**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for one (Resident #1) of three residents reviewed for discharges. The facility failed to have a wheelchair and assistant services set up upon Resident #1's discharge to her apartment. She was unable to transfer herself and was found by EMS over 24 hours later laying in the same spot without access to food or water. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 04/29/24 at 2:00 PM and an IJ template was provided to the ADM. While the IJ was removed on 05/01/24 at 7:00 PM, facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of harm, injury, rehospitalization, and death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dislocation of right patella, morbid obesity, need for assistance with personal care, and muscle wasting and atrophy. She was discharged from the facility on 04/25/24. Review of Resident #1's quarterly MDS assessment, dated 03/19/24, reflected a BIMS of 15, indicating she had no cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent for toileting, showering/bathing, and dressing and required maximum assistance with transferring. Section M (Skin Conditions) reflected she had a stage V pressure ulcer. Review of Resident #1's admission care plan, dated 01/11/24, reflected she was at risk for falls with an intervention of providing her safe environment. It further reflected she had an ADL self-care performance deficit with interventions of requiring one staff member for assistance with bathing and dressing and requiring two staff members using a hoyer lift for transfers. Review of an email sent by SW B to an agency (HA) that helps residents apply for Medicaid and locate LTCFs, dated 03/28/24, reflected the following: [Resident #1] is looking for LTC facility, wanting to see if she can apply for Medicaid as well. She is currently discharging to (IL facility) on Monday 4/1 . Review of Resident #1's NOMNC, dated 04/22/24, reflected the effective date coverage of her current skilled nursing services would end on 04/24/24. Review of Resident #1's Physical Therapy Discharge summary, dated [DATE], reflected she could transfer, stand, and walk ten feet with minimal assistance. Review of Resident #1's nursing progress noted, dated 04/25/24 and documented by LVN A, reflected the following: Comprehensive Nursing Note for [Resident #1]: AOX4. Vss. No s/s of distress. Incontinent of B&B . pending d/c @ 3:00 PM today to (independent living facility). Review of Resident #1's Discharge summary, dated [DATE] at 7:48 PM and completed by SW B, reflected no home health services were recommended and a wheelchair was to be provided. Review of an e-mail from a HH agency to SW B, dated 04/25/24 at 3:24 PM (after Resident #1 had been discharged ), reflected (HH agency) was able to accept Resident #1. The e-mail chain was started that day. Review of Resident #1's EMS documentation, dated 04/26/24 at 3:28 PM and documented by EMT D, reflected the following: 12/27 seen by EMS for dislocated patella and leg pain, [Resident #1] reports emergency surgery followed by admission into (facility). [Resident #1] she was kicked out of (facility) because she hit the 100 days maximum for Medicare. [Resident #1] states staff made her leave, and she was not assessed by a physician for mobility and safety. [Resident #1] states she never refused LTC. [Resident #1] states staff forced her out of NH. AFD responded for lift assist last night a req C4 follow up today per (doctor). [Resident #1] states she is in the same diaper NH discharged her in because she is unable to get to bathroom or in/out of bed without assistance. [Resident #1] states she slid to the floor and did not fall. [Resident #1] reports last meal was yesterday around noon when she was discharged from (facility). [Resident #1] states she has been snacking on candy she had in bed since then. [Resident #1] found lying in bed, alert to EMS, AO4/GCS15. Assessment recorded above with continuous assessment on scene. [Resident #1] appears in no distress. Poor hygiene with smell of foul urine/feces. [Resident #1] states she has been unable to get out of bed to use the restroom or clean herself since discharge. [Resident #1] has trash and laundry scattered about apartment with rotting food in sink. Consult with C4 on scene for [Resident #1]'s re-admission into NH due to inability to care for self with no caregiver or home health present or planned. No answer with NH and no other options. Unable to leave [Resident #1] on scene, transport to (hospital) . Notified hospital that [Resident #1] cannot be dx home and APS is being contacted. After the documentation there were pictures EMT D took of Resident #1's apartment. Observations of these pictures revealed a heavily soaked/stained mattress and a kitchen sink filled with dishes. Review of Resident #1's hospital records, dated 04/26/24, reflected the following: Primary Diagnosis: acute debility, unable to care for self . [Resident #1] was recently discharged home from (facility) but her wheelchair was not delivered so she was essentially unable to move or care for herself. PT/OT recommending return to SNF. APS is reportedly involved in [Resident #1]'s care During an interview on 04/29/24 at 9:42 AM, SW E stated she as one of two SWs that worked at the facility. She stated the discharge process started when a resident was admitted . They discussed as a team where the resident would be discharged to, and if any DME or services would be needed. She stated upon discharge, the SWs were responsible for issuing a non-coverage form (NOMNC), explaining their right to appeal, setting home health, ordering any DME, and any other resources needed. She stated she was not Resident #1's SW. During an interview on 04/29/24 at 9:49 AM, SW B stated she had been Resident #1's SW while she was at the facility. She stated the social worker's responsibilities were mainly to focus on discharges - setting up home health, care giver support, hospice, and ordering DME. She stated she was Resident #1's SW while she was at the facility. She stated she had used up all of her Medicare days (100 days) and wanted to go back to her IL facility where her belongings were. She stated she had informed Resident #1 that it would not be a safe discharge. She stated she worked closely with HA that helped residents find long-term care facilities and they usually took a week or so until they connected with the resident after discharge. The Surveyor asked how she would care for herself for the initial week and she stated Resident #1 had told her there were caregivers at the IL that assisted two hours a day, but she had not confirmed that with the IL. She stated she told the resident it would be safer to have more assistance, but Resident #1 told her she could not afford it. She stated she was not able to order a wheelchair for her because there was a co-pay of $258 and Resident #1 did not have her wallet with her so she had no way to pay it. She stated Resident #1 told her she would pay the co-pay once she got to her apartment. She stated she even sent an e-mail to Resident #1's family member about the wheelchair so he could make sure she paid the co-pay and he was also supposed to help her apply for Medicaid. During a telephone interview on 04/29/24 at 9:56 AM, Resident #1's FM F stated he had been contacted by EMT D and was informed of the condition she was in at her apartment and it sure as hell sounded like an unsafe discharge to him. He stated her IL facility does not have care givers or anyone to assist her. He stated he lived in another state and it was hard to assist Resident #1, especially since he was so much older than she was. He stated he had not planned to fly down to assist her because he was not physically able to do so. He stated he received an e-mail from SW E regarding the wheelchair, and Resident #1 did not have a lot of disposable income, so he called the number and paid the co-pay. He stated the wheelchair was supposed to be delivered that day (04/29/24), but it would be useless since she was still in the hospital. He stated SW E did have HA contact him about applying for Medicaid back in March (2024), but Resident #1's laptop (with banking information), wallet, and cell phone had been at her apartment while she was at the facility. He stated he did not have access her banking information and told HA there was nothing they could do until she returned home. He stated it was entirely inappropriate for her to be sent home without the ability to get out of bed or go to the bathroom. He stated, How did SW E expect her (Resident #1) to pay for the wheelchair or access her banking information if she did not have any assistance or a way to get to her wallet, cell phone, or laptop? He stated EMT D had told him she should not be returning to her apartment and he was in total agreeance. During an interview on 04/29/24 at 10:12 AM, the ADM stated the discharge process starts upon admission and the goal was always to communicate with the resident for the most appropriate discharge setting. She stated if the resident requested DME or HH services, the SW was responsible for getting that set up. She stated every situation and resident was different. She stated Resident #1 was alert and oriented times 4, had a BIMS of 15, and continuously stated she wanted to go home and that it was her right to make that choice. She stated the staff had encouraged her to have home health services but she could not afford them. She stated she was told it was not a safe discharge, but in the end, she had the right to choose. She stated Resident #1 had told SW B she had a caregiver at the IL that came for two hours a day but the SW B did not confirm that because the resident was fully competent. She stated Resident #1 told SW B that she would pay the co-pay for the wheelchair as soon as she got home and normally DME was delivered within four hours. She stated Resident #1's FM F had told staff he would be flying down to assist her. She stated they did not see it as an unsafe discharge. During a telephone interview on 04/29/24 at 10:55 AM, EMT D stated Resident #1 had initially contacted the fire department the night before (04/25/24) when she fell after trying to get up to go to the bathroom. He stated the fire department assisted her back into bed and requested that EMS follow-up with her the following day (04/26/24). He stated he was glad they did because the situation was horrible. He stated Resident #1 was able to stand and pivot with assistance but was unable to get herself out of bed or walk on her own. He stated her brief was heavily soiled and the odor of urine and feces was palpable. He stated the apartment itself was deplorable with