**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure a resident had the right to be free from abuse for 1 of 7 residents reviewed for abuse (Resident #1). LVN E and CNA D witnessed CNA C abusing Resident #1. CNA C hit Resident #1 and was allowed to remain in the facility for over three hours with access to Resident #1 and other Residents. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 4/19/24 and ended 4/19/24. The facility had corrected the noncompliance before the survey began. The facility failures could have caused residents serious physical injury. Findings Included: Record review of Resident #1's face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. She had a diagnosis of Alzheimer's disease (progressive disease that destroys memory), and unsteadiness on feet. Record review of Resident #1's Quarterly MDS dated [DATE] indicated she was severely cognitively impaired with a BIMS score of 5. The MDS did not indicate any mood or behavior issues. The resident required substantial to maximum assist with all ADLS except eating, and oral hygiene. Record review of Resident #1's care plan indicated a problem start date of 1/7/22 of frequent incontinence of bowel and bladder. An approach was to provide peri care after each incontinent episode. The plan indicated a problem of ADL Self Care Performance Deficit. Some of the approaches were the resident required maximum assist for bathing, supervised assist for bed mobility, and one person assist for toileting. The plan indicated a problem of Cognitive loss due to dementia. One of the approaches was to provide the resident with necessary cues, stop, and return if the resident was agitated. Record review a Provider Investigation Report indicated an incident occurred on 4/19/24 at 3:30 a.m. The report indicated LVN E and CNA D witnessed CNA C hit Resident #1 in the stomach area. The nurse heard Resident #1 screaming and yelling in her room. The nurse went to assess the resident in her room. When the nurse opened the door, CNA C was changing Resident #1. The resident was grabbing the blankets and yelling to get CNA C away from her and for CNA C to leave her alone. CNA C was seen balling up her fist on her right hand and to hit Resident #1 on her right side in the rib area. The nurse immediately yelled what are you doing? You cannot do that. CNA C stated, I'm tired of her pinching The investigation indicated Resident #1 was assessed by LVN E on 4/19/24 at 3:45 a.m. with no visible injuries noted and no complaints of pain. CNA C was suspended pending investigation 4/19/24 at 6:30 a.m. The resident received another head-to-toe assessment on 4/19/24 at 10:00 a.m. with no injuries noted from this morning's incident. The family, the physician and the police department were notified. LVN E and CNA D were given one on one education on 4/19 by the DON regarding the importance of reporting allegations of abuse immediately. LVN E and CNA D were issued a three-day suspension on 4/19/2024 for failing to report allegations of abuse immediately. CNA C was terminated due to abuse allegation on 4/19/24 being confirmed. All interview able residents were interviewed by the administrator and social worker regarding abuse on 4/19/24. All non-resident received head to toe assessment, to assess for any injuries or evidence of abuse, by Nurses on 4/19/24. The direct care staff were interviewed on 4/19/24 by the administrator and DON regarding abuse and reporting requirements. The Abuse/Reportable Event policy was reviewed on 4/19/24 at 11:00 a.m. by the Administrator, Regional Director of Operations, Regional Nurse, and DON no changes made to the policy at this time. The DON provided education to all staff regarding abuse/reportable events policy, including types of abuse, and reporting requirements all staff present in the facility were educated on 4/19/24. Staff that were not present for education would receive the education prior to their next shift. The social services, Director or design would continue to interview and assess Resident #1 for emotional distress. During an observation and interview on 11/25/24 at 3:10 p.m. Resident #1 was sitting in a wheelchair by the nursing station. She said she was fine; she said she was still breathing. The rest of her conversation was about her childhood. She was unable to answer any questions about the incident. Attempts were made to contact CNA C, but phone numbers for her appeared to be disconnected. During an interview on 11/26/24 at 11:40 a.m. the Administrator said after the incident with Resident #1 he did interviews with all staff available at that time. He said he was notified on 4/19/24 around 6:00 a.m. of the abuse. He said CNA C had already left, and he talked to CNA C on the phone. He said at first, CNA C denied the incident. He said he told her he had two witnesses, she seemed frustrated, and did not say much. He said she just asked if she was terminated. He said they had implemented corrective actions such as terminating CNA C immediately, calling the police, the physician and updated Resident #1's care plan. He said they monitored Resident #1 for three days after the incident from 4/19/24 through 4/22/24, and they completed safe surveys with Resident #1 on each shift to make sure she did not have any reoccurring memories of the event. He said CNA C went home that morning and she never came back. The Administrator said he received statements from LVN E and CNA D, they did specific in services with LVN E and CNA D. He said they conducted safe surveys with the residents and follow up interviews with any concerns voiced by residents and there no concerns with abuse. The Administrator said they conducted skin assessments on all the residents. He said they also talked to staff about burn out and he conducted regular training on abuse, at least once a month. During a telephone interview on 11/26/24 at 10:38 a.m. CNA D said Resident #1 had never hit or scratched her. She said the incident happened on the 10 to 6 a.m. shift on 4/19/24. CNA D said it could have been the way the aide approached Resident #1 in the middle of the night to make her resistive to care. She said Resident #1 was clutching the covers and saying, Stop leave me alone. She said she did not see Resident #1 trying to strike CNA C. CNA D said she was sitting in the lounge and LVN E was sitting at the nursing station. She said they kept hearing through the door a resident grunting and saying, no and stop can D said at first, they did not know which room the noise was coming from, there were two rooms right by the nurse's station. She said they thought someone had fallen. She said she had gotten up to follow the nurse. When LVN E opened Resident #1's, she opened the door abruptly. CNA