanical lift device was not owned by the facility and no one in the facility had been trained to use the device. She stated she could see by viewing the video that Hospitality Aide A did perform the transfer with the device, and this was not a duty for which she was currently trained to do according to her job description. She notified Resident #1's family of the need to remove the device from the resident's room. The sit to stand device was no longer in the building as of 9/3/25. Record review of the facility reporting protocol template indicated all areas of the self-reporting protocol had been completed, dated, and signed by the staff. Correction #2. Record review of the nurses note dated 9/2/2025 11:34 PM Note Text: BP-146/94. T-97.5. P-101. R-18.Resident had a fall. Location: Resident Bathroom Fall information: Assisted, Legs gave out, .Cognition / Behavior at Time of Event: Oriented / no problem,This nurse was notified by the Hospital Aide that she had assisted residents to the ground via a gait belt from sit to stand device. The Hospitality Aide was assisting the resident to bathroom and during the transfer to toilet, resident could not get bearings on her legs, and they gave out. No injuries noted at the time of assisted fall. The Resident #1 did not hit her head, alert and oriented x4. resident complained of left knee discomfort. Resident assisted to w/c from floor by 3 staff members and placed in bed. Will continue to monitor for delayed injuries. Appears and/or states to be in pain. Describes the pain as: Intermittent, Location of pain: left knee Pain relieving intervention used at this time: routine oxycodone.Initial Treatment/New Orders:Resident Statement: resident stated legs gave out trying to transfer from sit & stand to toiletName of MD/NP notified: Medical Director/Primary Care PhysicianDate/time of notification: 09/02/2025 9:00 PM.Name of RP notified: husband Date/time of notification: 09/02/2025 9:00 PM.Interventions in place prior to fall: Scheduled toileting program, x2 assist when toiletingInterventions initiated in response to fall: Scheduled toileting program, x2 assist with transfers9/3/2025 01:52 Transfer Notification Note Text: Resident #1 was transferred to a hospital on [DATE] 1:30 AM related to resident had assisted fall in bathroom and hurt left knee, swelling noted in left knee, unable to manage pain or get x-ray until business hours, resident request to be sent to ER. Correction #3Record review of the Ad Hoc QAPI meeting revealed the meeting was conducted on 9/3/25 with the following members attending: Medical Director, Administrator, DON, ADON #1, ADON #2, MDS Nurse #1, MDS Director 1, MDS Director #2, Social Worker, Medical Records, Medical Director. Correction #4Record review of the Employee Disciplinary Report dated 9/4/25 revealed the Hospitality Aide A was suspended for investigation of Neglect and the improper transfer. Correction #5Record review of Skin assessments on all non-verbal residents and Safe Surveys of interviewable residents on halls A, B, C, D, completed on 9/3/25 and 9/4/25. Record review of Residents #5, #6 safe survey forms and interviews with Residents #2, #3, and #4 from 2 PM to 4 Pm on 10/9 /24 confirmed that they did feel safe in the facility, and all stated they were transferred properly. During interviews with Residents #2, # 3, #4, #5, and #6 from 2 PM to 4 PM they stated they could tell the difference between the Nurse's Aide, Hospitality Aides and Certified CNAs by their name badge. Correction #6Reviewed the Abuse and Neglect inservice signature page and content of training dated 9/3/25. All facility staff had been trained on abuse and neglect Immediately after the incident with Resident #1 before they were allowed to return to work. Correction #7 Interviews with 10 staff members Hospitality Aides A, B, C, K, E, D, F, G, H, I, J (formerly titled Hospitality aides but now classified as Nurses' Aides) between 2:00 PM and 4:00 PM on 10/9/25 reflected that they all attended a training skills lab on 9/3/25 and competed competency checks on 9/11/25. They stated hey were trained on Abuse and Neglect, Safe Transfers, an checked off on the Hoyer lift. Hospitality Aides A, B, C, K, E, D, F, G, H, I and J stated they were not allowed to operate the hydraulic controls and must transfer a mechanical lift with 2 people. Observed Hospitality Aide B and CNA 1 perform a Hoyer lift on 10/4/25 at 1:30 PM using 2 people on Resident #4 and proper procedure and all all-safety rules were followed, and no incidents were noted. Correction #8Reviewed QAPI minutes for meeting last held 10.3.25. Reviewed PIP dated 9/3/25 for incident. Meeting attended by medical director. Signed on 10/3/25. Correction # 9Interview with the Medical Director on 10/6/25 at 4:00 PM verified that he had been notified of the incident and the PIP on 9/3/25. Correction #10 Reviewed monitoring by the facility of ADL assistance initiated on 9/3/25 revealed that the monitoring was complete and current with evidence of monitoring from 9/3/25 to 10/9/25. Monitoring continues daily at the time of exit. During an Interview with the Administrator on 10/10/25 at 8:00 AM stated she only had 1 hospitality aide left in the building as of 10/9/25. She stated everyone else had completed training and skills checks and were ready to test. She stated scheduling was in process with herself and the new DON monitoring compliance During an Interview with Resident #1 on 10/9/25 at 4:00 PM she stated she had not been transferred by staff other than CNAs, and LVN, and that no Hospitality Aides had transferred her since the incident. She stated they always use 2 people to transfer. She stated she was transferred by the Hoyer lift and that her family member was asked by the administrator to remove the sit to stand device from the building. During an Interview with the current DON and the RNC on 10/9/25 at 4:10 PM both stated all Hospitality aides were checked off on transfer skills as of 9/19/25. Interviews with 7 Nurses' Aides (B, D, E, F, G, H, I, J) and one Hospitality Aide K on 10/9/25 between 9:00 and 10:00 AM were able to state their job description and duties they were allowed to perform. They stated they would go to the Kardex in the point of care to make sure what kind of care they needed. Hospitality Aide K stated she was told by the administrator that she cannot work on the floor until she passes her Texas Nurse's Aide Training requirement online and supervised clinical with competency checks. During Interviews with resident numbers 1,3,4,5,6,7 and 8 on 10/9/25 between 11:00 AM and 1:00 PM all stated that that they were transferred appropriately and had no transfer related incidents. Residents #1, #7 and #4 stated that were transferred by a Hoyer lift by two people, and never just by one person. Residents stated they could tell if a resident was a Hospitality Aide or CNA or a Nurse's Aide by looking at their employee's name badge. They stated Hospitality aides were not allowed to transfer residents. Record reviews of skills checklist and CNA online training revealed certificates of training and skills check lists for Nurses' Aides B, E, F, G, H, I, J and one Hospitality Aide K were in their employee files and dated before entrance. During Interviews on 10/9/25 between 11:00 and 1:00 PM Nurses' Aides B, D, E, F, G, H, I, J and one Hospitality Aide K stated they signed a nurse's aide job description stating their duties and name tags were updated to reflect their current job duties. Record review of Resident #1's care plan reflected that she was a Hoyer lift as of 9/3/25. Record review of Resident #'s 1, 2, 3, 4, 5, 6, and 7's care plan and Kardex reflected accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure 1 (Resident #1) of 8 residents reviewed for accident hazards were free from accident hazards in their environment. The facility failed to ensure Resident # 1's received adequate supervision and assistive devices to prevent accidents. The lift used by facility staff was not an adequate assistive device since there was no manual for proper staff training and the device was the personal property of Resident #1. This resulted in a fall during a transfer in which Resident #1 received a fracture on her left knee on 9/3/25. The noncompliance was identified as PNC. The IJ began on 9/2/25 and ended on 9/3/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for serious injuries, a decline in the resident's condition, hospitalization, or death. Findings included: Record review of Resident #1's admission Sheet, not dated, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her active diagnoses included Paraplegia (paralysis that affects the legs and not the arms), muscle weakness, unsteadiness on feet, osteomyelitis of vertebrate, and pain in thoracic spine. Record review of Resident #1's Annual MDS dated [DATE] reflected Resident #1 had a BIMS score of 15 (cognitively intact) and impaired range of motion in both lower extremities and section GG documented Resident #1 required partial to moderate assistance to transfer. Record review of Resident #1's comprehensive care plan, dated 7/14/25, reflected that she had a self-care performance deficit and required 1 staff to reposition and turn in bed, and to transfer from bed to chair. A revision of the care plan on 7/15/24 indicated that she used a sit to stand device, and it was discontinued on 9/3/25 Review of the Provider Investigation report dated 9/3/25 revealed: Resident had a fall during sit to stand transfer to the bathroom, resulting in left knee fracture . The Hospitality Aide that was assisting Resident #1 in the sit to stand transfer to the toilet was not trained or oriented to the sit to stand machine. The resident was sent to the emergency room for evaluation and pain medication was administered as ordered and as needed. There were no other negative findings at this time. Record review of a radiology report for Resident #1 dated 9/3/25 documented: There is a cortical discontinuity (interruption or fracture in the hard, dense, outer layer of bone that makes up most of the skeleton) in the lateral aspect of the left medial femoral condyle (the rounded, smooth end of the thigh bone that forms part of the knee joint), suggesting a fracture. Record review of the video evidence (Clip #1) date 9/2/25 at 6:56 PM provided by Resident #1 from her personal monitoring device located in her room, revealed Resident #1 was transferred by the Hospitality Aide A on 9/2/25 using her personal transfer equipment. The hospitality aide could not be heard in the video stating to Resident #1 that she had never used the sit to stand transfer device to perform a transfer. Resident #1 could be heard stating you have to learn when you're young. The Resident #1 is seen sitting on the transfer device while Hospitality Aide A pushed her into the bathroom after which the resident could not be viewed by the camera. Video clip #2 - Resident #1 is not in view, but Hospitality Aide A is seen standing in the doorway of the bathroom and is heard stating I I can't get in there. I'm sorry. She turned toward the resident's room door which was closed, opened the door and stated: Let me get some help. She then left the room. The resident could be heard groaning and calling out help!. She was not in view of the camera and the clip ended. Record review of the nurses note dated 9/2/2025 11:34 PM Note Text: BP-146/94. T-97.5. P-101. R-18.Resident had a fall. Location: Resident Bathroom Fall information: Assisted, Legs gave out, .Cognition / Behavior at Time of Event: Oriented / no problem,This nurse was notified by the Hospital Aide that she had assisted residents to the ground via a gait belt from sit to stand device. The Hospitality Aide was assisting the resident to bathroom and during the transfer to toilet, resident could not get bearings on her legs, and they gave out. No injuries noted at the time of assisted fall. The Resident #1 did not hit her head, alert and oriented x4. resident complained of left knee discomfort. Resident assisted to w/c from floor by 3 staff members and placed in bed. Will continue to monitor for delayed injuries. Appears and/or states to be in pain. Describes the pain as: Intermittent, Location of pain: left knee Pain relieving intervention used at this time: routine oxycodone.Initial Treatment/New Orders:Resident Statement: resident stated legs gave out trying to transfer from sit & stand to toiletName of MD/NP notified: Medical Director/Primary Care PhysicianDate/time of notification: 09/02/2025 9:00 PM.Name of RP notified: husband Date/time of notification: 09/02/2025 9:00 PM.Interventions in place prior to fall: Scheduled toileting program, x2 assist when toiletingInterventions initiated in response to fall: Scheduled toileting program, x2 assist with transfers9/3/2025 01:52 Transfer Notification Note Text: Resident #1 was transferred to a hospital on [DATE] 1:30 AM related to resident had assisted fall in bathroom and hurt left knee, swelling noted in left knee, unable to manage pain or get x-ray until business hours, resident request to be sent to ER.Record review of the Hospitality Aide's job description stated in part: Knowledge base - ability to record information, good communication skills, genuine care for and interest in the elderly, ability to comply with company safety policies, provide support to the nursing department by assisting with non-nursing tasks, including but not limited to bed making, passing water and ice, answering call lights and gathering supplies. The Hospitality aide job description was signed on 8/27/25 by Hospitality Aide A. Record review of the facility incident logs for the months of July, August, and September 2025, revealed no other injuries related to transfers. Record review of the facility policy Transfers from Chair to Bed stated the following in part: .A gait belt should be used for all transfers and the resident supported by holding the gait belt. Record review of Hospitality Aide A's employee file revealed she was not trained for transfer skills and competency checked until 9/11/25 after which she was allowed to come back to work. During an interview and an observation on 10/1/25 at 11:35 AM Resident #1 was sitting up in her electric wheelchair in her room with her left leg elevated. She stated she was non weight bearing to her left leg because of the fracture and she had to be transferred with a Hoyer lift. Resident #1 stated she did persuade Hospitality Aide A to use the transfer device despite Hospitality Aide A telling her she did not know how to us the transfer device. She stated she persuaded her to use the device