Galveston Nursing and Rehabilitation Center

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely for 5 (Resident #5, #7, #25, #39, and #58) of 20 Residents reviewed for safe, comfortable, homelike environment. The facility failed to ensure call light cords were within reach of Resident #5, #7, #25, #39, and #58. This failure could place residents at risk of not being able to summon help if needed which could result in diminished quality of life and potential injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 8 of 8 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen in that: 1. One container of macaroni salad with plastic wrap not properly sealed, dated 07/09/26 - 07/12/26, located in refrigerator #1. 2. One container of potato salad with plastic wrap not properly sealed, dated 07/06/26 - 07/09/26, located in refrigerator #2. 3. One container of hard-boiled eggs dated 07/06/26 - 07/09/26, hot dog [NAME] dated 07/03/26 - 07/06/26, and a container of red sauce dated 07/09/26 - 07/12/26, located in refrigerator #2 indicating these food items should have been removed prior to surveyor entrance date of 07/13/26. 4. The facility failed to maintain the stove area, countertops, and food preparation area in a clean and sanitary manner. [...]

Inspectors wroteBased on interview and record review revealed the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that were readily accessible for Resident 4 of 6 (Resident #6, #20, #24 and #47) reviewed for clinical records. 1. The facility failed to ensure that consultant pharmacist medication regimen review was kept in residents' active clinical records for Resident #6, #24 and #47 after the facility underwent a change of partnership.2. The facility failed to ensure the medical records for Resident #20 included his code status. This failure placed residents at risk of not having access to their records or receiving thorough HHSC investigations of complaints.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all mechanical and electrical equipment in safe operating condition by failing to maintain the dishwasher in safe operating condition. The facility failed to ensure the dishwasher in the facility's only kitchen was cleaned, disinfected and reached minimum 120 degrees during wash and rinse cycles when the Dishwasher Aide was cleaning breakfast dishes on 7/13/26. These failures could place residents at risk of foodborne illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to equip privacy curtains to ensure full visual privacy for each resident in 5 rooms (Rooms 114, 301, 303, 307, and 402) of 20 rooms reviewed for privacy. The facility failed to ensure residents in Rooms 114, 301, 303, 307, and 402 had privacy curtains in place to ensure full visual privacy. This failure could place residents at risk of being exposed to people in the hallway during procedures when they are exposed.

Inspectors wroteBased on observations and interviews the facility failed to maintain an effective pest control program to keep the facility free of roaches for 1 (Resident #35) of 5 residents rooms reviewed for pest control. The facility failed to ensure Resident #35's room was free of roaches. This failure could affect residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the resident and resident's representative(s) of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #20) of 3 residents reviewed for discharge planning.1. The facility failed to notify Resident #20 of discharge, reasons for the move, and right to appeal in writing, in a language and manner he understands, and at least 30 days before Resident #20 was discharged from the facility on 07/13/26. 2. The facility failed to send a copy of the Resident #20's notice of discharge to the facility's Ombudsman. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents were screened for mental illness and coordinate with the State mental health authority the need for services for 1 of 4 residents (Resident #1) reviewed for PASARR screening. The facility failed to ensure Resident #1 was screened for services by the mental health authority once he received a diagnosis of Schizophrenia on 01/30/26.[BR31.1]This failure could result in residents with mental illness not receiving services to which they are entitled.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 2 of 8 residents (Residents #9 and #22) reviewed for baseline care plans. The facility did not develop a baseline care plan for Residents #9 and #22 within 48 hours of admission. This failure could place new residents at risk of not receiving necessary care and services or having important care needs identified.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 (Resident #10 and #20) of 8 residents for care plan revisions, in that:The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #10's psychoactive medication use. The failure could place residents at risk of receiving inappropriate care.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 Resident (Residents #5, #9) of 9 residents reviewed for pressure ulcer treatment. 1. The facility failed to ensure Residents #5 and #9 had dressings covering their wounds.2. The facility failed to ensure Resident #9 received wound care as ordered by the physician on 07/14/26. These failures could place residents at risk of developing wound infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 5 residents (Resident #10) reviewed for adequate monitoring of unnecessary medication. The facility did not monitor Resident #10 for side-effects related to the use of the anti-depressant medications Sertraline, Trazodone and the anti-psychotic medication Quetiapine Fumarate. This failure could place the residents at risk for adverse consequences of medication.