stains throughout and rotting food in the kitchen. He stated she had access to her medications that were near her bed and she told him she used her saliva to be able to take them as she had no access to food or whatever. He stated Resident #1 showed him her DC paperwork from the facility where it reflected, Recommended LTC but resident requested to go home. He stated Resident #1 was adamant stating that was a lie and no one had talked to her about LTC upon discharge. He stated she told him she initially wanted to go home when she was first admitted , but it was obvious now she was unable to care for herself. He stated Resident #1 was completely with it (mentally) and knew what she wanted. He stated he told the hospital she could not return to her apartment upon discharge as it would be completely unsafe. During an interview on 04/29/24 at 11:31 AM, PTA G stated he had been working with Resident #1 while she was at the facility. He stated she was independent with bed mobility, rolling from side to side. He stated when transferring from bed to wheelchair, she required minimal assistance while utilizing a grab bar. He stated she was able to walk up to ten steps while utilizing a walker. He stated he had made it known to SW B that Resident #1 would require a wheelchair upon discharge. He stated she should not have been discharged home without a wheelchair and in his opinion, she would not be able to live independently. During an observation and interview on 04/30/24 at 11:20 AM, revealed Resident #1 in a hospital bed. She stated she did initially tell the nursing facility she wanted to go home but she was under the impression she would have the proper medical equipment when she got home. She stated she had a walker at her apartment, but the facility did not ask her if she was able to get around using a walker. She stated the facility did not discharge her with a wheelchair because it had not been paid for. She stated it had been ordered but she owed a co-pay. She stated upon discharge the facility told her everything had been set up and taken care of for her to go home. She began crying and stated when she was alone for 24 hours without the ability to get out of bed, she felt helpless and still felt helpless. She stated she did not believe she could care for herself independently because she could not bear hardly any weight on her leg. Review of the facility's Transfer and Discharge Policy, revised 08/2023, reflected the following: Residents should be transferred and discharged by the Community in accordance with applicable Federal and State regulations. . 1. The resident should receive orientation by the social services director or designee on where he or she is being transferred or discharged and reason to minimize anxiety. The Community's policies and procedures for discharge planning should be following regarding resident preparation, education, and planning prior to transfer from the community unless the transfer is emergent. Review of the facility's Transition Care Policy, dated December 2013, reflected the following: The Transition Care Conference ensures the patient and family member are in agreement with the transfer timelines as well as the patient's status to goal and transfer disposition. An understanding of care, equipment, and home needs prior to their transfer home or an alternative care setting is another objective of this meeting, as well as pertinent discussions are the patients after care. Review of the facility's Transition of Care and Discharge Summary Policy, revised 10/23, reflected the following: When a resident discharge is anticipated, a recapitulation of the stay, final summary, and post-discharge plan should be completed. The ADM was notified on 04/29/24 at 2:00 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/01/24 at 3:10 PM and included: On 4/29/2024 an abbreviated survey was initiated at (facility). On 04/29/2024 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the health and safety. The notification of Immediate Jeopardy states as follows: F660 - The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Community Response On 4/29/24, Social Services verified with the Durable Medical Equipment (DME) Company that Resident 1 wheel chair was delivered fully assembled and ready to use at Resident 1's address on 4/29/24 delivery receipt signed by a caregiver. On 4/30/24, the community Healthcare Liaison contacted the hospital case manager and Resident 1 to inquire about discharge planning from the hospital. Resident 1 was offered to return to the community. The resident accepted and is scheduled to admit on 5/1/2024. On 4/29/24, Social Services audited actual planned discharges from 4/22/24 to the present and planned discharges scheduled to occur through 5/6/24 to verify that they include discharge date , location, DME, Home Health, and confirmation of services. Appropriate services were confirmed, and no additional residents were identified to be impacted. On 4/29/24, the Divisional Director of Clinical Operations re-educated the Administrator on the discharge planning process and policies. From 4/29/2024 to 4/30/24, the Administrator and/ or designee re-educated licensed nurses the interdisciplinary team (IDT) members, which include therapy, social services, resident programs, nursing management, and the Registered Dietician on