D said as the door opened CNA C had her forearm up with her fist balled up and hit Resident #1 in the stomach area. CNA D said she could see CNA C and Resident #1 quite well. She said all CNA C said was I am tired of her hitting and scratching me. CNA D said LVN E told her she could not do that and to leave the room. CNA D said CNA C walked out of the room. She said Resident #1 was saying to get CNA C out of her room and she appeared upset at the time, but later she was back to her old self. CNA D said it appeared Resident #1 had forgotten the incident. She said she was in shock because had worked with CNA C a long time and had not expected that type of behavior from her. During a telephone interview on 11/26/24 at 2:24 p.m. LVN E said she was sitting at the nursing station and heard a resident saying stop. She said she kept hearing words, grunting, and wanted to know where the noise was coming from. She said she and CNA D opened Resident # 1's and saw CNA C appeared to have just changed Resident #1. LVN E said Resident #1 was holding tight to the covers. She said CNA C was standing facing the door, over Resident #1 and the bed. She said CNA C was yakking on the covers, bulled up her fist, and punched Resident #1 in her side area. LVN E said she told the aide she could not do that, and to leave the room. She said CNA C left the room. LVN E said she assessed Resident #1 after the incident. She said she had two or three blankets on her, and there was no redness or busies. She said Resident #1 said she did not want CNA C in her room and for CNA C to leave her alone. She said she had gone back later, and Resident #1 was asleep. She said she and CNA D had gone in later to provide care to Resident #1 on the last round of the night and she appeared fine. The LVN said she knew to protect Resident #1 and get the aide away from the Resident #1. LVN E said she and CNA D were both in disbelief at the actions of CNA C. LVN E said CNA C disappeared for about 30 minutes. She finished working that night, but she was not allowed to go back into Resident #1's room. The LVN said she had never had anything like that happen before and her concern was protecting Resident #1. LVN E said she did not report the incident until the end of her shift. She said she was written up and in serviced on abuse and reporting. She said the next time she would notify they Administrator and everybody. Record review of the facility policy on Abuse/Reportable Events (not dated) indicated all residents have the right to be fee from abuse. Resident should not be subjected to abuse by anyone. The facility will provide and ensure the promotion and protection of resident's rights. Abuse is the willful infliction of injury. Willful individual must have intended to inflict injury or harm. Physical abuse includes hitting, slapping, pinching, and kicking. The facility took the following actions to correct the noncompliance on 4/19/24. Record review of Resident #1's care plan indicated a problem with a start date of 4/19/24 of psychosocial wellbeing, the resident was a victim of abuse related to an inappropriate interaction by staff. Some of the approaches were the resident received a full head to toe skin assessment. She would have emotional distress monitoring every shift for 72 hours. Record review of Resident #1's skin assessment dated [DATE] indicated no new areas. Review of Safe Surveys indicated a questionnaire was completed on Resident #1 each shift from 4/19/24 through 4/22/24 with no concerns noted. Record review of one-hour checks indicated they were completed on Resident #1 every hour with her vital signs from 4/19/24 through 4/22/24. Record review of Abuse pre and posttest and Abuse/Reporting in service was completed on 4/19/24 by more than 70 staff to include all departments and agency staff. The in service included the Resident Rights Policy, Abuse/Reporting Events policy the Abuse Coordinator information and to report immediately. Record review of CNA C's Employee Timecard indicated her last date of employment was 4/19/24 and she clocked out on 4/19/24 at 6:06 a.m. Record review of CNA C's employee training indicated she received abuse training on 5/2/23 prior to the incident on 4/19/24. Record review of CNA C's employee file indicated she received a disciplinary action of discharge form employment and to be banned from the property dated 4/19/24. The employee was discharged due to resident abuse or neglect or directly related to the safety and wellbeing of a resident. Record review of LVN E's employee training indicated LVN E received abuse training on 5/5/23 prior to the incident on 4/19/24. Record review of LVN E's employee file indicated LVN E received a disciplinary action with unpaid suspension on 4/19/24. Due to failure to promptly report to the immediate supervisor on the job injury or accident involving an employee. The employee did not report witnessed resident abuse immediately instead reported 3 hours after the incident. Record review of CNA D's employee training indicated she received abuse training on 4/17/23 prior to the incident on 4/19/24. Record review of CNA D's employee file indicated CNA D received a disciplinary action with unpaid suspension on 4/19/24. Due to failure to promptly report to the immediate supervisor on the job injury or accident involving an employee. The employee did not report witnessed resident abuse immediately instead reported 3 hours after the incident. During an interview on 11/26/24 at 8:49 a.m. CNA F said she had worked at the facility for 28 years. She said she had heard CNA C had hit Resident #1, but she had not seen the incident. CNA F said she was shocked because she and CNA F had worked at the facility together for about the same amount of time. CNA F said Resident #1 would holler out occasionally, but she was not resistive to care. CNA F said she was in serviced on abuse regularly. She said she had not seen or heard any abuse and if she did, she would report to the administrator immediately. During an interview on 11/26/24 at 9:08 a.m. CNA G said she had worked at the facility for a little over a year. She said Resident #1 was a sweet and confused. She said she did not holler out. CNA G said Resident #1 would sometimes be resistive to getting up in the morning but if you give her a little while she was fine. She said she was aware of the multiple types of abuse. She said if she saw or heard abuse, she would report it immediately to the administrator. During an interview on 11/26/24 at 9:30 a.m. CNA I said she did aid Resident #1. She said Resident #1 did not holler out. She said Resident #1 could be stubborn especially in the morning when she did not want to get up. She said she was familiar with what abuse was and if she saw or head abuse, she would report it to the administrator immediately. During an interview on 11/26/24 at 9:41 a.m. CNA J said she was aware of what abuse was and if she saw or heard any abuse she would report to the Administrator immediately. She said Resident #1 did not holler out and was not resistive to care. During an interview on 11/26/24 at 9:50 a.m. LVN K said Resident #1 did not holler out and she was not resistive to care. LVN K said she had never known Resident #1 to hit. LVN K said the only way Resident #1 would strike was if they were forcing her to do something she did not want to do. During an interview on 11/26/24 at 1:20 p.m. LVN L said she worked at the facility for two weeks. She said she received training on abuse and neglect. She said if she saw or heard abouts she would report immediately to the administrator. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 4/19/24 and ended 4/19/24. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the alleagtion involve abuse or result in serious bodily injury, to the Administrator of the facility and to other officials in accordance with State law for 1 of 7 residents reviewed for abuse (Resident #1.) LVN E and CNA D did not immediately report abuse to the Administrator after they witnessed CNA C abusing Resident #1. CNA C hit Resident #1 and was allowed to remain in the facility for over three hours with access to Resident #1 and other Residents. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 4/19/24 and ended 4/19/24. The facility had corrected the noncompliance before the survey began. This failure could have caused continued abuse to Resident #1 and possibly other residents. Findings included: Record review of Resident #1's face sheet indicated she was an [AGE] year-old female admitted to the facility on [DATE]. She had a diagnosis of Alzheimer's disease (progressive disease that destroys memory), and unsteadiness on feet. Record review of Resident #1's Quarterly MDS dated [DATE] indicated she was severely cognitively impaired with a BIMS score of 5. The MDS did not indicate any mood or behavior issues. The resident required substantial to maximum assist with all ADLS except eating, and oral hygiene. Record review of Resident #1's care plan indicated a problem start date of 1/7/22 of frequent incontinence of bowel and bladder. An approach was to provide peri care after each incontinent episode. The plan indicated a problem of ADL Self Care Performance Deficit. Some of the approaches were the resident required maximum assist for bathing, supervised assist for bed mobility, and one person assist for toileting. The plan indicated a problem of Cognitive loss due to dementia. One of the approaches was to provide the resident with necessary cues, stop, and return if the resident was agitated. Record review a Provider Investigation Report indicated an incident occurred on 4/19/24 at 3:30 a.m. The report indicated LVN E and CNA D witnessed CNA C hit Resident #1 in the stomach area. The nurse heard Resident #1 screaming and yelling in her room. The nurse went to assess the resident in her room. When the nurse opened the door, CNA C was changing Resident #1. The resident was grabbing the blankets and yelling to get CNA C away from her and for CNA C to leave her alone. CNA C was seen balling up her fist on her right hand and hit Resident #1 on her right side in the rib area. The nurse immediately yelled what are you doing? You cannot do that. CNA C stated, I'm tired of her pinching The investigation indicated Resident #1 was assessed by LVN E on 4/19/24 at 3:45 a.m. with no visible injuries noted and no complaints of pain. CNA C was suspended pending investigation 4/19/24 at 6:30 a.m. The allegation of abuse was reported to HHSC on 4/19/24 at 8:33 a.m. The resident received another head-to-toe assessment on 4/19/24 at 10:00 a.m. with no injuries noted from this morning's incident. The family, the physician and the police department were notified. LVN E and CNA D were given one on one education on 4/19 by the DON regarding the importance of reporting allegations of abuse immediately. LVN E and CNA D were issued a three-day suspension on 4/19/2024 for failing to report allegations of abuse immediately. CNA C was terminated due to abuse allegation on 4/19/24 being confirmed. All interview able residents were interviewed by the administrator and social worker regarding abuse on 4/19/24. All non-resident received head to toe assessment, to assess for any injuries or evidence of abuse, by Nurses on 4/19/24. The direct care staff were interviewed on 4/19/24 by the administrator and DON regarding abuse and reporting requirements. The Abuse/Reportable Event policy was reviewed on 4/19/24 at 11:00 a.m. by the Administrator, Regional Director of Operations, Regional Nurse, and DON no changes made to the policy at this time. The DON provided education to all staff regarding abuse/reportable events policy, including types of abuse, and reporting requirements all staff present in the facility were educated on 4/19/24. Staff that were not present for education would receive the education prior to their next shift. The social services, Director or design would continue to interview and assess Resident #1 for emotional distress. During an interview on 11/26/24 11:40 a.m. the Administrator after the incident with Resident #1 he did interviews with all staff available at that time. The Administrator said he was notified about the incident on 4/19/24 around 6:00 a.m. He said CNA C had already left, and he talked to CNA C on the phone. He said at first, CNA C denied the incident. He said he told her he had two witnesses, she seemed frustrated, and did not say much. He said she just asked if she was terminated. He said LVN E or CNA D did not notify him that night, they informed him the first thing the next morning. He called the incident into the state at that time around 8:30 a.m. He said they had implemented corrective actions such as terminating CNA C immediately, calling the police, the physician and updated Resident #1's care plan. He said they monitored Resident #1 for three days after the incident from 4/19/24 through 4/22/24, and the completed safe surveys with Resident #1 on each shift to make sure she did not have any reoccurring memories of the event. He said CNA C went home that morning and she never came back. The Administrator said he wrote LVN E and CNA D up for not reporting the incident immediately. He said CNA C was allowed to remain in the building for over three hours before the incident was reported. The Administrator said he received statements from LVN E and CNA D, and they did specific in services with LVN E and CNA D. He said they