because it was easier for her but stated some of the girls didn't like to use the device because it was difficult to maneuver in her small bathroom and she slid off the edge of the seat. She stated her leg was caught between the lift and the wall and it hurt. She stated they had to get the assistance of Hospitality Aide B to get her off of the floor and LVN C watched. Hospitality Aide A did not come back to the room. During an interview with Hospitality Aide A on 10/3/25 at 6:00 PM Hospitality A stated she didn't know how to use the sit to stand equipment, but she answered Resident #1's call light and Resident #1 kept telling her she needed to urinate. Hospitality Aide A stated she knew Resident #1's call light had been on for about 20 minutes before she went into the room to answer it. She then stated they were shorthanded that evening and she had been assigned by LVN C to work as a floater in 3 different halls. Hospitality Aide A stated she knew there was no one around to assist at that time because no one else answered the call light. Hospitality Aide A stated Resident # 1 asked her to use the sit to stand machine to transfer her to the toilet in the bathroom, so she did it anyway, knowing that she was not supposed to do a transfer. Hospitality Aide A stated she assisted Resident #1 to the toilet but was unable to get her lined up over the toilet seat. Hospitality Aide A stated Resident #1 then said her legs were giving way and she was unable stand. Resident #1 then fell to the floor. Hospitality Aide A stated she was unable to use a gait belt to aid in the support of Resident #1. Hospitality Aide A stated she realized after the incident that she should not have done the transfer because she had not been trained and that she had no training on the use of the transfer device before the incident. Hospitality Aide A stated the facility then told Resident #1 the device would have to be taken home because it did not belong to the facility and there was no manual for its use. Hospitality Aide A stated she was suspended after the incident and was allowed to come back after 9 days when the facility completed their investigation and that is when they had the training and check off skills for her. During an interview with Hospitality Aide B on 10/10/25 at 6:15 PM he was called to Resident #1's room after the fall on 9/2/25 to get her off the floor. He stated her leg was between the machine and the wall of the bathroom and he was unable to use a gait belt to lift her off the floor. He stated he lifted her underneath her arms and put her back into her chair. He then returned to the memory care unit where he was stationed that night. Hospitality aide B stated he had no training on use of the device by the facility. During an interview with the Administrator on 10/3/25 at 10:00 AM, she stated she was not aware that staff were not trained on the sit-to-stand machine until after the incident. She stated she thought the machine belonged to the facility; and that the DON that was no longer employed with the facility had trained them. She stated the prior DON had been in charge of training of Hospitality Aides and following through to ensure staff complete training for all equipment used for transfers and that they were tested and competency checked before using the equipment and all skills were performed. The Administrator stated that after the incident and during the time of the facilities investigation of the incident, that there was no policy manual for the use of the sit- to-stand device. The administrator stated she did not know Hospitality Aide A was performing transfers without training and competency checks. She stated that her expectation was that a Hospitality Aide does not perform transfers and duties that were not included in their job description and for which they had not been trained appropriately. The Administrator then stated she expected the DON to be responsible for monitoring and education of all staff. Attempted to interview LVN C on 10/8/25 and again 10/9/25 (Charge Nurse) regarding the incident with Resident #1, but she replied by text to the Administrator stating she was in the hospital, and she was unable to interview. During an interview on 10/9/25 at 11:00 AM The Administrator stated she was no longer employed by the facility effective today 10/9/25. During an interview with the Director of Therapy on 10/3/25 at 10:30 AM he stated Resident #1 was a one-person transfer prior to her fall, but she was now a 2 person Hoyer lift due to the non-weight bearing status to her left leg and her therapy had been put on hold. He stated he communicated to the former DON that the sit-to-stand lift did not belong to the facility and there was no manual for the equipment. He stated the residents had not been checked off to use the device and the staff were not trained. He stated he made it clear to the former DON that he was not qualified to do the training, because the use of the equipment was not a part of his curriculum in therapy school. He stated he assumed everyone in the facility knew the device was used by the resident because it was in her room and it was a large piece of equipment and hard to miss. He stated he did not recall the date that he relayed this information to the former DON, but he asked her to ensure staff did not use the device. During an interview with the former DON on 10/3/25 at 4:16 PM she stated her last day at the facility was 8/15/25. She stated she did not remember the Director of Therapy telling her that the staff should not use the device. She stated she did know that the device was being used by staff to do the transfers of Resident #1 without training and competency checks. During an interview with the Medical Director/Primary Physician on 10/6/25 at 4:00 PM he stated his expectation was that residents be transferred by staff that had been trained and the equipment used had been safely checked. Review of Hospitality Aide A's training record reflected that she had completed training on Position and Transfer Techniques and fall prevention on 9 /11/25. She had also signed an acknowledgment on 10/3/25 that she was to follow the resident's care plan to know who required a Hoyer lift or who was to be lifted by two people. During an interview on 10/3/25 with Hospitality Aide A, she stated if there were any questions about how a resident was to be transferred, she knew she was to clarify this with the nurse.Observed Hospitality Aide B and CNA 1 perform a Hoyer lift on 10/4/25 at 1:30 PM using 2 people on Resident #4 and proper procedure and all all-safety rules were followed, and no incidents were noted. In an interview with the Administrator on 10/8/25 at 9:00 A.M., she stated after the incident on 9/3/25 they immediately completed the following corrections/interventions. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. Review of the Plan reflected: 1. Self-reporting protocol initiated on 9/3/25 and dated 9/3/25 by the Administrator . 2. Reported incident to the State within 2 hours of incident 9/3/25.3. Known perpetrator (Hospitality Aide A) suspended immediately pending investigation.4. Care plan for Resident #1 updated immediately and revised for injury.5. Skin assessments on all non-verbal residents and Safe Surveys of interviewable residents on halls A, B, C, D, were completed on 9/3/25 and 9/4/25.6. Interviews with staff members regarding whether they have seen a fellow staff member act in an abusive or neglectful manner toward a resident was completed on 9/3/257. Abuse and neglect Inservices started with all staff on 9/3/258. Ad HOC QAPI meeting held 9/3/25 for Inappropriate transfer by untrained staff.6. Audited all resident's Kardex/care plan on 09/3/25 to ensure all resident's level of care was updated and accurate.7. Educated and validated all staff understood the use of the Kardex/care plan system on 09/3/258. Review plan in QAPI monthly until resolved. Completed risk management entry 9/3/259. Medical director notified of this plan on 9/3/25 by the Administrator.10. The DON and Admin will monitor for potential neglect by reviewing incidents in stand up daily 9/3/2511. Monitor at least 10 of the following ADL Actions each week to ensure that the proper number of staff is providing assistance: bathing, bed mobility, transferring, walking initiated 9/3/25All monitoring above will continue for at least 4 weeks. The QAPI committee will review the findings and make revisions to the plan, as necessary. Verification 10/9/25 :Correction #1:In an Interview on 10/9/25 at 11:00 AM the Administrator stated that she received a call from the Charge Nurse notifying her of Resident #1's fall 0n 92/25. The resident was assessed and did not complain immediately. She did begin to complain of pain and the charge nurse notified her that the resident was requesting to go to the hospital. She was sent to the hospital and diagnosed with a fracture on her left knee. During the course of the investigation the administrator discovered that the resident was transferred by Hospitality Aide A that was performing duties such as transfer, that were not in her signed job description and was doing so without appropriate training on safety and operation. She stated she immediately filed a self-report and suspended the perpetrator pending the results of the investigation. She was informed by therapy staff that the mechanical lift device was not owned by the facility and no one in the facility had been trained to use the device. She stated she could see by viewing the video that Hospitality Aide A did perform the transfer with the device, and this was not a duty for which she was currently trained to do according to her job description. She notified Resident #1's family of the need to remove the device from the resident's room. The sit to stand device was no longer in the building as of 9/3/25. Record review of the facility reporting protocol template indicated all areas of the self-reporting protocol had been completed, dated, and signed by the staff. Correction #2. Record review of the nurses note dated 9/2/2025 11:34 PM Note Text: BP-146/94. T-97.5. P-101. R-18.Resident had a fall. Location: Resident Bathroom Fall information: Assisted, Legs gave out, .Cognition / Behavior at Time of Event: Oriented / no problem,This nurse was notified by the Hospital Aide that she had assisted residents to the ground via a gait belt from sit to stand device. The Hospitality Aide was assisting the resident to bathroom and during the transfer to toilet, resident could not get bearings on her legs, and they gave out. No injuries noted at the time of assisted fall. The Resident #1 did not hit her head, alert and oriented x4. resident complained of left knee discomfort. Resident assisted to w/c from floor by 3 staff members and placed in bed. Will continue to monitor for delayed injuries. Appears and/or states to be in pain. Describes the pain as: Intermittent, Location of pain: left knee Pain relieving intervention used at this time: routine oxycodone.Initial Treatment/New Orders:Resident Statement: resident stated legs gave out trying to transfer from sit & stand to toiletName of MD/NP notified: Medical Director/Primary Care PhysicianDate/time of notification: 09/02/2025 9:00 PM.Name of RP notified: husband Date/time of notification: 09/02/2025 9:00 PM.Interventions in place prior to fall: Scheduled toileting program, x2 assist when toiletingInterventions initiated in response to fall: Scheduled toileting program, x2 assist with transfers9/3/2025 01:52 Transfer Notification Note Text: Resident #1 was transferred to a hospital on [DATE] 1:30 AM related to resident had assisted fall in bathroom and hurt left knee, swelling noted in left knee, unable to manage pain or get x-ray until business hours, resident request to be sent to ER. Correction #3Record review of the Ad Hoc QAPI meeting revealed the meeting was conducted on 9/3/25 with the following members attending: Medical Director, Administrator, DON, ADON #1, ADON #2, MDS Nurse #1, MDS Director 1, MDS Director #2, Social Worker, Medical Records, Medical Director. Correction #4Record review of the Employee Disciplinary Report dated 9/4/25 revealed the Hospitality Aide A was suspended for investigation of Neglect and the improper transfer. Correction #5Record review of Skin assessments on all non-verbal residents and Safe Surveys of interviewable residents on halls A, B, C, D, completed on 9/3/25 and 9/4/25. Record review of Residents #5, #6 safe survey forms and interviews with Residents #2, #3, and #4 from 2 PM to 4 Pm on 10/9 /24 confirmed that they did feel safe in the facility, and all stated they were transferred properly. During interviews with Residents #2, # 3, #4, #5, and #6 from 2 PM to 4 PM they stated they could tell the difference between the Nurse's Aide, Hospitality Aides and Certified CNAs by their name badge. Correction #7 Interviews with 10 staff members Hospitality Aides A, B, C, K, E, D, F, G, H, I, J (formerly titled Hospitality aides but now classified as Nurses' Aides) between 2:00 PM and 4:00 PM on 10/9/25 reflected that they all attended a training skills lab on 9/3/25 and competed competency checks on 9/11/25. They stated hey were trained on Abuse and Neglect, Safe Transfers, an checked off on the Hoyer lift. Hospitality Aides A, B, C, K, E, D, F, G, H, I and J stated they were not allowed to operate the hydraulic controls and must transfer a mechanical lift with 2 people. Observed Hospitality Aide B and CNA 1 perform a Hoyer lift on 10/4/25 at 1:30 PM using 2 people on Resident #4 and proper procedure and all all-safety rules were followed, and no incidents were noted. Correction #8Reviewed QAPI minutes for meeting last held 10.3.25. Reviewed PIP dated 9/3/25 for incident. Meeting attended by medical director. Signed on 10/3/25. Correction # 9Interview with the Medical Director on 10/6/25 at 4:00 PM verified that he had been notified of the incident and the PIP on 9/3/25. Correction #10 Reviewed monitoring by the facility of ADL assistance initiated on 9/3/25 revealed that the monitoring was complete and current with evidence of monitoring from 9/3/25 to 10/9/25. Monitoring continues daily at the time of exit. During an Interview with the Administrator on 10/10/25 at 8:00 AM stated she only had 1 hospitality aide left in the building as of 10/9/25. She stated everyone else had completed training and skills checks and were ready to test. She stated scheduling was in process with herself and the new DON monitoring compliance During an Interview with Resident #1 on 10/9/25 at 4:00 PM she stated she had not been transferred by staff other than