Inspectors wroteBased on observations and interviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 residents (Residents #33, #56, and #65) of 8 residents reviewed for infection control. Medication Aide-E failed to sanitize the reuseable blood pressure cuff between uses on Residents #33, #56, and #65. This failure could place residents at risk from infection from another resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters reviewed for garbage disposal. -The facility failed to ensure one dumpster door and surrounding gate were secured. -The facility failed to ensure one dumpster was emptied and not overflowing. -The facility failed to clean the areas around both dumpsters. These failures could place residents at risk of infection, and potential exposure to vermin and pests from improperly disposed of garbage.

Inspectors wroteBased on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify consistent with his or her authority, the resident representative when there was a need to alter treatment significantly, that is a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment for 1 of 3 residents (Resident #1) reviewed for notification. 1. The facility failed to notify Resident #1's NP or MD when Resident #1 refused her medication/s, nutritional supplements, and meal/s from her facility admission on [DATE] through 04/17/2026. 2. The facility failed to ensure Resident #1's physician was notified when the resident had a change in condition and had difficulty swallowing. An immediate Jeopardy (IJ) situation was identified on 04/18/2026. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 3 residents (Resident #1) reviewed for nutrition status. 1. The facility failed to ensure Resident #1 did not have a significant weight loss of 19% due to losing 23lbs in 12 days. 2. The facility failed to provide Resident #1 with feeding and nutrition via her PEG tube. 3. The facility failed to ensure Resident #1 had dietary recommendations in place from her admission on [DATE] until 4/17/2026, the date of State Surveyor facility entrance. 4. The facility failed to ensure Resident #1 had weekly weights obtained per physician order. 5. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 14 residents (Resident#1) reviewed for accuracy of assessments. The facility failed to ensure Resident#1's admission MDS assessment accurately reflected her gastrostomy tube status. This failure could place residents at risk of receiving inadequate care and services.

Inspectors wroteBased 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 time frames to meet resident's medical, nursing, mental, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 14 residents (Resident #1) reviewed for care plans. 1. The facility failed to develop or implement a care plan for Resident #1 to address the resident's gastrostomy tube status. 2. The facility failed to develop or implement a care plan for Resident #1 to address the residents' diet. These failures could place residents at risk of not receiving care and services tailored to their identified needs.

Inspectors wroteBased on interview and record review , the facility failed to report the results of an investigation in accordance with State Law including the State Survey Agency within 5 working days of the incident for 2 of 2 (Resident #1 and Resident #2) incidents reviewed for reporting. The facility failed to ensure the Administrator reported the results of an investigation within 5 days to the State Survey Agency. This failure could place residents at risk if appropriate corrective actions are not taken. Record review completed on 03/31/2026 at 12:13 p.m., of the TULIP system revealed that a PIR, Form 3613-A, was not filed in the system for two separate incidents reported by the facility on 3/18/2026 to the Complaint and Incident Intake. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety for 3 of 6 (Resident #1, Resident #2, and Resident #3) residents reviewed for staffing, in that:The facility failed to ensure RN K's control count sheet for Resident #1 matched the actual Lacosamide, and Resident #2's tramadol blister packet seal was broken and exposed. The facility failed to ensure LVN J's control count sheet for Resident #3 matched Acetaminophen-COD#3 in the blister packet. These failures could place residents at risk of not being provided care by nursing staff with sufficient skills/training.

Inspectors wroteBased on 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 and biologicals and a system of medication records that enables periodic accurate reconciliation and accounting of all controlled medications to meet the needs of 3 of 6 residents (Resident #1, Resident #2, and Resident #3) reviewed for pharmacy services, in that: The facility failed to ensure RN K control count sheet for Resident #1 matched with the actual Lacosamide. The facility failed to ensure Resident #2's tramadol blister packet seal was not broken and exposed. The facility failed to ensure LVN J control count sheet for Resident #3 matched Acetaminophen-COD#3 in the blister packet. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical, mental, and psychosocial needs for 1 (Resident #1) of 5 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #1's care plan was not cancelled on 01/19/26. This failure could have placed residents at risk of his needs not being monitored and cared for at the facility.

Inspectors wroteBased 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 1 of 4 residents (Resident #4) observed for infection control. The facility failed to ensure LVN J followed appropriate infection control procedures while counting prefilled morphine syringes for Resident #4. This failure could have placed the residents at risk for infection.

Inspectors wroteBased on interview and record review the facility failed to ensure the facility assessments were documented and facility-wide assessments determined what resources were necessary to care for residents competently during both day-to-day operations and emergencies for 1 of 1 facility (Facility) reviewed for facility assessment. The facility failed to ensure the facility assessment contained information regarding the level of staff needed to meet the needs of each resident. This failure could place residents at risk of inadequate care or treatment.