conducted safe surveys with the residents and follow up interviews with any concerns voiced by residents and there no concerns with abuse. The Administrator said they conducted skin assessments on all the residents. He said they also talked to staff about burn out and he conducted regular training on abuse, at least once a month. During an observation and interview on 11/25/24 at 3:10 p.m. Resident #1 was sitting in a wheelchair by the nursing station. She said she was fine; she said she was still breathing. The rest of her conversation was about her childhood. She was unable to answer any questions about the incident. Attempts were made to contact CNA C, but phone numbers for her appeared to be disconnected. During a telephone interview on 11/26/24 at 10:38 a.m. CNA D said Resident #1 had never hit or scratched her. She said the incident happened on the 10 to 6 a.m. shift on 4/19/24. CNA D said it could have been the way the aide approached Resident #1 in the middle of the night to make her resistive to care. She said Resident #1 was clutching the covers and saying, Stop leave me alone. She said she did not see Resident #1 trying to strike CNA C. CNA D said she was sitting in the lounge and LVN E was sitting at the nursing station. She said they kept hearing through the door a resident grunting and saying, no and stop CNA said at first, they did not know which room the noise was coming from, there are two rooms right by the nurse's station. She said they thought someone had fallen. She said she had gotten up to follow the nurse. When LVN E Resident #1's door, she opened the door abruptly. CNA D said as the door opened CNA C had her forearm up with her fist balled up and hit Resident #1 in the stomach area. CNA D said she could see CNA C and Resident #1 quite well. She said all CNA C said was I am tired of her hitting and scratching me. CNA D said LVN E told her she could not do that and to leave the room. She said CNA C left the room. CNA D said CNA C left the room. She said Resident #1 was saying to get CNA C out of her room and she appeared upset at the time, but later she was back to her old self. CNA D said it appeared Resident #1 had forgotten the incident. She said she was a shock because had worked with CNA C a long time and had not expected that type of behavior from her. During a telephone interview on 11/26/24 at 2:24 p.m. LVN E said she was sitting at the nursing station and heard a resident saying stop. She said she kept hearing words, grunting, and wanted to know where the noise was coming from. She said she and CNA D opened Resident #1's door and saw CNA C appeared to have just changed Resident #1. LVN E said Resident #1 was holding tight to the covers. She said CNA C was standing facing the door, over Resident #1 and the bed. She said CNA C was yakking on the covers, bulled up her fist, and punched Resident #1 in her side area. LVN E said she told the aide she could not do that, and to leave the room. LVN E said she assessed Resident #1. She said she had two or three blankets on her, and there was no redness or busies. She said Resident #1 said she did not want CNA C in her room and for CNA C to leave her alone. LVN E said CNA C left the room. She said she was gone for about 30 minutes but did finish her shift. LVN E said she had gone back later, and Resident #1 was asleep. She said she and CNA D had gone in on the last round of the night to provide care to Resident #1 and she appeared fine. The LVN said she knew to protect the patient and get the aide away from the Resident #1. LVN E said she and CNA D were both in disbelief at the actions of CNA C. She said she had never had anything like that happen before, and had not sent CNA C home. She was only thinking of keeping Resident #1 safe and not allowing the aide back in her [NAME]. LVN E said she had reported the incident when the dayshift staff came in. She said she was suspended for three days for not reporting the incident immediately. The LVN said if anything like that happened, she would call everybody as soon as possible. LVN E said CNA C had already left by the time she had reported the incident. Record review of the facility policy on Abuse/Reportable Events with no dated indicated all residents have the right to be fee from abuse. Resident should not be subjected to abuse by anyone. The facility will provide and ensure the promotion and protection of resident's rights. Abuse is the willful infliction of injury. Willful individual must have intended to inflict injury or harm. Physical abuse includes hitting, slapping, pinching, and kicking. Facility employees must report all allegations of abuse. If the allegations involve abuse or result in serious bodily injury, the report is to be made within two hours of the allegation. The facility took the following actions to correct the noncompliance on 4/19/24. Record review of Resident #1's care plan indicated a problem with a start date of 4/19/24 of psychosocial wellbeing, the resident was a victim of abuse related to an inappropriate interaction by staff. Some of the approaches were the resident received a full head to toe skin assessment. She would have emotional distress monitoring every shift for 72 hours. Record review of Resident #1's skin assessment dated [DATE] indicated no new areas. Review of Safe Surveys indicated a questionnaire was completed on Resident #1 each shift from 4/19/24 through 4/22/24 with no concerns noted. Record review of one-hour checks indicated they were completed on Resident #1 every hour with her vital signs from 4/19/24 through 4/22/24. Record review of Abuse pre and posttest and Abuse/Reporting in service was completed on 4/19/24 by more than 70 staff to include all departments and agency staff. The in service included the Resident Rights Policy, Abuse/Reporting Events policy the Abuse Coordinator information and to report immediately. Record review of CNA C's Employee Timecard indicated her last date of employment was 4/19/24 and she clocked out on 4/19/24 at 6:06 a.m. Record review of CNA C employee training indicated she received abuse training on 5/2/23 prior to the incident on 4/19/24. Record review of CNA C employee file indicated she received a disciplinary action of discharge form employment and to be banned from the property dated 4/19/24. The employee was discharged due to resident abuse or neglect or directly related to the safety and wellbeing of a resident. Record review of LVN E's employee training indicated LVN E received abuse training on 5/5/23 prior to the incident on 4/19/24. Record review of LVN E's employee file indicated LVN E received a disciplinary action with unpaid suspension on 4/19/24. Due to failure to promptly report to the immediate supervisor