CNAs, and LVN, and that no Hospitality Aides had transferred her since the incident. She stated they always use 2 people to transfer. She stated she was transferred by the Hoyer lift and that her family member was asked by the administrator to remove the sit to stand device from the building. During an Interview with the current DON and the RNC on 10/9/25 at 4:10 PM both stated all Hospitality aides were checked off on transfer skills as of 9/19/25. Interviews with 7 Nurses' Aides (B, D, E, F, G, H, I, J) and one Hospitality Aide K on 10/9/25 between 9:00 and 10:00 AM were able to state their job description and duties they were allowed to perform. They stated they would go to the Kardex in the point of care to make sure what kind of care they needed. Hospitality Aide K stated she was told by the administrator that she cannot work on the floor until she passes her Texas Nurse's Aide Training requirement online and supervised clinical with competency checks. During Interviews with resident numbers 1,3,4,5,6,7 and 8 on 10/9/25 between 11:00 AM and 1:00 PM all stated that that they were transferred appropriately and had no transfer related incidents. Residents #1, #7 and #4 stated that were transferred by a Hoyer lift by two people, and never just by one person. Residents stated they could tell if a resident was a Hospitality Aide or CNA or a Nurse's Aide by looking at their employee's name badge. They stated Hospitality aides were not allowed to transfer residents. Record reviews of skills checklist and CNA online training revealed certificates of training and skills check lists for Nurses' Aides B, E, F, G, H, I, J and one Hospitality Aide K were in their employee files and dated before entrance. During Interviews on 10/9/25 between 11:00 and 1:00 PM Nurses' Aides B, D, E, F, G, H, I, J and one Hospitality Aide K stated they signed a nurse's aide job description stating their duties and name tags were updated to reflect their current job duties. Record review of Resident #1's care plan reflected that she was a Hoyer lift as of 9/3/25. Record review of Resident #'s 1, 2, 3, 4, 5, 6, and 7's care plan and Kardex reflected accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to maintain clinical records that were complete and/or accurate for 1 of 10 residents (Resident #1) reviewed for clinical records in that:<BR/>The RN A did not document Resident # 1 was transferred to the ER on 5.12.25. <BR/>This failure could place residents at risk of inaccurate and incomplete clinical records resulting in an inaccuracy in the care the resident received.<BR/>The findings include: <BR/>Record review Record review of Resident # 1's Face Sheet revealed she was a [AGE] year-old female originally admitted to the facility on 4.20.25 and readmitted on 5.20.25. She had diagnoses of fracture of hip, end stage renal disease (last stage of kidney failure) osteoporosis (porous brittle bone that breaks easily with spontaneous fractures common), and calciphylaxis (rare and life-threatening syndrome which involves calcium buildup in the skin and fat tissue leading to clotting and painful lesions).<BR/>Record review of admission MDS dated 5.3.25 documented Resident #1 had a BIMS score of 7 (which indicated moderate cognitive impairment).<BR/>Record review of Resident #1's Nursing progress Notes for 5.12.25 stated:<BR/>Transfer Notification - Late entry<BR/>Effective Date: <BR/>5/12/2025 10:38:0<BR/>Created By: DON<BR/>Created Date : <BR/>5/23/2025 11:21:03<BR/> Resident was transferred to a hospital on [DATE] 10:38 AM related to AMS<BR/>Hypoxia(low oxygen content in the blood)<BR/>This is intended to serve as notice of an emergency transfer<BR/>Record review of the nurses note dated 5.12.25 indicated Resident #1 returned to the facility with a diagnoses of urinary tract infection at 1:39 PM on 5.12.25<BR/>Resident #1 was nonresponsive and unavailable for an interview at the time of the investigation.<BR/>In an interview on 5.22.25 at 2:30 PM, Resident # 1's family member said she was not aware of Resident #1's transfer to the emergency room on 5.12.25 @ 10:38 AM when she experienced an altered mental status. She stated she found out the resident had a UTI when she visited the resident at the nursing facility later that day. <BR/>In an interview on 5.23.25 at 11.43 AM RN A stated she thought she did notify Resident #1's family member <BR/>of the transfer on 5.12.25 but if it was not documented, and the family member stated she did not notify her she could not state with certainty that she did notify her. She stated she failed to follow proper procedure by not documenting the event when it occurred which could result in an inaccuracy in the care the resident received. <BR/>In an interview on 5.23.25 at 11:50 AM the DON stated she was in the facility and she and another nurse were present and assisted with the transfer. She stated it was her expectation that resident information was documented in a resident's record at the time it occurred. She stated if documentation were not made a late entry could be made at a later date and identified as a late entry with the date and time the event occurred and the time and date the documentation was created. <BR/>Record review of the facility's policy, Documentation not dated, revealed [in part]:<BR/>Documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. The facility will maintain complete and accurate documentation for each resident.<BR/>The facility will ensure that information is comprehensive and timely and properly signed.<BR/>Complete documentation in the electronic health record in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview and record review the facility failed to ensure the assessments accurately reflected the resident status for 2 of 11 residents (Residents #4 and #24) reviewed for assessments . <BR/>1. The Facility failed to ensure Resident #4's MDS was accurately completed with the residents tobacco use. <BR/>2. The facility failed to ensure Resident #24's MDS was accurately completed with Resident #24's anticoagulant. <BR/>These failures could place residents at risk by decreasing the accurate information available to determine the care and services needed for each resident.<BR/>The findings include:<BR/>1. Record review of Resident # 4's face sheet, dated 1/22/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Rhabdomyolysis (rare muscle injury where your muscles break down), high blood pressure and congestive heart failure. <BR/>Record review of Resident #4's Annual MDS, dated [DATE], revealed Section C- Cognitive Patterns BIMS score of 5, which indicated Severely impaired cognition. Section J- Health Conditions revealed no evidence of current tobacco use. <BR/>Record review of Resident #4's Care Plan, dated 12/23/2024, revealed no problem, goal or intervention related to Resident #4's use of smokeless tobacco.<BR/>During an observation and interview on 01/202/2025 at 2:43 PM Resident # 4 was sitting up in his bed. A brown ball of substance was sitting on his bedside table. Resident #4 stated the substance was his chewing tobacco. Resident #4 stated he took it out to eat and then put it back into his mouth. <BR/>2. Record review of Resident #24's face sheet, dated 1/22/2025, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. with a readmission date on 01/07/2025 with the following diagnosis of respiratory failure, dementia, high blood pressure, congestive heart failure and Cerebral Infraction (stroke). <BR/>Record review of Resident #24's Physician order revealed a start date of 09/26/2024 Pradaxa oral capsule 150 MG (Dabigatran Etexilate Mesylate) Give 1 capsule by mouth two times a day related to Cerebral Infraction. <BR/>Record review of Resident #24's Quarterly MDS, dated [DATE], revealed: Section C- Cognitive Pattern she had a BIMS score of 13, which indicated cognitively intact cognition. Section N- Medications documented no evidence of anticoagulant use. <BR/>During an interview on 01/22/2025 at 3:18 PM, LVN B stated she was the MDS coordinator and the MDS should have included Resident #4's tobacco use and Resident #24's anticoagulant use. LVN B stated their cooperate monitored the MDS. LVN B stated the effect on residents could have affected residents' ability to receive outside resources. LVN B stated what led to the failure was oversight staff not looking at documentation completely. <BR/>During an interview on 01/22/2025 at 3:33 PM, the DON stated her expectation was for MDS to be completed correctly and include all resident care needs. The DON stated the MDS was responsible to ensure MDS's were completed and their corporate monitored. The DON stated the effect on residents could have had interference with the resident's plan of care and what was being done to meet their goals. The DON stated they did not have a policy for the MDS, they followed the CMS Resident Assessment Instrument User's Manual. <BR/>Record review of the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (https://www.cms.gov/files/document/finalmds-30-rai-manual-v11811october2023.pdf accessed on 01/22/2025) documented the following:<BR/>J1300 Current Tobacco Use: <BR/>Steps for Assessment<BR/>1. Ask the resident if they used tobacco in any form during the <BR/>7-day look-back period. <BR/>2. If the resident states that they used tobacco in some form <BR/>during the 7-day look-back period, code 1, yes. <BR/>DEFINITION<BR/>TOBACCO USE<BR/>Includes tobacco used in any <BR/>form.<BR/>CMS's RAI Version 3.0 Manual CH 3: MDS Items [J]<BR/>October 2023 Page J-27<BR/>J1300: Current Tobacco Use (cont.)<BR/>3. If the resident is unable to answer or indicates that they did not use tobacco of any kind <BR/>during the look-back period, review the medical record and interview staff for any indication <BR/>of tobacco use by the resident during the look-back period. <BR/>Coding Instructions<BR/>o Code 0, no: if there are no indications that the resident used any form of tobacco. <BR/>o Code 1, yes: if the resident or any other source indicates that the resident used tobacco <BR/>in some form during the look-back period.<BR/>N0415: High-Risk Drug Classes: Use and Indication .Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days).<BR/>N0415E2. Anticoagulant: Check if there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days) .<BR/>N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days). <BR/>N0415I2. Antiplatelet: Check if there is an indication noted for all antiplatelet medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 24 residents (Resident #4, Resident #44 and Resident #76) reviewed for comprehensive person-centered care plans. <BR/>1. The facility failed to ensure Resident #4's comprehensive care plan was person centered and measurable when addressing Resident #4's Tobacco use.<BR/>2. The facility failed to ensure Resident #44's comprehensive care plan contained the resident's use of Trapeze bar (medical device used to help patient move and positions themselves in bed) for bed mobility.<BR/>3. The facility failed to ensure Resident # 76's comprehensive care plan contained Resident #76's amputation .<BR/>4. The facility failed to ensure Resident #76's use of a fall mat was implemented as documented in the resident's care plan. <BR/>These failures could place residents at risk for not receiving care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.<BR/>Findings include: <BR/>1. Record review of Resident #4's electronic face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Rhabdomyolysis (breakdown of muscle tissue causing chemical release) Syncope and collapse (brief loss of consciousness), Hypertension (high blood pressure), Congestive heart failure , and Unsteadiness on feet.<BR/>Record review of Resident #4's Annual MDS, dated [DATE], revealed Section C cognitive Patterns BIMS score 05, which indicated severely impaired cognition. Section FF0115 Functional Limitation in range of Motion Upper Extremity impairment on one side. Lower extremity impairment on both sides. Section GG0120 Mobility Devices Wheelchair. Section J 1300 Current Tobacco use No.<BR/>Record review of Resident #4's Care Plan, dated 12/23/2024, revealed no problem, goal or intervention related to Resident #4's use of smokeless tobacco.<BR/>During an observation and interview on 01/20/2025 at 2:43 PM revealed Resident # 4 was sitting up in his bed. A brown ball of substance sat on his bedside table. Resident #4 stated it was his chewing tobacco. Resident #4 stated he took it out to eat and then put it back into his mouth. <BR/>2. Record review of Resident #44's electronic face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a previous admission on [DATE]. Resident #44 had diagnoses which included Encounter for orthopedic aftercare involving surgical amputation, Heart Failure, Nicotine Dependence, Pressure ulcer of sacral region, stage 4 and Acquired Absence of left leg below knee.<BR/>Record review of Resident #44's Physician Orders, last reviewed 11/17/2024, revealed no orders for use of a Trapeze bar.<BR/> Record review of Resident #44's Annual MDS, dated [DATE], Section C cognitive Patterns BIMS score 14, which indicated Intact cognition ). Section GG Functional Abilities-GG0130 Toileting Dependent, Lower body dressing setup or clean-up assistance, lying to sitting on bed Independent, Chair to bed transfer Independent. Section I Active Diagnosis Amputation. J1300 Current Tobacco Use Yes.<BR/>Record review of Resident #44's Care Plan, dated 12/20/204, did not address use of a Trapeze Bar for bed mobility. No goals or interventions for use of a Trapeze Bar were addressed in the Care Plan, dated 12/20/2024.<BR/>During an observation on 01/21/2025 at 09:03 AM revealed Resident #44 lying in bed and a trapeze bar attached to the bed frame . <BR/>During an interview on 01/22/2025 at 12:05 PM, LVN A stated she was not sure how long Resident #44 had been using the trapeze bar. She stated she thought therapy recommended it. She stated she was not sure if he needed a physician order for the trapeze bar or if it should be on care plan.<BR/>During an interview on 01/22/2025 at 1:30 PM with PTA D stated Resident #44 had a trapeze bar for a long time. PTA D stated he did not believe the therapy department recommended use of the trapeze bar.<BR/>During an interview on 01/22/2025 at 2:40 PM with MDS Coordinator LVN B stated use of a trapeze bar should be care planned. LVN B stated if not care planned staff would not have known he needed the trapeze bar and how often he needed it. LVN B stated she did not know how long the resident had been using the trapeze bar. LVN B stated she was not sure who ordered the trapeze bar for this resident. LVN B stated if there was no order then it would not be triggered to be care planned .