Inspectors wroteBased on interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility's assessment tool for 3 of 7 residents (Residents #1, #2 and #4) reviewed for sufficient staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store drugs and biologicals in locked compartments during medication storage inspection for 4 (medication Cart #1, #2, #3 and #4) of 6 medication carts reviewed for storage. The facility failed to ensure Medication Cart #1, #2, #3 and #4 were locked and secured while unattended. This failure could place residents at risk of drug diversion. Based on observation, interview and record review, the facility failed to store drugs and biologicals in locked compartments during medication storage inspection for 4 (medication Cart #1, #2, #3 and #4) of 6 medication carts reviewed for storage. The facility failed to ensure Medication Cart #1, #2, #3 and #4 were locked and secured while unattended. This failure could place residents at risk of drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #1) of 10 residents reviewed for comprehensive resident centered care plan. - Resident #1 was not care planned for G-J tube (soft, narrow tube that enters the stomach in the upper part of the abdomen and is threaded into the small intestine) feeding with small amounts of pureed textured snacks (not to exceed >1/2 a meal tray) for pleasure with SLP supervision or trained caregiver. This failure could place residents at risk for not receiving appropriate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 2 (Resident #2 and Resident #3) of 4 residents reviewed for physical environment. - Resident #2 was in her bedroom sitting in her wheelchair when roaches were observed by Nurse A crawling on her floor, bed, and wheelchair. -A small live roach was observed on the floor of Resident #3's bedroom floor near the doorway. This failure could place residents at risk of experiencing emotional and physical distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess each resident's status for 3 of 18 residents(Resident #6, #30 and #57) reviewed for accuracy of assessments. --the facility failed to ensure Resident # 6's Significant Change MDS did not code grab bars to aid with bed mobility as restraints --the facility failed to ensure Resident # 30's Significant Change MDS assessment did not have catheter which had been removed prior to the MDS assesement --the facility failed to ensure that Resident #57's admission MDS assessment accurately reflected she did not have a catheter These failures could place residents at risk of inaccurate care and decline in health. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical well-being for 2 of 24 residents (Resident #13 and Resident #57) reviewed for care plans. -The facility failed to ensure Resident #13's comprehensive care plan included information regarding his indwelling urinary catheter. -The facility failed to ensure that Resident # 57's care plan included her use of oxygen These failures could place residents at risk of not receiving appropriate care and interventions to meet their needs.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to consult with the resident's physician when there was a significant change in resident condition for 1 (Resident #2) of 5 residents reviewed for notification of changes. -The facility failed to notify Resident #2's physician after testing positive at the hospital for THC (psychoactive compound found in cannabis) on 04/25/25. This failure could place residents at risk for not receiving necessary medical care.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to revise the comprehensive care plan for 2 (Resident #1 and Resident #2) of 5 residents reviewed for care plan timing and revision. -The facility failed to revise Resident #1's care plan after testing positive for benzodiazepines (class of psychotropic medications that help relieve nervousness, tension, and other symptoms by slowing the central nervous system) and THC (psychoactive compound found in cannabis) at the hospital on [DATE]. -The facility failed to revise Resident #2's care plan after testing positive for THC (psychoactive compound found in cannabis) at the hospital on [DATE]. This failure could place residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that residents are free of significant medications error for 2 of (Resident #1 and #2) of 5 residents reviewed for medications errors. The facility failed to ensure Resident #1's Midodrine for low blood pressure was held when the SBP was above 100. The facility failed to ensure that Resident #2's, medication Toprol X oral tablet extended release (Metoprolol Succinate) for high blood pressure was given as ordered by the physician. This failure placed all resident who received medications at risk of not getting their medications as ordered which could result in resident not receiving the therapeutic benefits of the blood pressure medication that could result in decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 5 Residents (Resident #1 and Resident #2) reviewed for medical records accu.[NAME], in that: Resident #1 and Resident #2's May 2024 MARs did not reflect documentation for medication given. The deficient practices could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. Findings Included: Resident #1 Record review of Resident #1's admission face sheet dated 05/17/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately consult with the resident's physician of G- tube dysfunction or malfunction for 1 of 4 residents reviewed for physician notification (Resident #1). The facility failed to immediately consult with the resident's physician when facility staff did not implement physician order due to the inadequate supply of adnominal binder to protect G-tube and G-tube site for 1 of 4 residents reviewed for physician notification (Resident #1). The facility failed to notify the resident's physician of complications related to Resident# 1 G-tube site pain and administering medications to Resident #1 via the G-Tube. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four residents (Resident #1) who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding, in that: The facility failed to implement the physician's order for an abdominal binder indicated to prevent complications of gastrostomy tube. The facility failure resulted in Resident #1 requiring discharge to the hospital for G-Tube replacement. LVN V failed to use the facility's identified proper technique and safety precautions for Resident # 1 for administering medications via G- Tube. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. Twenty-five opportunities were observed with a total of four errors, resulting in a 16 percent medication error rate involving 1 resident (Residents #1) and 1 of 4 staff (LVN V) reviewed for medication error, in that: LVN L administered the wrong dose of Lactulose (medication is a laxative used to treat constipation) to Resident #1. LVN V flushed Resident #1's g-tube with the wrong volume of water as evidenced by pushing a full 60 ml syringe of water instead of the physician ordered volume of 30ml into Resident #1's g-tube before and after administering medication. [...]