on the job injury or accident involving an employee. The employee did not report witnessed resident abuse immediately instead reported 3 hours after the incident. Record review of CNA D's employee training indicated she received abuse training on 4/17/23 prior to the incident on 4/19/24. Record review of CNA D's employee file indicated CNA D received a disciplinary action with unpaid suspension on 4/19/24. Due to failure to promptly report to the immediate supervisor on the job injury or accident involving an employee. The employee did not report witnessed resident abuse immediately instead reported 3 hours after the incident. During an interview on 11/26/24 at 8:49 a.m. CNA F said she had worked at the facility for 28 years. She said she had heard CNA C had hit Resident #1, but she had not seen the incident. CNA F said she was shocked because she and CNA F had worked at the facility together for about the same amount of time. CNA F said Resident #1 would holler out occasionally, but she was not resistive to care. CNA F said she was in serviced on abuse regularly. She said she had not seen or heard any abuse and if she did, she would report to the administrator immediately. During an interview on 11/26/24 at 9:08 a.m. CNA G said she had worked at the facility for a little over a year. She said Resident #1 was a sweet and confused. She said she did not holler out. CNA G said Resident #1 would sometimes be resistive to getting up in the morning but if you give her a little while she is fine. She said she was aware of the multiple types of abuse. She said if she saw or heard abuse, she would report it immediately to the administrator. During an interview on 11/26/24 at 9:30 a.m. CNA I said she did aid Resident #1. She said Resident #1 did not holler out. She said Resident #1 could be stubborn especially in the morning when she did not want to get up. She said she was familiar with what abuse was and if she saw or head abuse, she would report it to the administrator immediately. During an interview on 11/26/24 at 9:41 a.m. CNA J said she was aware of what abuse was and if she saw or heard any abuse. She said she would report to the Administrator immediately. She said Resident #1 did not holler out and was not resistive to care. During an interview on 11/26/24 at 9:50 a.m. LVN K said Resident #1 did not holler out and she was not resistive to care. LVN K said she had never known Resident #1 to hit. LVN K said the only way Resident #1 would strike was if they were forcing her to do something she did not want to do. During an interview on 11/26/24 at 10:14 a.m. the DON said LVN E did immediately remove CNA C from Resident #1 and the LVN assessed the resident. The DON said LVN E did not call immediately, the incident occurred about 3:30 a.m. The DON said they were not informed until the end of the shift about 6:00 a. she said the LVN worked for agency and the aide no longer worked for the facility. During an interview on 11/26/24 at 1:20 p.m. LVN L said she worked at the facility for two weeks. She said she received training on abuse and neglect. She said if she saw or heard abouts she would report immediately to the administrator. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 4/19/24 and ended 4/19/24. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident received adequate supervision and assistive devices to prevent accidents for 1 of 7 residents reviewed for accidents (Resident #2). CNA A failed to ensure two staff members provided a Hoyer lift transfer. A family member assisted with the transfer, the Hoyer lift sling strap was not attached properly, and Resident #2 fell out of the Hoyer lift. The noncompliance was identified as PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 3/3/24 and ended 3/3/24. The facility had corrected the noncompliance before the survey began. This failure could have caused serious injury. Findings included: Record review of Resident #2's face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were muscle weakness, obesity, and lack of coordination. Record review of Resident #2's admission MDS dated [DATE] indicated the resident had a BIMs score of 13 indicating she was cognitively intact. Her ADLs were listed as partial to moderate assist for transfers with the helper doing less than half the effort. Record review of Resident #2's care plan indicated a problem with a start date of 2/20/24. Resident #2 had limited ability to transfer herself related to morbid obesity and recent hospitalization. The goal was the resident would transfer with the use of a mechanical lift by staff and a transfer belt with therapy with an edited dated of 3/25/24. The resident had a problem with a start date of 2/20/24 with the category of falls, and an edited date of 3/5/24. The resident had the potential for injury related to falls due to a decline in medical condition, attempts to stand unassisted, impulsiveness, and recent hospitalization. Resident had an actual fall since admission. Some of the approaches were Resident #2 was to be transferred with a Hoyer lift by two staff for all transfers. Record review of Resident #2's physician orders dated 3/4/24 indicated an order for Tylenol 325 mg, two tablets every six hours as need or pain. Record review of a nursing note dated 3/3/24 at 10:58 a.m. indicated LVN B found Resident #2 on the floor in her room beside the bed. CNA A and Resident #2's family member was also in the room. CNA A was attempting to transfer Resident #2 from the bed to the shower chair with the mechanical lift when the resident fell. Resident #2 complained of a sharp pain in her neck and back at a pain scale of 10 out of 10(with 10 being the worst pain possible.) Resident #2 was assessed, and no abnormalities found. She had a small red area over her left eyebrow. Resident #2 did not complain of head pain. Resident #2 was assisted back to bed. Resident #2 wanted Tylenol and Tylenol was administered. Resident #2 did not want to go to the hospital. Resident #2 and the family member were educated on the benefits of going to the hospital for an evaluation and Resident #2 continued to refuse. The nurse practitioner gave orders for an immediate imaging of the head spine and neck. Resident #2 was checked for a pain level 10 minutes later and voiced her pain was a 7 out of 10. Resident #2's vital signs were within normal limits. Resident #2 was checked again for pain at 10:45 a.m. and said her pain was a 3 out of 10. Resident #2 continued to refuse to go to the hospital. Review of a radiology report dated 3/3/24 indicated Resident #2's x-ray of the skull, and three views of the spine were all negative. Record review of the facility Provider Investigation Report indicated on 3/3/24 at 8:50 a.m. CNA