<BR/>During an interview on 01/22/2025 at 2:45 PM, the DON stated use of trapeze bars should be care planned and did not need an order. The DON stated this could affect residents in that staff would not be able to monitor the effectiveness of the trapeze bar. The DON stated this could be a negative effect on the resident if trapeze bar use was not monitored and not being used correctly by the resident. The DON stated she did not know why this was not care planned and she monitored care plans for accuracy. The DON stated no one else at the facility monitored care plans . <BR/>3. <BR/>Record review of Resident #76's electronic face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #76 had diagnoses which included Diabetes Mellitus, Acute Kidney Failure, Hypertension , Acquired Absence of Right Leg Below Knee (Amputation)<BR/>Record review of Resident #76's Physician Orders, dated 01/21/2025, revealed: no orders for fall mat at bedside.<BR/>Record review of Resident #76's admission MDS, dated [DATE], Section C Cognitive status BIMS score 14, which indicated the resident was intact cognitively. Section GG0115 Functional Limitation in Range of Motion Upper extremity impairment on one side, Lower extremity impairment on one side. GG0120 Mobility Devices Walker, Wheelchair, Limb Prosthesis Section J Health Conditions J1300 Current Tobacco User No. Section J1 900 Number of falls since Admission/Entry two or more.<BR/>Record review of Resident #76's Care Plan, dated 12/18/2024, reflected Focus: the resident is risk for fall. Date initiated: 12/06/2024 Revision on 12/182024 Goal: the resident will be free of falls through the renew date.12/17/2024. Intervention included fall mat while in bed. Amputation of right leg below knee was not addressed. Use of Prosthetic leg was not addressed.<BR/>During an observation on 01/2025 at 10:30 AM and 01/21/2025 at 09:03 AM revealed no fall mat was observed by the bed in the room for Resident #76.<BR/>During an interview on 01/22/25 at 09:20 AM, the DON stated she was responsible for entering fall risk assessments on care plans and MDS Coordinators entered items triggered on the CAA (Care Area Assessment)from the MDS. The DON stated care plans were reviewed weekly during the standard of care meeting. The DON stated she conducted quarterly audits to identify issues that had been resolved and needed to be cancelled. The DON stated equipment specified in the care plan must be in place for the resident such as a f all mat. The DON stated the expectations were interventions on the care plan were done and if not coaching/retraining was provided. The DON stated if a fall mat was noted in an intervention, a fall mat should be in place if the resident was in bed or in the room . <BR/> During an interview on 01/22/2025 at 01:46 PM, LVN C stated she looked at care plans from time to time. LVN C stated the DON reviewed changes during the daily morning meeting. LVN C stated any equipment used for a resident should be on the care plan. LVN C stated the consequences for a resident if the equipment was not addressed on the care plan, a needed device could be missed by the caregiver and not be used. <BR/>Record review of the facility's, undated, policy titled Comprehensive Care Planning, reflected:<BR/>The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .<BR/>The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. <BR/>Record review of the facility's, undated, policy titled Uniform Smoke Free Policy reflected.<BR/>Residents will be allowed to keep smokeless tobacco, i.e., chewing tobacco, snuff, in their room and in their possession. Residents may use smokeless tobacco at their own discretion. Residents will be educated regarding cleanliness and proper disposal of the smokeless tobacco.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to update the comprehensive care plan after the assessment for 1 of 6 residents (Resident #'s 53) reviewed for plan of care revision. <BR/>The facility failed to include in the care plan, nutritional interventions for a significant weight loss for Resident #53 after the 11/26/2023 Comprehensive MDS . <BR/>This failure could place the residents at risk of staff and providers not having the most current information for the Resident's plan of care. <BR/>Findings included:<BR/>Record review of Resident #53's electronic health record revealed a [AGE] year-old male with a, re-admission date 11/21/2023, Diagnoses: dysphagia (difficulty swallowing), essential (primary) hypertension (high blood pressure), Alzheimer's disease (progressive memory loss), atrial <BR/>fibrillation (the hearts upper chambers beat out of sequence with the lower chambers which can lead to poor blood flow, blood clots and stroke), anxiety disorder (feelings of worry and fear that interfere with daily activities), muscle weakness and muscle wasting and atrophy (decreased muscle mass resulting in weakness due to decreased physical activity, and nutritional deficiencies).<BR/>Record review of Resident 53's electronic health record revealed the most recent Care Plan dated 3/21/23 listed a focus area for potential risk for malnutrition dated 3/1/23. The goal was for Resident #53 to maintain a stable weight and nutritional parameters. The Care Plan further revealed the interventions were last updated 5/16/23, the interventions were not reviewed or revised after the 31-pound weight loss in November 2023. <BR/>Record review of Resident #53's electronic health record revealed he had a weight of 131.6 on 11/21/23 and a weight of 164.6 on 11/8/23 (a 31-pound weight loss loss). The weight documented on 11/21/23 was the last recorded weight for the resident.<BR/>Record review of Resident #53's admission MDS with an assessment reference date of 11/26/23, section K 0200 documented a weight of 132 pounds and a height of 72 inches. Section K0300 documented that Resident #53 had a weight loss of 5 percent or more in the last month and was not on a prescribed weight loss program. Section K0520 he had not received intravenous feeding, a feeding tube, mechanically altered diet, or a therapeutic diet while not a resident, or while a resident. <BR/>Record review of the electronic health record revealed the physician orders, dated 12/6/23, for Resident #53 reflected that he was on a Regular diet with Regular consistency and thin fluids.<BR/>In an interview on 12/06/23 at 10:52 AM Resident #53's wife stated that he did not eat as much due to his dementia. She stated she did not know that he had a significant weight loss . She stated she was here for every meal, and she cuts his meat. She stated he has dentures and has no trouble chewing.<BR/>Interview on 12/07/23 at 3:32 pm with the DON revealed it would be her expectation that re-weight would happen if a large discrepancy in weight was discovered, and she would also expect the family and physician to be notified. She stated the care plan should be updated by the MDS nurse after the MDS was completed. She stated failure to update the care plan could result in the resident not receiving the care he needs. <BR/>Interview on 12/07/23 at 4:03 pm with MDS Coordinator revealed she was responsible for updating the care plan with the MDS but if it is an acute problem then it was nursing that was to update the care plan. She stated failure to update the care plan and communicato the te the weight loss to the interdisciplinary team could result in the resident not receiving the care he needs. <BR/>Review of the facilities undated policy titled: Comprehensive Care Planning revealed the following:<BR/>The facility will establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives interventions are the specific services that will be implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 (Resident # 55) residents reviewed for quality of care.<BR/>The facility failed to ensure Resident #55's pain was managed at a level that did not interfere with the resident's sleep or day to day activities <BR/>This deficient practice could place residents at risk of pain, discomfort, and a diminished quality of life.<BR/>Findings included:<BR/>A review of Resident #55's Electronic Health Record (EHR) indicated her admission date was 05/31/2023 with relevant diagnoses of pain in left ankle and joints of left foot, abnormal gait, and mobility (difficulty walking and moving from place to place), muscle atrophy (decrease in size of the muscle tissue from not using the muscle). <BR/>Review of Resident #55's routine medications indicated :<BR/>Tylenol 500 mg 2 tablets every 6 hours for fever with a start date of 8/8/23, and Tylenol 500 mg 2 po every 6 hours as needed for pain/inflammation with a start date of 12/7/23.<BR/>Review of Resident #55's quarterly MDS assessment dated [DATE] revealed Resident #55 experienced pain o at a level of an 8 constantly during the 5-day lookback period. <BR/>Review of the MDS assessment dated [DATE] showed a Quarterly Assessment which revealed in the pain assessment the following: interview; Section J0300- <BR/>Have you had pain or hurting at any time in the last 5 days? - Yes<BR/>How much of the time have you experienced pain or hurting over the last 5 days? - Almost Constantly<BR/>Please rate your pain over the last 5 days on a zero to ten pain scale, with zero being no pain and ten as the worst pain you can imagine. 08. <BR/>Record Review of Resident #52's MAR revealed the resident had recieved Tylenol 500 mg caps 2 by mouth on 11/5/23 for a pain level of 5, on 11/9/23 for a pain level of 4, and on 11/27/23 and 11/28/23 for pa pain level of 5, and not again until 12/5/23 for a pain level of 3. <BR/>In an interview with Resident #55 on 12/06/23 at 10:25 AM she said that she normally, constantly had pain since her admission in May 2023. She said that she had told someone that she needed a pain medication, the pain medication that had been given did not help and they were supposed to get her something else ordered for pain. She stated she did not remember who she told about her pain, or if it was a nurse. She stated that the pain limits her day-to-day activity and was constant. <BR/>In an interview with the DON (Director of Nursing) on 12/07/23 at 2:28 PM She stated said she did not know the resident was having so much pain. She stated it was her expectation that the pain assessment information gathered on the 11/10/23 MDS would have resulted in the nurse communicating with the physician and getting her an order for pain medication She said that the RN MDS Coordinator signed the MDS, and the social worker did the actual interview for pain on the 11/10/23 quarterly MDS and it should have been addressed by nursing. The social worker did the MDS and did not notify her with her pain score. She said stated she would be contacting the physician to get a new order for pain. She stated it would be her expectation that a nurse completes the pain interview in section J of the MDS.A facility policy on pain management was not reviewed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents with PRN orders for psychotropic drugs were limited to 14 days for 3 of 5 residents (Resident #s 14, 53 and 47) and a gradual dose reduction for a sedative/hypnotic medication was attempted for 1 of 5 residents (Resident #18) whose medication regimens were reviewed for unnecessary medications in that:<BR/>A. Resident #14's order for PRN diazepam/Haldol gel was not discontinued after 14 days. <BR/>B. Resident #53's order for PRN Lorazepam (antianxiety medication) was not discontinued after 14 days. <BR/>C. Resident #47 had an order for the antianxiety medication Alprazolam (Xanax) 1 mg by mouth every 12 hours as needed (PRN) for anxiety, dated 8/25/22, which did not have an end/stop date.<BR/>D. Resident #18 had an order for the sedative/hypnotic medication Zolpidem (Ambien) 10 mg by mouth at bedtime for difficulty sleeping, dated 7/02/2022, with no attempts of a gradual dose reduction.<BR/>This failure could place residents administered PRN and routinely scheduled psychotropic medications at risk of adverse side effects from prolonged use of psychotropic medications including stroke and death.<BR/>The findings included:<BR/>Resident #14<BR/>Review of Resident #14's face sheet, dated 10/25/2022, revealed he was a [AGE] year-old male, admitted to the facility on [DATE] and was receiving hospice care services. Diagnosis included: senile degeneration of the brain; anxiety disorder; and other specified depressive episodes. <BR/>Review of Resident #14's Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 1 out of 15 (Severe Cognitive Impairment). <BR/>Review of Resident #14's Physician Orders, dated 10/25/2022, revealed Resident #14 was prescribed diazepam/Haldol gel 2mg/2mg, give 1 ml topically to inner wrist, rub in well, PRN every 4 hours as needed for anxiety, with a start date of 09/06/2022, and an end date of indefinite. <BR/>Review of Resident #14's pharmacy consultant reviews for September 2022 revealed the consultant pharmacist had not recommended that the resident's order for diazepam/Haldol gel be discontinued because the 14-day maximum allowed prescribed length for prn psychotropic medications had been met. <BR/>Resident #53<BR/>Review of Resident #53's face sheet, not dated, revealed she was admitted to the facility on [DATE] and was 82-years-old and had diagnoses including anxiety disorder, insomnia, Alzheimer's Disease, and major depressive disorder.<BR/>Review of Resident #53's Quarterly MDS, dated [DATE], documented she had a BIMS score of 11 out of 15 (Moderate Cognitive Impairment). During the seven-day look-back period she had received an anti-anxiety medication for 7 days. No behavioral symptoms were documented. <BR/>Review of Resident #53's pharmacy consultant reviews for September did not reveal the consultant pharmacist recommended that the resident's order for Lorazepam be discontinued because the 14-day maximum allowed prescribed length for PRN psychotropic medications had been met. <BR/>Review of Resident #53's Physician Orders, dated 10/25/2022, revealed that the resident was to continue receiving Lorazepam 2 mg/ml 0.5 ml every 4 hours PRN and Lorazepam 2 mg/ml 1 ml every 4 hours PRN as needed for anxiety. The medication was ordered on 08/26/2021. The orders did not specify a stop date. <BR/>Review of Resident #53's Medication Administration Records dated 10/1/2022 through 10/25/2022 did reveal documentation of PRN Lorazepam 2 mg/ml give 1 ml as given two times on 10/01/2022.