Inspectors wroteBased on record review and interview the facility, with the capacity of more than 120 beds, failed to employ a qualified social worker on a full-time basis. The facility, licensed for 150 beds, did not employ a full-time social worker. This failure could affect all residents in need of social services and place them at risk of psychosocial decline and poor quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for one (Resident #27) of 20 residents reviewed for comprehensive assessments in that. The facility did not assess the resident #27 for hospice (health care that focuses on the comfort of terminally ill patient) and lack of natural teeth on her oral cavity. These failures could place residents at risk of not having all medical needs assessed and met. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition for one (Resident #27) of 18 residents reviewed for significant change. The facility failed to update Resident #27's MDS assessment within 14 days of the resident being discharge from hospice. This failure could result in residents not receiving the care and coordination of services necessary to meet their needs and/or desires. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident assessments were completed within 7 to14 days, and electronically transmitted, encoded accurately and completely, MDS data to the CMS System for discharge and death for 1 of 29 residents (CR #3) reviewed for encoding and transmitting resident assessments, in that: - The facility failed to complete a Death in Facility MDS for CR #3. - CR #3 did not have a Death in Facility MDS transmitted/exported within the required timeframe. These failures could place discharged residents at risk of not having a proper discharge and of not having their assessments transmitted/exported timely.

Inspectors wroteBased on interview, and record review, the facility failed to ensure assessment accurately reflects the resident's status for 1I of 29 (CR #65), residents reviewed for accuracy of assessments, in that -The facility failed to ensure CR #65's Death in Facility assessment accurately reflected her date of death . This failure could place residents at risk for inadequate care, services, and dignity in death.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 (Resident # 1) of 7 residents reviewed for respiratory care. The facility failed to ensure Resident #1 was provided oxygen during transport to doctors appointment in which Resident #1 arrived to appointment with O2 level at 73%, had difficulty breathing adn required O2. An IJ was identified on 3/7/2024. The IJ template was provided to the facility on 3/7/2024 at 4:20 pm. While the IJ was removed on 3/8/2024, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interviews and record review, the facility failed to immediately consult with the resident's physician of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (CR #1) of 5 residents reviewed for resident rights. -The facility failed to notify CR #1's physician when CR #1 became weak, confused, and short of breath which resulted in CR #1 falling and passing away at the facility on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:35 p.m. [...]

Inspectors wroteBased on interviews and records reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice for 1 (CR #1) of 5 residents reviewed for quality of care. -The facility failed to follow physician orders for CR #1 who was weak, confused, and short of breath resulting in a O2 saturation at 90% and who passed away a little under 2 hours later. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 3:35 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents who received oxygen therapy at risk of respiratory complications and/or death.

Inspectors wroteBased on observation, record reviews and interviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (CR#1) of five residents reviewed for quality of care. The facility failed to ensure CR#1 received necessary care and treatment for a diabetic foot wound on the 4th toe on his right foot resulting in dry gangrene and bone infection. The facility failed to ensure that no new wounds were acquired at the facility. The 1st right toe, left ischium and left buttock wounds were acquired at the facility. CR#1 was admitted to the ER at local hospital on 9/15/2023 after the Wound care Physician B completed an assessment and found that his wounds were worse than documented by Wound Care Physician A. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide care consistent with professional standards of practice promoting healing and prevent new pressure ulcers from developing for 1(CR#1) of 5 residents reviewed for pressure ulcers. The facility failed to ensure that no new pressure wounds were acquired at the facility. The 1st right toe, left ischium and left buttock wounds were acquired at the facility. CR#1 was admitted to the ER at local hospital on 9/15/2023 after the Wound care Physician B completed an assessment and found that his wounds were worse than documented by Wound Care Physician A. This failure caused (CR#1) bone infection and placed other residents at risk for pain, worsening wounds, infection, emotional distress and harm. An Immediate Jeopardy (IJ) situation was identified on 9/25/2023 at 2:03 p.m. [...]