A was transferring Resident #2 from the bed to the wheelchair. The resident was transferred with a Hoyer lift, and her family member was in the room along with CNA A. During the transfer Resident #2 slipped out of the Hoyer sling and fell to the floor. Charge nurse LVN B inspected the Hoyer lift and discovered a strap was not completely in place and caused the resident to slip out. At the time of the incident Resident #2 said her neck and back hurts. The initial assessment indicated Resident #2 had range of motion in all 4 extremities within normal limits. LVN B tried to send Resident #2 to the hospital, but Resident #2 adamantly refused. The nurse practitioner was notified, and neuro checks were initiated. Resident #2 was alert and oriented and her own medical power of attorney. X rays were ordered in house, and they were negative for any fractures. The resident was provided as needed Tylenol for pain. All lifts and slings were checked for proper functioning with no issues noted. Education and disciplinary actions were given to CNA A. The investigation findings were confirmed. The facility took the following actions to correct the noncompliance on 3/3/24. Record review dated 3/3/24 indicated in- services were conducted on Hoyer transfers, Abuse /Reportable events, and Resident Rights. Mechanical lift competency check offs were also completed by staff. Record review an Employee Disciplinary Report dated 3/3/24 indicated CNA A received a written counseling and education training on the mechanical lift transfer safety with a skills competency check. A thirty-day probation, a one-day suspension. Record reviews indicated CNA A had a Certificate of [NAME] Completion on Fall Prevention competed 3/5/24 and Certificate of [NAME] Completion on Position and Transfer Techniques dated 3/5/24. Record review of In-Service Training report dated 3/3/24 indicated staff were in serviced on Abuse Reportable Events, Resident Rights and Mechanical Lift Transfer. Record review of Using a Mechanical Lifting Machine competency demonstration indicated they were conducted on 3/4/24. Record review of the facility Mechanical Lift policy with and effective August 2020. The policy stated it is the policy of this home to utilize the Hoyer or similar lift when it is necessary to safely transfer a resident due to body wight or physical condition. Lifting a resident with a mechanical lift is always a two-person procedure. One of the procedures indicated to check chains and hooks to make [NAME] they are properly positioned. Record review of a Discharge Summary indicated Resident #2 was discharged to home on 3/10/24. During an interview on 11/25/24 at 9:15 a.m. the Administrator said CNA A had been educated on not allowing family members to help her with transfers. He said she was educated on always having another staff member with her for Hoyer lift transfers. She was also given a disciplinary action and was required to take some online courses. He said Resident # 2 did not want to go to the hospital and had no injuries. The Administrator said the resident had since discharged home. During an interview on 11/26/24 at 8:57 a.m. CNA A said she worked at the facility for 15 years. CNA A said on the morning of 3/3/24 she was transferring Resident #2 from the bed to the shower chair. CNA A said she did not get another staff member to help her with the Hoyer lift transfer because Resident #2's family member was in the room. CNA A said the family member had assisted with transfers in the past. She said they had placed the loops on the transfer pad/sling to the Hoyer lift. CNA A said she had worked the controls on the mechanical/Hoyer lift and the family member had guided the resident towards the chair. She said they had lifted her from the bed and pivoted around toward the chair. CNA A said right before Resident #2 was at the chair one of the loops connected to the pad/sling came off, and Resident #2 slid to the floor. She said the family member likely did not secure the loop on the Hoyer securely. CNA A said she was in serviced on abuse neglect, and Hoyer lift transfers. She said she was also written up and was now aware to always get another staff for Hoyer lift transfers. She said she was told family members were not to assist with transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure the drug regimen was free from unnecessary medication for 1 of 5 (Resident #74) residents reviewed for unnecessary medications. 1. The facility failed to ensure Resident #74 did not receive a medication she was allergic to (ibuprofen) ordered for a swollen right hand on 5/22/23. 2. The facility failed to ensure Resident #74 was not given medications she was allergic to as ordered (ibuprofen 400 mg by mouth 4 times a day for 14 days). Resident #1 received ibuprofen from 05/22/23 to 07/23/23 (63 days). 3. The facility failed to ensure Resident #74's ibuprofen was discontinued after Resident #1 returned from the hospital from an upper GI bleed. Resident #1 received scheduled ibuprofen on 07/26/23 through 07/27/23 (4 doses). An Immediate Jeopardy (IJ) was identified on 10/20/23. While the IJ was removed on 10/21/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate threat due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm or death related to receiving unnecessary medications. Findings included: Record review of Resident #74's face sheet, dated 10/20/23, indicated she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses including dementia (damage to or loss of nerve cells in the brain that causes memory loss, confusion, the ability to think or make decisions), gastrointestinal hemorrhage (bleeding in the digestive tract caused by a disease or condition) and gastro-esophageal reflux disease (stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #74's Care Plan dated 04/27/21 and last revised on 07/31/23 indicated she had an allergy to Lisinopril and Pravastatin and interventions included do not administer allergen, make note on chart of allergies and notify the physician if allergen is ordered. Resident #74's care plan did not address an allergy to ibuprofen. Record review of Resident #74's MDS dated [DATE] indicated she usually made herself understood and sometimes understood others. Resident #74 had severely impaired cognition. Record review of Resident #74's admission History and Physical dated 04/27/21by the Nurse Practitioner indicated she had a past medical history of dementia, anemia (blood disorder in which the blood has a reduced ability to carry oxygen due to a lower-than-normal number of red blood cells), gastro-esophageal reflux disease and peptic ulcer disease (open sores that develop on the inside lining of your stomach and the upper portion of your