<BR/>In an interview on 10/25/22 at 3:32 PM, the Director of Nurses stated that PRN orders for psychotropic medications were to be discontinued after 14 days and that justification from the prescriber was required for PRN orders for psychotropic medications that extended beyond the 14-day limit. She stated the Lorazepam continued because the hospice staff refused to write a PRN order for 14 days duration. She stated the diazepam/Haldol gel continued because hospice refused to write a PRN order for 14 days duration. The DON stated she was responsible for seeing that PRN psychotropic medications were not administered PRN longer than 14 days. <BR/>Resident #47<BR/>Review of Resident #47's face sheet, not dated, revealed a [AGE] year-old male who was initially admitted to the facility on [DATE]. The form documented the resident's diagnoses included quadriplegia, other specified depressive episodes, anxiety disorder, and insomnia.<BR/>Review of Resident #47's Physician Orders, dated 10/25/2022, revealed an order for Alprazolam 1 mg by mouth every 12 hours as needed (PRN) for anxiety, with a start date of 8/25/2022. The order did not include and end/stop date.<BR/>Review of Resident #47's quarterly MDS assessment, dated 10/05/2022, revealed the resident had received antianxiety medication 1 out of 7 days during the assessment review period.<BR/>Resident #18<BR/>Review of Resident #18's face sheet, not dated, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Additional diagnoses included cerebral infarction, hemiplegia and hemiparesis affecting right side, diabetes mellitus type 2, epilepsy unspecified, insomnia, hypertension, gastro-esophageal reflux disease, and hypothyroidism. <BR/>Review of Resident #18's active Physician Orders, dated 10/25/2022, revealed the following medication orders:<BR/>Amitriptyline 75 mg by mouth one time daily related to insomnia, dated 6/14/2022 (Elavil - antidepressant medication);<BR/>Zolpidem Tartrate 10 mg by mouth at bedtime for difficulty sleeping, dated 7/06/2022 (Ambien - sedative/hypnotic medication).<BR/>The physician orders did not include a referral for mental health/psychological evaluation and services.<BR/>The physician orders did not include orders for anti-anxiety medication.<BR/>Review of Resident #18's quarterly MDS assessment, dated 10/21/22, revealed the resident had received antidepressant medication and hypnotic medication 7 out of 7 days during the assessment review period. The diagnosis section for psychiatric/mood disorder did not have any diagnoses selected. (The diagnoses of depression and anxiety were not selected.)<BR/>Review of Resident #18's comprehensive care plan revealed a care plan, dated 9/09/2022, which documented The resident uses anti-anxiety/hypnotic medications - anxiety disorder - Zolpidem. The goal did address decreased episodes and signs/symptoms of sleep disturbance. The interventions/approaches included administering anti-anxiety medication as ordered by physician, monitoring for effectiveness and side effects of anti-anxiety medication.<BR/>Review of the Pharmacist Consultant Medication Regimen Review reports revealed a Director of Nursing Report, dated 7/29/2022. The report documented the Pharmacist Consultant had reviewed Resident #18's medication orders on 7/08/22 - High Dose - Medication: Ambien tablet 10 mg (Zolpidem Tartrate) 1 po QHS (by mouth at bedtime). <BR/>Recommendation: In geriatric patients, clearance of zolpidem is similar in men and women. The recommended dose of AMBIEN in geriatric patients is 5 mg regardless of gender per the FDA. Please consider reducing dose of Ambien to 5 mg QHS (at bedtime). <BR/>There was no documented evidence on the report that the recommendation had been followed-up on by the DON.<BR/>Review of the Pharmacist Consultant Medication Regimen Review report to Resident #18's physician, dated 9/30/2022, revealed the request for a response to the review date on 9/24/2022.<BR/>The report documented High Dose - Medication: Ambien tablet 10 mg (Zolpidem Tartrate) 1 po QHS (by mouth at bedtime).<BR/>Recommendation: In geriatric patients, clearance of zolpidem is similar in men and women. The recommended dose of AMBIEN in geriatric patients is 5 mg regardless of gender per the FDA. Please consider reducing dose of Ambien to 5 mg QHS (at bedtime). <BR/>The physician response, dated 10/19/22, documented Disagree - Lots of anxiety regarding uterine cancer that is metastatic. Having difficulty sleeping.<BR/>In an interview on 10/25/2022 at 6:32 PM, the DON stated the Medical Director was not Resident #18's physician. The DON stated Resident #18 had a lot of anxiety related to having cancer.<BR/>Review of the facility policy titled Psychotropic Drugs, dated as revised 10/25/2017, revealed the following [in part]:<BR/>The facility must ensure that .<BR/>1. Residents who have not psychotropic drugs will not be given psychotropic drugs unless the medication is used to treat a specific condition as diagnosed and documented in the clinical record.<BR/>2. Residents who use psychotropic drugs receive gradual dose reduction, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.<BR/>4. PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing physician believes that it is appropriate for the prn order to be extended beyond 14 days, he should document their rationale in the resident's medical record and indicate the duration for the prn order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report the results of investigations of allegations of abuse in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 4 (Resident #2, Resident #3, Resident #7and Resident #12) of 10 residents reviewed for abuse. <BR/>The facility failed to report the investigations findings of abuse when Resident #3 attempted to remove Resident #2 from dinner table resulting Resident #2 receiving nail marks on her arm from Resident #3. <BR/>The facility failed to report the investigation findings of abuse when Resident #12 slapped Resident #7 in the face while both residents were passing in the hall. <BR/>This failure could place residents at risk for abuse. <BR/>Findings include:<BR/>Resident #2<BR/>Record review of Resident #2's, , MDS dated [DATE] indicated the resident was an [AGE] year-old female with a BIMS of 3 (severely cognitively impaired). The residents Medical Diagnoses were Dementia (a decline in cognitive abilities), and Psychotic Disturbances (a severe mental disorder that causes abnormal thinking and perceptions). The resident was a Hospice patient. Resident #2 resided in secure unit of facility.<BR/>Resident #3<BR/>Record review of Resident #3's, MDS dated [DATE] indicated the resident was an [AGE] year-old female with a BIMS 1 (severely cognitively impaired). The residents Medical Diagnoses were Dementia (a decline in cognitive abilities) and Rhabdomyolysis (rare muscle tissue breakdown). Resident #3 resided in the secure unit of facility. <BR/>Record review of incident report date 7/22/23, LVN A witnessed Resident #3 attempting to remove Resident #2 from dining room table. Resident #2 refused to move, and Resident #3 clawed her fingernails into Resident #2's inner left arm, leaving nail marks. LVN A immediately separated residents and de-escalated situation. LVN A assessed Resident #2, skin was not broken, red marks from nails were visible. Vitals taken. Resident #2 did not seem bothered by incident or upset. Resident #3 was placed on 1 on 1 supervision, social services provided. Resident #3 was assessed, no injuries, had no concerns moments after incident. Resident #3 has no history of aggressive behaviors towards others. LVN A notified the DON, physician, Hospice, and family of both residents.<BR/>Interview on 8/8/23 at 10:30 am, the DON stated she reported the incident to HHSC on 7/22/23. The DON stated her investigation did not establish what caused the behavior of Resident #3 to try and remove Resident #2 from the table. Neither resident was interview-able and both residents had no concerns or any mental stress. The DON stated she provided in-service training to staff on 7/23/23, topics include Prevention of Physical abuse, Preventing and Recognizing Triggers of Behaviors and Dementia. The DON stated Resident #3 does not have any history of aggression and has not done anything like this before. The DON stated she performed an investigation on incident, but she must have forgotten to submit the PIR findings for incident on 7/22/23, on form (3613-A) to HHSC. <BR/>Resident #7<BR/>Record review of Resident #7, [AGE] year-old female, discharged from facility 7/14/23 (moved closer to family) last MDS dated [DATE] BIMS 6 (severely cognitively impaired). Medical Diagnosis Alzheimer (a neurodegenerative disease), Resident # 7 resided in facilities secured unit. <BR/>Resident #12<BR/>Record review of Resident #12, [AGE] year-old female, MDS dated [DATE] BIMS 00 (severely cognitively impaired), Medical Diagnosis Alzheimer (a neurodegenerative disease), Resident #12 resides in facility secure unit. <BR/>Record review of incident report dated 5/30/23 indicated as Resident #12 and Resident #7 passed each other in the hall on the secure unit at 3:45 pm, Resident #12 slapped Resident #7 on the left side of face. CNA A witnessed incident. CNA B stated no words were exchanged between residents before or after the incident. CNA B stated both residents kept walking down the hall as if nothing happened. CNA A reported incident to LVN A. LVN A assessed both residents, Resident #7 did not have any marks or redness on left side of face or injuries anywhere on face or body. Resident #12 had no injuries. LVN A stated neither Resident #7 or Resident #12 had any clue or was aware of any incident. LVN A reported incident to the DON, resident's physicians, and families. <BR/>Interview on 8/9/23 at 11: 00 am, the DON stated she reported incident to HHSC on 5/30/23, and an Intake Investigation Worksheet was assigned to incident. The DON stated her investigation did not establish what caused the behavior of Resident #12 to slap Resident #7, neither resident had any history of aggression towards anyone or each other. Neither resident suffered injury or mental destress over incident. Both residents are non-interview able. The DON stated she provided in-service training to staff on 5/31/23, topics include Tips and Strategies for De-Escalating Aggressive, Hostile, or Violent Patients. The DON stated she has been submitting incidents to HHSC for several months due to not having a permanent Administrator, (facility has been using interim Administrators for the past several months). The DON stated she performed an investigation on the incident, but she must have forgotten to submit the PIR findings for the incident on 5/30/23, on form (3613-A) to HHSC. <BR/>Record review of facility's Resident-to-Resident Altercations policy Revised 9/2022 indicated the following:<BR/>4. If two residents are involved in an altercation:<BR/> j. Report incidents, findings, and corrective measures to appropriate agencies as outlined in <BR/> Abuse, Neglect-Reporting, and Investigation<BR/>Record review of facility's Abuse/Neglect Policy Revised 3/29/18<BR/>Section F Investigation<BR/> 3. G. Other pertinent information as available. <BR/>The written report must be sent to HHSC no later than the Fifth working day after the initial report. The facility will use the designed state reporting form (3613-A). <BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 24 residents (Resident #4, Resident #44 and Resident #76) reviewed for comprehensive person-centered care plans. <BR/>1. The facility failed to ensure Resident #4's comprehensive care plan was person centered and measurable when addressing Resident #4's Tobacco use.<BR/>2. The facility failed to ensure Resident #44's comprehensive care plan contained the resident's use of Trapeze bar (medical device used to help patient move and positions themselves in bed) for bed mobility.<BR/>3. The facility failed to ensure Resident # 76's comprehensive care plan contained Resident #76's amputation .<BR/>4. The facility failed to ensure Resident #76's use of a fall mat was implemented as documented in the resident's care plan. <BR/>These failures could place residents at risk for not receiving care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.<BR/>Findings include: <BR/>1. Record review of Resident #4's electronic face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included Rhabdomyolysis (breakdown of muscle tissue causing chemical release) Syncope and collapse (brief loss of consciousness), Hypertension (high blood pressure), Congestive heart failure , and Unsteadiness on feet.<BR/>Record review of Resident #4's Annual MDS, dated [DATE], revealed Section C cognitive Patterns BIMS score 05, which indicated severely impaired cognition. Section FF0115 Functional Limitation in range of Motion Upper Extremity impairment on one side. Lower extremity impairment on both sides. Section GG0120 Mobility Devices Wheelchair. Section J 1300 Current Tobacco use No.<BR/>Record review of Resident #4's Care Plan, dated 12/23/2024, revealed no problem, goal or intervention related to Resident #4's use of smokeless tobacco.<BR/>During an observation and interview on 01/20/2025 at 2:43 PM revealed Resident # 4 was sitting up in his bed. A brown ball of substance sat on his bedside table. Resident #4 stated it was his chewing tobacco. Resident #4 stated he took it out to eat and then put it back into his mouth. <BR/>2. Record review of Resident #44's electronic face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a previous admission on [DATE]. Resident #44 had diagnoses which included Encounter for orthopedic aftercare involving surgical amputation, Heart Failure, Nicotine Dependence, Pressure ulcer of sacral region, stage 4 and Acquired Absence of left leg below knee.<BR/>Record review of Resident #44's Physician Orders, last reviewed 11/17/2024, revealed no orders for use of a Trapeze bar.<BR/> Record review of Resident #44's Annual MDS, dated [DATE], Section C cognitive Patterns BIMS score 14, which indicated Intact cognition ). Section GG Functional Abilities-GG0130 Toileting Dependent, Lower body dressing setup or clean-up assistance, lying to sitting on bed Independent, Chair to bed transfer Independent. Section I Active Diagnosis Amputation. J1300 Current Tobacco Use Yes.<BR/>Record review of Resident #44's Care Plan, dated 12/20/204, did not address use of a Trapeze Bar for bed mobility. No goals or interventions for use of a Trapeze Bar were addressed in the Care Plan, dated 12/20/2024.<BR/>During an observation on 01/21/2025 at 09:03 AM revealed Resident #44 lying in bed and a trapeze bar attached to the bed frame . <BR/>During an interview on 01/22/2025 at 12:05 PM, LVN A stated she was not sure how long Resident #44 had been using the trapeze bar. She stated she thought therapy recommended it. She stated she was not sure if he needed a physician order for the trapeze bar or if it should be on care plan.<BR/>During an interview on 01/22/2025 at 1:30 PM with PTA D stated Resident #44 had a trapeze bar for a long time. PTA D stated he did not believe the therapy department recommended use of the trapeze bar.<BR/>During an interview on 01/22/2025 at 2:40 PM with MDS Coordinator LVN B stated use of a trapeze bar should be care planned. LVN B stated if not care planned staff would not have known he needed the trapeze bar and how often he needed it. LVN B stated she did not know how long the resident had been using the trapeze bar. LVN B stated she was not sure who ordered the trapeze bar for this resident. LVN B stated if there was no order then it would not be triggered to be care planned .<BR/>During an interview on 01/22/2025 at 2:45 PM, the DON stated use of trapeze bars should be care planned and did not need an order. The DON stated this could affect residents in that staff would not be able to monitor the effectiveness of the trapeze bar. The DON stated this could be a negative effect on the resident if trapeze bar use was not monitored and not being used correctly by the resident. The DON stated she did not know why this was not care planned and she monitored care plans for accuracy. The DON stated no one else at the facility monitored care plans . <BR/>3. <BR/>Record review of Resident #76's electronic face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #76 had diagnoses which included Diabetes Mellitus, Acute Kidney Failure, Hypertension , Acquired Absence of Right Leg Below Knee (Amputation)<BR/>Record review of Resident #76's Physician Orders, dated 01/21/2025, revealed: no orders for fall mat at bedside.<BR/>Record review of Resident #76's admission MDS, dated [DATE], Section C Cognitive status BIMS score 14, which indicated the resident was intact cognitively. Section GG0115 Functional Limitation in Range of Motion Upper extremity impairment on one side, Lower extremity impairment on one side. GG0120 Mobility Devices Walker, Wheelchair, Limb Prosthesis Section J Health Conditions J1300 Current Tobacco User No. Section J1 900 Number of falls since Admission/Entry two or more.<BR/>Record review of Resident #76's Care Plan, dated 12/18/2024, reflected Focus: the resident is risk for fall. Date initiated: 12/06/2024 Revision on 12/182024 Goal: the resident will be free of falls through the renew date.12/17/2024. Intervention included fall mat while in bed. Amputation of right leg below knee was not addressed. Use of Prosthetic leg was not addressed.<BR/>During an observation on 01/2025 at 10:30 AM and 01/21/2025 at 09:03 AM revealed no fall mat was observed by the bed in the room for Resident #76.<BR/>During an interview on 01/22/25 at 09:20 AM, the DON stated she was responsible for entering fall risk assessments on care plans and MDS Coordinators entered items triggered on the CAA (Care Area Assessment)from the MDS. The DON stated care plans were reviewed weekly during the standard of care meeting. The DON stated she conducted quarterly audits to identify issues that had been resolved and needed to be cancelled. The DON stated equipment specified in the care plan must be in place for the resident such as a f all mat. The DON stated the expectations were interventions on the care plan were done and if not coaching/retraining was provided. The DON stated if a fall mat was noted in an intervention, a fall mat should be in place if the resident was in bed or in the room . <BR/> During an interview on 01/22/2025 at 01:46 PM, LVN C stated she looked at care plans from time to time. LVN C stated the DON reviewed changes during the daily morning meeting. LVN C stated any equipment used for a resident should be on the care plan. LVN C stated the consequences for a resident if the equipment was not addressed on the care plan, a needed device could be missed by the caregiver and not be used. <BR/>Record review of the facility's, undated, policy titled Comprehensive Care Planning, reflected:<BR/>The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .<BR/>The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. <BR/>Record review of the facility's, undated, policy titled Uniform Smoke Free Policy reflected.<BR/>Residents will be allowed to keep smokeless tobacco, i.e., chewing tobacco, snuff, in their room and in their possession. Residents may use smokeless tobacco at their own discretion. Residents will be educated regarding cleanliness and proper disposal of the smokeless tobacco.

**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 procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs for 1 (Resident#) of 6 residents reviewed for pharmaceutical services. <BR/>LVN-B, facility failed to administer medications to Resident #50 according to physician's orders.<BR/>LVN-B left Resident #50's medication with her in a pill cup to take later<BR/> . <BR/>This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications. <BR/>The findings included:<BR/>Record review of the face sheet dated 10/27/22 revealed Resident # 50 was originally admitted to the facility on [DATE] and had a recent admission date of 10/20/2022. Her diagnoses included: Type 2 Diabetes, end stage renal disease, and hypertension.<BR/>In an observation and interview on 10/23/2022 at 11:35 AM, Resident #50 was sitting up in her w/c in the small dining room and LVN B came up to resident #50 with a plastic cup with water and a medication cup with 3 white tablets. Resident stated the medication tablets were her Selvamere - and she takes them due to having kidney failure and going to dialysis. Stated she takes them 3 times daily before meals. Resident told the LVN that she wanted to wait until it was closer to the time to eat to take the pills, as they do not work as well if she takes them too early before eating. LVN B let the resident keep the medication cup with the 3 tablets and the resident put the medication cup in her left breast pocket of her flannel shirt. LVN B walked away and back to her medication cart carrying a cup of water that she had taken to Resident # 50 to use for swallowing her medicine. Resident stated she always leaves my medicine for me to take when I'm ready. I take it with food <BR/>Observation of the medication administration record on 10/23/2022 at 11:35 AM revealed resident 50's Selvelamer was initialed as taken when the pills remained in her left breast pocket. <BR/>Record review of Resident #50's, physicians' orders dated 10/25/2022 documented an order for Sevelamer tablets 800 mg 3 tablets by mouth with meals for chronic kidney disease stage 5. <BR/>In an interview on 10/23/2022 at 12:45 PM with LVN B, who was assigned med pass during the observation stated she did not know why she had left the medication with the resident to take. She stated residents should be observed to ensure the medication was taken by the correct resident at the correct time. She stated the medication should not be documented as taken unless the nurse actually watched them take the medication. <BR/>In an interview on 10/23/2022 at 1:05 PM, the DON stated the person administering the medication should always verify medication with resident, date, time, and route with medication being given. When giving medication to a resident the nurse providing medications should always witness medication has been taken by the resident for whom it was ordered taken per the orders given. <BR/>Review of the facility policy statement on Administering Oral Medications, dated 2001 MED-PASS, Inc. (Revised October 2010) stated [in part]: check the label on the medication and confirm the medication name, dose with the medication administration record, check the expiration date, check the medication dose and recheck the dose to confirm, then remain with the resident until all medications have been taken. Follow documentation guidelines. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to act upon and notify the attending physician of the pharmacist consultant's recommendation for 2 of 5 residents (Resident #s 18 and 47) whose records were reviewed for pharmacist drug regimen review. <BR/>A. The facility did not follow up with the attending physician on the Pharmacist Consultant's recommendation to add parameters to hold hypertensive medication for Resident #18.<BR/>B. The facility did not follow up with the attending physician on the Pharmacist Consultant's recommendation to attempt a gradual dose reduction of Resident 47's order for Fluoxetine (Prozac) 60 mg daily.<BR/>This failure placed residents at risk for receiving medication for an extended duration without monitoring and physician review for continuation and necessity of the medication.<BR/>The findings include:<BR/>Resident #18<BR/>Review of Resident #18's face sheet, not dated, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Additional diagnoses included cerebral infarction, hemiplegia and hemiparesis affecting right side, and hypertension.<BR/>Review of Resident #18's active Physician Orders, dated 10/25/2022, revealed the following medication orders:<BR/>Benazepril 10 mg, give 1 tablet by mouth one time a day for hypertension, related to the diagnosis essential (primary) hypertension, with an order start date of 6/14/2022;<BR/>Propranolol 20 mg, give 1 tablet by mouth two times a day related to secondary hypertension, unspecified, with an order start date of 6/14/2022.<BR/>Review of the Pharmacist Consultant Medication Regimen Review reports revealed a Director of Nursing Report, dated 7/29/2022. The report documented the Pharmacist Consultant had reviewed Resident #18's medication orders on 7/08/2022. The Pharmacist Consultant documented the resident was being treated for hypertension and recommended hold parameters be added to the hypertension medication orders. <BR/>The DON documented her initials on the report that the recommendation had been followed-up on by her.<BR/>Review of Resident #18's active Physician Orders, dated 10/25/2022, revealed no parameters for holding the medications had been added to the orders for Benazepril and Propranolol.<BR/>Resident #47<BR/>Review of Resident #47's face sheet, not dated, revealed a [AGE] year-old male who was initially admitted to the facility on [DATE]. The form documented the resident's diagnoses included quadriplegia, other specified depressive episodes, anxiety disorder, and insomnia.<BR/>Review of Resident #47's Physician Orders, dated 10/25/2022, revealed an order for Fluoxetine 20 mg, give 60 mg by mouth one time a day related to other specified depressive episodes.<BR/>Review of the Pharmacist Consultant Medication Regimen Review reports revealed a Director of Nursing Report, dated 8/08/2022. The report documented the Pharmacist Consultant had reviewed Resident #18's medication orders on 8/02/2022. The Pharmacist Consultant had reviewed Resident #47's order for Fluoxetine 60 mg by mouth daily and inquired if a gradual dose reduction could be attempted. There was no documented evidence on the report that the recommendation had been followed-up on by the DON.<BR/>In an interview on 10/25/22 at 6:32 PM, the DON stated the Pharmacist Consultant had not been here yet this month. She stated recommendations were made on the Director of Nursing Report and the Medical Director Report. She stated the Medical Director responded to recommendations. The DON stated she and the Medical Director sat down together sometimes and reviewed the Pharmacist Consultant's report and recommendations. She stated the Medical Director would initial on the Medical Director Report and she initialed on the DON report when recommendations had been followed-up. The DON stated she would add parameters to Resident #18's orders for blood pressure medication. She stated there were standing orders for some parameters.<BR/>Review of the facility's policy for Consultant Pharmacist, dated as revised 10/25/2017, revealed the following [in part]:<BR/>The facility will contract the services of a pharmacist to provide consultation on all aspects of pharmaceutical services. The facility and the pharmacist will collaborate for effective consultation regarding pharmaceutical services. The pharmacist reviews and evaluates the pharmaceutical services by helping the facility identify, evaluate, and address medication issues that may affect resident care, medical care, and quality of life .<BR/>Procedure<BR/>6. The Consultant Pharmacist shall provide the facility with documentation that he has reviewed each patient's drug therapy. When potential irregularities are identified, the consultant pharmacist shall complete an individualized report detailing the potential irregularity <BR/>7. The pharmacist will provide a separate written report of irregularities to the attending physician, medical director, and director of nursing after their review.<BR/>8. The attending physician will be notified of irregularities within 2 business days .<BR/>9. If an irregularity requires immediate action by the physician, the facility will call the physician and notify them of the irregularity.<BR/>10. The attending physician will review the identified irregularity and will document what, if any, action is to be taken to address it. If there is no change in the medication, the attending physician should document his or her rationale .<BR/>12. The completed report will be filed in the resident's clinical record.<BR/>13. Any irregularities that do not require a physician's order will be initiated within a timely manner by the director of nurses and/or designee .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents with PRN orders for psychotropic drugs were limited to 14 days for 3 of 5 residents (Resident #s 14, 53 and 47) and a gradual dose reduction for a sedative/hypnotic medication was attempted for 1 of 5 residents (Resident #18) whose medication regimens were reviewed for unnecessary medications in that:<BR/>A. Resident #14's order for PRN diazepam/Haldol gel was not discontinued after 14 days. <BR/>B. Resident #53's order for PRN Lorazepam (antianxiety medication) was not discontinued after 14 days. <BR/>C. Resident #47 had an order for the antianxiety medication Alprazolam (Xanax) 1 mg by mouth every 12 hours as needed (PRN) for anxiety, dated 8/25/22, which did not have an end/stop date.<BR/>D. Resident #18 had an order for the sedative/hypnotic medication Zolpidem (Ambien) 10 mg by mouth at bedtime for difficulty sleeping, dated 7/02/2022, with no attempts of a gradual dose reduction.