small intestine causing dark or black stool and vomiting). Resident #74 had an allergy to lisinopril, and pravastatin. Resident #74's admission History and Physical did not list ibuprofen as an allergy. Record review of hospital records dated 04/30/21 indicated Resident #74 had a fall and was sent to the hospital. Records indicated Resident #74 had an allergy to ibuprofen, lisinopril, and pravastatin. Record review of hospital records dated 08/28/21 indicated Resident #74 had a fall and was sent to the hospital. Records indicated Resident #74 had an allergy to ibuprofen, lisinopril, and pravastatin. Record review of a handwritten telephone order dated 05/22/23 indicated Resident #74 had an order to receive ibuprofen 400 mg by mouth 4 times a day for 14 days. The telephone order was signed by LVN E. Record review of Resident #74's physician's order dated 05/22/23 indicated she had an order for ibuprofen 400 mg by mouth 4 times a day. Resident #74's ibuprofen was discontinued on 07/31/23. Record review of Resident #74's MAR for the month of May, June, and July of 2023 indicated she received ibuprofen on the following dates: *05/22 through 05/31 (10 days) *06/01 through 06/30 (30 days) *07/01 through 07/23 (23 days) Record review of Resident #74's nursing progress notes dated 07/24/23 at 3:00 a.m. by LVN E, indicated at 2:50 a.m. she was called to the shower room. The resident had a black tarry bowel movement with blood. LVN E notified the hospice nurse. Record review of Resident #74's nursing progress notes dated 07/24/23 at 3:59 a.m. by LVN E, indicated she was instructed by the hospice nurse to check the resident's blood pressure and to send her to the hospital for possible gastrointestinal bleed if it was low. Resident's manual blood pressure was 98/54 (normal blood pressure 120/80). Resident was transported to the hospital. Record review of Resident #74's nursing progress notes dated 07/26/23 at 10:22 a.m. by the ADON, indicated she called the hospital, and informed the resident was admitted for a gastrointestinal bleed. Record review of Resident #74 hospital records dated 07/26/23 indicated she had dark bloody stools and was transferred to the hospital on [DATE]. She had an allergy to ibuprofen and a history of peptic ulcer disease (an open sore that develops on the inside lining of your stomach and the upper portion of your small intestine). She had a hemoglobin (a protein in blood that carries oxygen to the body) level of 6.0 (Normal range 12.0-16.0) and was transfused with 2 units (approximately 2 pints) of blood in the emergency department. She was admitted to the intensive care unit (unit with specialized staff, equipment, and standards that handles severe, potentially life-threatening cases) diagnosed with an upper gastrointestinal bleed. She was transfused with 1 unit (approximately 1 pint) of blood in the intensive care unit 07/25/23. She was discharged back to the nursing facility on 07/26/23. Record review of Resident #74's MAR for July 2023 indicated she received ibuprofen on the following dates: *07/26 and 07/27 (2 days) Record review of Resident #74's nursing progress notes dated 07/26/23 at 8:17 p.m. by RN G, indicated she returned to the nursing facility and had dark blood in her brief upon arrival. Record review of Resident #74's nursing progress notes dated 07/27/23 at 6:10 p.m. by RN G, indicated the family notified her the resident had vomited. RN F observed a moderate amount of coffee ground emesis and the family requested for the resident to be sent to the emergency room. Record review of Resident #74's nursing progress notes dated 07/27/23 at 6:22 p.m. by RN G, indicated the resident was transferred to the hospital. Record review of Resident #74 hospital records dated 07/31/23 indicated she had vomited blood at the nursing facility and was transferred to the emergency department on 07/27/23. She had an allergy to ibuprofen and a history of peptic ulcer disease. She had a hemoglobin level of 9.8 (Normal range 12.0-16.0) on arrival and trended to a hemoglobin level of 6.9. She received 2 units (approximately 2 pints) of blood and was admitted . She was discharged to the nursing facility on 07/31/23. Record review of Resident #74's allergy history indicated ibuprofen was added as an allergy on 08/01/23 by the ADON. Record review of Resident #74's census dated 10/21/23 indicated she was discharged from the facility on 08/16/23 to another nursing facility. During an interview on 10/20/23 at 2:14 p.m., LVN E said she worked the 6:00 a.m.-2:00 p.m. shift and was the charge nurse for Resident #74 when the ibuprofen was ordered on 05/22/23. LVN E said Resident #74 had a swollen wrist, and she notified the hospice nurse. LVN E said the hospice nurse came to the facility to assess Resident #74 then notified the physician. LVN E said the hospice nurse hand wrote an order for Resident #74 to take ibuprofen 4 times a day for 14 days. LVN E said she signed the hospice nurse's handwritten order then entered it into Resident #74's electronic chart. LVN E said she did not enter the date to discontinue the ibuprofen after 14 days. LVN E said Resident #74 received ibuprofen for almost 2 months because she entered the incorrectly. LVN E said a resident taking ibuprofen with peptic ulcer disease is at risk of bleeding. LVN E said Resident #74 had peptic ulcer disease and was taking ibuprofen when she was sent to hospital for a gastrointestinal bleed. LVN E said she did not know Resident #74 had an allergy to ibuprofen prior to going to the hospital. During an interview on 10/20/23 at 2:23 p.m., the DON said the charge nurse was responsible for entering physician's orders in a resident's chart and she was responsible they were entered in correctly. The DON said Resident #74 had a swollen wrist and was ordered ibuprofen for 14 days. The DON said LVN E entered the order in Resident #74's chart and she did not enter the date to discontinue the ibuprofen after 14 days. The DON said she did not check Resident #74's chart to see if LVN E entered the order correctly. The DON said Resident #74 received ibuprofen for almost 2 months. The DON said Resident #74 was sent to hospital twice for a gastrointestinal bleed. The DON said the ibuprofen was discontinued and added as an allergy to her electronic chart when Resident #74 returned from the hospital the second time . The DON said she did not know Resident #74's past hospital records listed ibuprofen as an allergy. The DON said she did not review Resident #74's hospital records because she assumed they were reviewed by the previous DON before she was hired. The DON said a resident taking ibuprofen with peptic ulcer disease is at risk of bleeding. The DON said Resident #74 had peptic