<BR/>This failure could place residents administered PRN and routinely scheduled psychotropic medications at risk of adverse side effects from prolonged use of psychotropic medications including stroke and death.<BR/>The findings included:<BR/>Resident #14<BR/>Review of Resident #14's face sheet, dated 10/25/2022, revealed he was a [AGE] year-old male, admitted to the facility on [DATE] and was receiving hospice care services. Diagnosis included: senile degeneration of the brain; anxiety disorder; and other specified depressive episodes. <BR/>Review of Resident #14's Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 1 out of 15 (Severe Cognitive Impairment). <BR/>Review of Resident #14's Physician Orders, dated 10/25/2022, revealed Resident #14 was prescribed diazepam/Haldol gel 2mg/2mg, give 1 ml topically to inner wrist, rub in well, PRN every 4 hours as needed for anxiety, with a start date of 09/06/2022, and an end date of indefinite. <BR/>Review of Resident #14's pharmacy consultant reviews for September 2022 revealed the consultant pharmacist had not recommended that the resident's order for diazepam/Haldol gel be discontinued because the 14-day maximum allowed prescribed length for prn psychotropic medications had been met. <BR/>Resident #53<BR/>Review of Resident #53's face sheet, not dated, revealed she was admitted to the facility on [DATE] and was 82-years-old and had diagnoses including anxiety disorder, insomnia, Alzheimer's Disease, and major depressive disorder.<BR/>Review of Resident #53's Quarterly MDS, dated [DATE], documented she had a BIMS score of 11 out of 15 (Moderate Cognitive Impairment). During the seven-day look-back period she had received an anti-anxiety medication for 7 days. No behavioral symptoms were documented. <BR/>Review of Resident #53's pharmacy consultant reviews for September did not reveal the consultant pharmacist recommended that the resident's order for Lorazepam be discontinued because the 14-day maximum allowed prescribed length for PRN psychotropic medications had been met. <BR/>Review of Resident #53's Physician Orders, dated 10/25/2022, revealed that the resident was to continue receiving Lorazepam 2 mg/ml 0.5 ml every 4 hours PRN and Lorazepam 2 mg/ml 1 ml every 4 hours PRN as needed for anxiety. The medication was ordered on 08/26/2021. The orders did not specify a stop date. <BR/>Review of Resident #53's Medication Administration Records dated 10/1/2022 through 10/25/2022 did reveal documentation of PRN Lorazepam 2 mg/ml give 1 ml as given two times on 10/01/2022.<BR/>In an interview on 10/25/22 at 3:32 PM, the Director of Nurses stated that PRN orders for psychotropic medications were to be discontinued after 14 days and that justification from the prescriber was required for PRN orders for psychotropic medications that extended beyond the 14-day limit. She stated the Lorazepam continued because the hospice staff refused to write a PRN order for 14 days duration. She stated the diazepam/Haldol gel continued because hospice refused to write a PRN order for 14 days duration. The DON stated she was responsible for seeing that PRN psychotropic medications were not administered PRN longer than 14 days. <BR/>Resident #47<BR/>Review of Resident #47's face sheet, not dated, revealed a [AGE] year-old male who was initially admitted to the facility on [DATE]. The form documented the resident's diagnoses included quadriplegia, other specified depressive episodes, anxiety disorder, and insomnia.<BR/>Review of Resident #47's Physician Orders, dated 10/25/2022, revealed an order for Alprazolam 1 mg by mouth every 12 hours as needed (PRN) for anxiety, with a start date of 8/25/2022. The order did not include and end/stop date.<BR/>Review of Resident #47's quarterly MDS assessment, dated 10/05/2022, revealed the resident had received antianxiety medication 1 out of 7 days during the assessment review period.<BR/>Resident #18<BR/>Review of Resident #18's face sheet, not dated, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Additional diagnoses included cerebral infarction, hemiplegia and hemiparesis affecting right side, diabetes mellitus type 2, epilepsy unspecified, insomnia, hypertension, gastro-esophageal reflux disease, and hypothyroidism. <BR/>Review of Resident #18's active Physician Orders, dated 10/25/2022, revealed the following medication orders:<BR/>Amitriptyline 75 mg by mouth one time daily related to insomnia, dated 6/14/2022 (Elavil - antidepressant medication);<BR/>Zolpidem Tartrate 10 mg by mouth at bedtime for difficulty sleeping, dated 7/06/2022 (Ambien - sedative/hypnotic medication).<BR/>The physician orders did not include a referral for mental health/psychological evaluation and services.<BR/>The physician orders did not include orders for anti-anxiety medication.<BR/>Review of Resident #18's quarterly MDS assessment, dated 10/21/22, revealed the resident had received antidepressant medication and hypnotic medication 7 out of 7 days during the assessment review period. The diagnosis section for psychiatric/mood disorder did not have any diagnoses selected. (The diagnoses of depression and anxiety were not selected.)<BR/>Review of Resident #18's comprehensive care plan revealed a care plan, dated 9/09/2022, which documented The resident uses anti-anxiety/hypnotic medications - anxiety disorder - Zolpidem. The goal did address decreased episodes and signs/symptoms of sleep disturbance. The interventions/approaches included administering anti-anxiety medication as ordered by physician, monitoring for effectiveness and side effects of anti-anxiety medication.<BR/>Review of the Pharmacist Consultant Medication Regimen Review reports revealed a Director of Nursing Report, dated 7/29/2022. The report documented the Pharmacist Consultant had reviewed Resident #18's medication orders on 7/08/22 - High Dose - Medication: Ambien tablet 10 mg (Zolpidem Tartrate) 1 po QHS (by mouth at bedtime). <BR/>Recommendation: In geriatric patients, clearance of zolpidem is similar in men and women. The recommended dose of AMBIEN in geriatric patients is 5 mg regardless of gender per the FDA. Please consider reducing dose of Ambien to 5 mg QHS (at bedtime). <BR/>There was no documented evidence on the report that the recommendation had been followed-up on by the DON.<BR/>Review of the Pharmacist Consultant Medication Regimen Review report to Resident #18's physician, dated 9/30/2022, revealed the request for a response to the review date on 9/24/2022.<BR/>The report documented High Dose - Medication: Ambien tablet 10 mg (Zolpidem Tartrate) 1 po QHS (by mouth at bedtime).<BR/>Recommendation: In geriatric patients, clearance of zolpidem is similar in men and women. The recommended dose of AMBIEN in geriatric patients is 5 mg regardless of gender per the FDA. Please consider reducing dose of Ambien to 5 mg QHS (at bedtime). <BR/>The physician response, dated 10/19/22, documented Disagree - Lots of anxiety regarding uterine cancer that is metastatic. Having difficulty sleeping.<BR/>In an interview on 10/25/2022 at 6:32 PM, the DON stated the Medical Director was not Resident #18's physician. The DON stated Resident #18 had a lot of anxiety related to having cancer.<BR/>Review of the facility policy titled Psychotropic Drugs, dated as revised 10/25/2017, revealed the following [in part]:<BR/>The facility must ensure that .<BR/>1. Residents who have not psychotropic drugs will not be given psychotropic drugs unless the medication is used to treat a specific condition as diagnosed and documented in the clinical record.<BR/>2. Residents who use psychotropic drugs receive gradual dose reduction, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.<BR/>4. PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing physician believes that it is appropriate for the prn order to be extended beyond 14 days, he should document their rationale in the resident's medical record and indicate the duration for the prn order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 2 residents (#'s 36 and 44) reviewed for blood glucose monitoring.<BR/>A. LVN A failed to disinfect the multi-use glucometer between uses on different resident's according to the required contact time for the disinfectant.<BR/>B. LVN C failed to disinfect the multi-use glucometer between uses on different resident's according to the required contact time for the disinfectant.<BR/>The facility's failure could place residents at risk for development of infection and a decline in health status.<BR/>The findings include: <BR/>Resident ID #36<BR/>Review of Resident #36's Face Sheet, not dated, revealed he was a [AGE] year-old male with the following diagnoses: Type 1 diabetes; low vision.<BR/>Review of Resident #36's physician order summary revealed she received finger stick blood glucose checks 4 times daily (before meals and at bedtime) and Humalog 100 units/ml per sliding scale 4 times daily, and Glargine 100units/ml Subcutaneous solution 30 units daily. <BR/>In an observation on 10/24/22 at 11:50 AM, LVN A removed the glucometer from the medication cart and placed it on top of the medication carthe sanitized her hands and wiped the glucometer with a Biactive wipe and laid it back on the med cart. She entered Resident ID #36's room and performed the finger stick. She then carried the glucometer back to the cart and disposed of the used supplies and her gloves. She performed hand hygiene with an alcohol-based hand sanitizer and placed the glucometer back into the drawer of the medication cart without disinfecting it with an EPA approved sanitizer using the proper contact time. <BR/>In an interview at 11:55 AM on 10/24/22, LVN A stated the contact time for the Bactive wipes to disinfect an object was 2 minutes. She stated the contact time was the length of time it took the chemical to kill bacteria and the failure to disinfect equipment could result in an infection. <BR/>Resident ID #44 <BR/>Review of resident #44's Face Sheet revealed she was a [AGE] year-old male with the following diagnoses: type 2 diabetes mellitus with hyperglycemia, atherosclerotic heart disease, and cerebrovascular disease. <BR/>In an observation and interview on 10/24/22 at12:20 PM, LVN C removed the glucometer from the drawer of the medication cart and placed it on top of the cart with a wax paper barrier underneath. She cleaned the glucometer and let it air dry for 2 minutes. She stated 2 minutes was the required contact time for the wipes to disinfect the glucometer. She entered Resident 44' s room and performed the finger stick wearing gloves. She carried the glucometer back to the cart, disposed of the used supplies and her gloves appropriately. She performed hand hygiene with an alcohol-based hand sanitizer and placed the glucometer back into the drawer of the medication cart.<BR/>In an interview on 10/24/22 at 12:20 PM LVN C stated she knew that the multi-use glucometer should be disinfected with the Disinfectant after each use. She stated she was nervous and had not disinfected the glucometer properly during the observation. She stated the appropriate contact time for the bioactive was 4 minutes and it should remain wet for 4 minutes and then be allowed to air dry. <BR/>In an interview on 11/5/19 at 2:30 PM the DON stated that she expected the nurses to cleanse the multi-use glucometer with the antimicrobial wipes after each use. She stated the appropriate contact time for the bioactive was 4 minutes and it should remain wet for 4 minutes and then be allowed to air dry. She stated failure to follow these steps could lead to the spread of infection. <BR/>Review of the facility's procedure titled Glucose , dated as revised 02/13/2007, revealed the following [in part]:<BR/>Clean and inspect meter exterior with each use.<BR/>Meter will be cleaned with a germicidal and allowed to air dry between patient testing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to provide each resident with necessary respiratory care consistent with professional standards of practice, for 2 of 3 residents (Resident's #13 and #53) reviewed for respiratory care, by failing to ensure:<BR/>Resident's #13 and #53 oxygen tubing was changed weekly as ordered by the Physician. <BR/>This failure could place residents requiring oxygen at risk for respiratory infections due to the potential for microorganisms infiltrating their oxygen equipment and supplies causing a decline in physical health. <BR/>The findings Include:<BR/>Resident #13<BR/>Record Review of Resident #13's face sheet, dated 10/25/2022, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Diagnosis included chronic obstructive pulmonary disease, unspecified (primary). <BR/>Observation and interview during initial rounds, on 10/23/2022 at 10:07 AM, revealed Resident #13's oxygen tubing was dated 10/10/2022. Resident said she uses oxygen at night or when needed. <BR/>Record review of Resident #13's Order Summary Report, dated 10/25/2022, revealed Resident #13 had an order for: A) O2 2 LPM per nasal canula to maintain O2 status &gt;90% every day and night shift; B) Change Respiratory Tubing, Mask, Bottled Water, clean filter every 7 days, PRN as needed with use every night shift every Sun.<BR/>Resident #53<BR/>Record Review of Resident #53's face sheet, dated 10/25/2022, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Diagnosis included chronic obstructive pulmonary disease, unspecified (primary). <BR/>Observation and interview during initial rounds, on 10/23/2022 at 10:30 AM, revealed Resident #53's oxygen tubing was dated 10/10/2022. Resident said she does not remember when her tubing was last changed. <BR/>Record review of Resident #53's Order Summary Report, dated 10/25/2022, revealed Resident #53 had an order for: A) May have O2 2 LPM per nasal canula to maintain O2 states &gt; 90% as needed; B) May use oxygen 2 LPM per nasal canula. every night shift; C) Change Respiratory Tubing, Mask, Bottled Water, 02 BAG, clean 02 MACHINE FILTER every night shift every 2 weeks on Sunday.<BR/>In an interview with the DON, on 10/25/22 at 3:37 PM, when asked about the oxygen tubing being dated for 10/10/22, she said the facility policy had recently changed for oxygen tubing to be changed only when visible dirty or as needed. However, she did acknowledge the doctor orders were still active for oxygen tubing to be changed every 7 days and that doctor orders supersedes facility policy. <BR/>Review of the facility's policy for Oxygen Administration (undated) revealed Oxygen tubing was to be changed when visibly soiled or as needed.

Based on interview and record review the facility failed to develop and implement written policies and procedures prohibited and prevented abuse, neglect, and exploitation, of residents and misappropriation of resident property for 1 of 4 employee files (Employee C) reviewed for abuse protocol. <BR/>The facility failed to complete annual Criminal Background Checks for Employee C. <BR/>This failure could place residents at risk for abuse, neglect, and exploitation. <BR/>Findings include:<BR/>In a record review of Employee C's personnel file reflected the facility did not complete annual Criminal History checks. The last check completed was date 12/2/22. <BR/>In an interview on 10/16/24 at 4:45 PM, the Human Resource Specialist said the annual Criminal History checks for Employee C were not completed. He said it was the responsibility of the Human Resource Specialist to ensure reference checks were completed and documented during annual review. He said Criminal History checks helped prevent abuse . Human Resource Specialist stated he has worked for facility for only 3 weeks and has not completed reviews of all staff to see if background checks and training are up to date. Human Resource Specialist stated the former HRS must have missed the annual background check for Employee C. <BR/>In an interview on 10/17/24 at 5:15 PM, the Administrator said Human Resources should be completing employee reference checks prior to employment and annually. The Administrator said Employee C's Criminal History was not checked or documented. The Administrator said a potential negative outcome of not checking employee Criminal History annually was to ensure the facility did not employ a person whose criminal history did not put the safety for the resident in jeopardy. A Criminal Background check was conducted for Employee C on 10/16/24, Employee C was employable. <BR/>Record review of the facility's policy Criminal Background Checks , dated as revised 11/17/2017, reflected the following [in part]:<BR/>Policy: It is the policy of the company to conduct criminal background checks of all applicants within 72 hours of employment . and complete annual Criminal History checks,<BR/>Procedure: <BR/>6. The Criminal History Coordinator will be responsible for obtaining reference checks and licensure verification/registries prior to employment and annually. Written documentation of reference checks and licensure/verification will be maintained in the personnel file . <BR/>Record review of the facility's Abuse and Neglect policy dated as revised 3/29/2018, reflected the following:<BR/>The facility will conduct criminal background checks of all personnel in accordance with Texas Health and Safety Code, Chapter 250.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours for 2 of 5 residents (Residents #39 and #56) whose record were reviewed for recent admission to the facility, in that:<BR/>1. Resident #39 was admitted to the facility on [DATE] and a baseline care plan had not been developed within 48 hours of his admission.<BR/>2. Resident #56 was admitted to the facility on [DATE] and a baseline care plan had not been developed within 48 hours of her admission. <BR/>This failure placed the residents at risk for not receiving care and services to meet their needs and to promote their physical and mental health and well-being within their new living environment.<BR/>The findings included:<BR/>1. Resident #39<BR/>Review of Resident #39's admission Record, dated 12/07/2023, revealed an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included: Type 2 diabetes mellitus with foot ulcer; hyperlipidemia (high cholesterol); hypertension (high blood pressure); heart failure; end stage renal disease (kidney failure); dependence on renal dialysis; and dysphagia (difficulty swallowing).<BR/>Review of Resident #39's Baseline Care Plan Acknowledgement form, dated 09/30/2023, revealed a copy of the baseline care plan was provided to the resident's representative. <BR/>Review of Resident #39's Baseline Care Plan revealed it was dated as developed on 10/03/2023, later than 48 hours after admission. <BR/>During an interview and record review on 12/07/2023 at 10:37 AM, the DON reviewed the Baseline Care Plan Acknowledgement form and the Baseline Care Plan for Resident #39. She stated the Baseline Care Plan dated 10/03/2023 was done late. She stated the Baseline Care Plan Acknowledgement had been done by the LVN charge nurse and she probably did the form as part of the nursing admission packet. The DON stated she was the one who initiated the baseline care plan within 48 hours and the LVN should not have completed the acknowledgement form. The DON stated the LVN would not have given the resident's representative a copy of a baseline care plan. <BR/>2. Resident #56<BR/>Review of Resident #56's admission Record, dated 12/07/2023, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included: iron deficiency anemia; depression; Alzheimer's disease; hypertension (high blood pressure); and cardiac arrhythmia (abnormal heartbeat).<BR/>Review of Resident #56's Baseline Care Plan Acknowledgement form, dated 04/17/2023, revealed a copy of the baseline care plan was provided to the resident's representative. <BR/>Review of Resident #56's Baseline Care Plan revealed it was dated as developed on 04/25/2023, later than 48 hours after admission. <BR/>Review of the facility's policy and procedure for Base Line Care Plans, not dated, revealed the following [in part]:<BR/>Completion and implementation of the baseline care plan withing 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen. <BR/>The facility failed to protect the 3 of 58 residents who are provided puree diets in the facility's only kitchen from bacterial contamination when [NAME] D assembled the puree machine processor touching the cutting blades post with his bare hands.<BR/>This failure could place residents who are provided puree food at risk for food borne illness and compromise health status<BR/>The findings included:<BR/>Observation on 10/24/2022 at 11:00 AM during puree processing for 3 residents revealed [NAME] D processing puree food 3 times (clean and sanitized between food processing) for different food stuff, hamburger steak, green beans, and bread he assembled the food processor he touching the center post of the blades adjusting the seating of the blades with his bare hand. The center post was touched by the food pureed during processing potentially contaminating the food. <BR/>During an interview on 10/24/2022 at 11:35 AM Dietary Manager said their expectation regarding touching food processor with bare hands she said [NAME] D should not have touched the inside of the food processor with bare hands. <BR/>Review of the facility's policy and procedure dated 2012 titled Equipment Sanitation revealed the following: <BR/>Will clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. <BR/>Review of the facility's policy and procedure dated 2012 titled, Infection Control revealed the following:<BR/>Procedure:<BR/> .2. Careful handwashing by personnel will be done in the following situations:<BR/> .b. Between handling of dirty dishes boxes or equipment and handling clean food or utensils. <BR/> .5. Equipment sanitation<BR/> .d. Cups, glasses, and bowels must be handled so that fingers or thumbs do not contact inside surfaces.

Based on interview and record review the facility failed to develop and implement written policies and procedures prohibited and prevented abuse, neglect, and exploitation, of residents and misappropriation of resident property for 1 of 4 employee files (Employee C) reviewed for abuse protocol. <BR/>The facility failed to complete annual Criminal Background Checks for Employee C. <BR/>This failure could place residents at risk for abuse, neglect, and exploitation. <BR/>Findings include:<BR/>In a record review of Employee C's personnel file reflected the facility did not complete annual Criminal History checks. The last check completed was date 12/2/22. <BR/>In an interview on 10/16/24 at 4:45 PM, the Human Resource Specialist said the annual Criminal History checks for Employee C were not completed. He said it was the responsibility of the Human Resource Specialist to ensure reference checks were completed and documented during annual review. He said Criminal History checks helped prevent abuse . Human Resource Specialist stated he has worked for facility for only 3 weeks and has not completed reviews of all staff to see if background checks and training are up to date. Human Resource Specialist stated the former HRS must have missed the annual background check for Employee C. <BR/>In an interview on 10/17/24 at 5:15 PM, the Administrator said Human Resources should be completing employee reference checks prior to employment and annually. The Administrator said Employee C's Criminal History was not checked or documented. The Administrator said a potential negative outcome of not checking employee Criminal History annually was to ensure the facility did not employ a person whose criminal history did not put the safety for the resident in jeopardy. A Criminal Background check was conducted for Employee C on 10/16/24, Employee C was employable. <BR/>Record review of the facility's policy Criminal Background Checks , dated as revised 11/17/2017, reflected the following [in part]:<BR/>Policy: It is the policy of the company to conduct criminal background checks of all applicants within 72 hours of employment . and complete annual Criminal History checks,<BR/>Procedure: <BR/>6. The Criminal History Coordinator will be responsible for obtaining reference checks and licensure verification/registries prior to employment and annually. Written documentation of reference checks and licensure/verification will be maintained in the personnel file . <BR/>Record review of the facility's Abuse and Neglect policy dated as revised 3/29/2018, reflected the following:<BR/>The facility will conduct criminal background checks of all personnel in accordance with Texas Health and Safety Code, Chapter 250.

Based on observation, interview, and record review the facility failed to provide written notice to the State Agency responsible for licensing the facility at the time of change, for a change in the facility's administrator for 1 of 1 facility. The facility failed to notify the State Agency of a change in the facilities administrator within 30 days. This failure could result in the lack of knowledge and inability to connect with the appropriate leadership of the facility. Findings included: In an observation on 11/07/2025 at 11:45 a.m., the investigator located the named administrator of the facility in TULIP during offsite preparation and documented the name for contact and accountability purposes. In an interview on 11/08/25 at 10:45 a.m., the facility Administrator introduced herself and indicated she started as the Administrator of the facility in May 2025. She was not the individual named in TULIP. In an interview on 11/08/25 at 3:02 p.m., CNA A stated that she started working at the facility in June 2025 and the ADM is the only administrator she had seen since she had worked there. CNA A stated that the ADM was who she reported to with any report of abuse or neglect, because the ADM was the abuse coordinator. In a follow-up interview on 11/08/25 at 7:58 p.m., the ADM stated she started as the AIT at the facility in December 2024 with another administrator. She stated he left, and she became full time administrator in March 2025. The ADM stated she is responsible for the day-to-day responsibilities and was in charge of the facility. The ADM stated it was her responsibility to contact the state agency about the administrator change but thought the previous administrator would do it when he left. The ADM stated she can make the change in TULIP, and she was aware it was to be done within 30 days. No corporate personnel were present to interview. In an observation on 11/8/25 at 10:10am of the facility posting in Hall C near the nurse's station, it revealed the Administrator, Abuse coordinator, named as the current ADM, not the name in TULIP. Record review of Facility Business card provided by ADM named her as the facility administrator. No policy provided.