ulcer disease and was taking ibuprofen when she went to the hospital. The DON said she did not know Resident #74 had an allergy to ibuprofen prior to going to the hospital and have since changed how they monitored medications. The DON said a list of new medications ordered from the previous day is printed out and reviewed during their daily clinical meeting for resident allergies and to ensure orders are entered accurately. Record review of the facility's Medication-Administration policy dated 08/2020 indicated, It is the policy of this home that medication will be administered and documented as ordered by the physician and in accordance with state regulations . Record review of the facility's Physician Services policy dated 08/2020 indicated, .Procedure .8. Physician's orders for treatment and medication shall be recorded in the medical record and shall be signed by the attending physician. Such orders shall be in effect for the number of days specified by the physician .11. The DON/Administrator will be responsible to monitor physician visits to assure that the resident is receiving appropriate care and services . The Administrator was notified on 10/20/23 at 6:38 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 10/20/23 at 6:44 p.m. The facility's Plan of Removal was accepted on 10/21/23 at 3:00 p.m. and included: Resident Specific o An allergy for ibuprofen was added into Resident #1's electronic medical record on 8/1/23 due to having the GI bleed. o Resident #1 no longer resides at the facility as Resident #1 was discharged on 8/16/2023. o Medical Director notified of IJ on 10/20/2023 at 7:58 PM by Administrator. o Notified Pharmacy Consultant of IJ on 10/20/2023 at 7:58 PM by Director of Nursing. System Changes o Audit of all medication orders for NSAID use and stop dates completed on 10/20/2023 for all residents by Director of Nursing and Assistant Director of Nursing at 10:30 PM. o Head to toe assessment completed for all residents on 10/20/2023 by Treatment Nurse/LVN at 11:50 PM. o During stand up/clinical meeting DON and/or ADON to review new orders with stop dates if applicable to ensure correct transcription into EMR. Education o Director of Nursing provided education to all staff on signs/symptoms of GI Bleeding. If signs and/or symptoms of GI Bleeding are identified the staff member should report to charge nurse immediately. Once notified the charge nurse should contact physician. All staff present in the facility were educated on 10/20/2023. Staff not present for the education will receive education prior to their next shift. o Director of Nursing provided education to nursing staff regarding Medication Administration of Long Term NSAID's and Risks. All nursing staff present in the facility were educated on 10/20/2023. Staff not present for the education will receive education prior to their next shift. o Director of Nursing provided education to nursing staff regarding The 5 Rights of Medication Administration. All nursing staff present in the facility were educated on 10/20/2023. Staff not present for the education will receive education prior to their next shift. o Administrator, Director of Nursing, and Assistant Director of Nursing in-serviced on 10/20/2023 at 9:43 PM by Regional Clinical Consultant in regard to Monitoring New Orders for Accurate Transcription into EMR. Monitoring o Order obtained from Medical Director by Director of Nursing for every resident on 10/20/2023 to monitor for abnormal bleeding i.e. excessive bruising, bleeding gums, nose bleeds, tarry stools, etc. This is documented Q Shift on the medication administration record in the EMR. On 10/21/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verifying the Medical Director had been informed of the Immediate Jeopardy from documentation signed by the Administrator. Verifying the Pharmacy Consulted had been informed of the Immediate Jeopardy from documentation signed by the DON. Record review of in services revealed staff were educated on signs and symptoms of gastrointestinal bleeding, report signs and symptoms of bleeding to charge nurse, long term NSAID's and Risks, and The 5 Rights of Medication Administration. Record review of in services revealed the Administrator, DON and ADON were educated on Monitoring New Orders for Accurate Transcription into EMR (electronic medical record) and reviewing new orders with stop dates to ensure correct transcription into EMR during clinical meeting. Record reviews on four resident charts taking ibuprofen were completed to ensure medication orders for NSAID use and stop dates were completed, head to toe assessment were completed and orders to monitor for abnormal bleeding, excessive bruising, bleeding gums, nose bleeds, tarry stools, etc. each shift. There were no issues identified. Interviews with 5 Licensed Nurses, 3 MA and 9 CNAs (on all shifts 6 a.m.- 2 p.m., 2 p.m.-10 p.m., 10 p.m.- 6 a.m., 6 a.m.-6 p.m., and Weekend Doubles) were performed on 10/21/23. All licensed nursing staff were able to correctly identify signs and symptoms of gastrointestinal bleeding, who to report it to, monitoring for bleeding each shift and documenting it on the MAR. Licensed nurses and MA were able to correctly identify medication administration of long-term use and risks of NSAIDs (nonsteroidal anti-inflammatory drugs) and 5 Rights of Medication Administration. During an interview on 10/21/23 at 4:31 p.m., the DON said she in-serviced the nursing staff on signs and symptoms of gastrointestinal bleeding, report signs and symptoms of bleeding to charge nurse, long term NSAID's and Risks, and The 5 Rights of Medication Administration. The DON said staff who were not in serviced would be prior to their next shift. The DON said she was in serviced on Monitoring New Orders for Accurate Transcription into EMR (electronic medical record) and reviewing new orders with stop dates to ensure correct transcription into EMR during clinical meeting. The DON said clinical meetings are held daily. During an interview on 10/21/23 at 4:44 p.m., the ADON said she was in serviced on Monitoring New Orders for Accurate Transcription into EMR (electronic medical record) and reviewing new orders with stop dates to ensure correct transcription into EMR during clinical meeting. The ADON said clinical meetings are held daily. During an interview on 10/21/23 at 4:53 p.m., the Administrator said he was in serviced on Monitoring New Orders for Accurate Transcription into EMR (electronic medical record) and reviewing new orders with stop dates to ensure correct transcription into EMR during clinical meeting. The Administrator said clinical meetings are held daily. On 10/21/23 at 5:30 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.