completing the transitions discharge summary. The in-services included the Transition Care Conference policy and Transition of Care and Discharge Summary Policy, which will be re-educated before their next scheduled shift. New staff and agency staff will have the training included in orientation. The Administrator re-educated Social Services on listing the date home health has confirmed services and the planned start of care. Re-education includes notification of Adult Protective Services (APS) and Ombudsman for any discharges identified to be unsafe. This notification will be ongoing as part of a systematic change. Licensed Nurses and IDT members including as needed staff who were not available from 4/29 to 4/30/24 will be re-educated before their next scheduled shift by the Administrator and/ or designee. The training will be documented on an in-service form, and competency will be validated by a post-test. The administrator or designee is responsible for administering the posttest and ensuring compliance. On 4/29/24, the community conducted an impromptu Quality Assurance Process Improvement (QAPI) to review the discharge planning process. In attendance were the Medical Director, Administrator, Executive Director, Regional Director of Operations, Regional RAI Director, and Divisional Director of Clinical Operations. Effective 4/30/24, during the weekly Medicare meeting, the IDT will review the discharge checklist, home health services, and DME as indicated for planned discharges. Social Services will arrange for home health services and order DME as indicated. Social Services will confirm the delivery date of the ordered DME and the start of home health services. The delivery date and start dates will be documented in the medical record. IDT will provide residents with a choice to postpone discharge when services as reported not available greater than 2 days from discharge. This is an ongoing systematic change. Social Services and/ or designee will complete weekly audits of planned discharges for 90 days. The audits will be documented on an audit form and the results will be reported to the monthly QAPI Meeting for 3 months. Audit commenced on 4/29/24. The Survey Team monitored the POR on 05/01/24 as followed: During interviews conducted on 05/01/24 from 2:59 PM - 4:54 PM, with the DRE, MCS, 7LVNs, the DOR, two SWs, and the MDSC (from different shifts) all stated they were in-serviced prior to their shifts on safe discharges. All stated social services team was responsible for coordinating discharges and the facility was responsible for ensuring safe discharges. Each staff member stated they needed to ensure DME (if needed) was delivered and services (if needed) such as home health were in place prior to discharge. They stated if they thought it was going to be an unsafe discharge, they would notify the ADM and DON immediately. They stated if a resident left the facility unsafely, they would notify the Ombudsman and APS. Review of the facility's QAPI agenda, dated 04/29/24, reflected the ED, ADM, DDCO, RDO, RDCS, RRD, and MD were in attendance. Review of an e-mail received by the ADM, dated 04/29/24, reflected the wheelchair had been deliver to Resident #1's apartment on 04/29/24. Review of the facility's in-service entitled Discharge Planning conducted by the ADM, dated 04/30/24 - 05/01/24, reflected all staff from each shift were in-serviced on the following: Transition Care Conference Policy, Transition of Care and Discharge Summary Policy, and Notification of APS and Ombudsman for any discharges identified to be unsafe. Review of Planned Discharge Post-Tests , dated 04/30/24 - 05/01/24, reflected staff were completing the tests after being in-serviced. Review of the facility's resident roster, dated 05/01/24, reflected Resident #1 had been readmitted to the facility. While the IJ was removed on 05/01/24 at 7:00 PM, facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents for 1 (Resident #11) of 6 residents reviewed for accidents. The facility failed to ensure that the water used to prepare hot beverages for residents was maintained at a temperature appropriate to prevent scalding and burns. Water temperatures were taken on 01/24/24 from the coffee machine hot water Bunn dispenser the water temperature was 188 degrees Fahrenheit. On 09/12/23, Resident #11 spilled hot tea on herself, and she sustained a second degree burn to her right hip, which required wound care. An Immediate Jeopardy was identified on 01/25/24 at 11:50 AM. While the Immediate Jeopardy was removed on 01/26/24 at 12:50 PM, the facility remained out of compliance at a scope of pattern with no actual harm with a potential for more than minimal harm that is not immediate jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal. These failures put residents at risk for serious injury when drinking hot beverages. Findings included: Review of Resident #11's Face Sheet dated 01/26/24 revealed she was a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Parkinson's disease (disorder that affects the nervous system) without dyskinesia (a movement disorder that often appears as uncontrolled shakes, tics, or tremor), abnormal posture, muscle weakness, pain, and other lack of coordination. Review of Resident #11's Significant change in status MDS assessment, dated 01/11/24, reflected a BIMS score of 13 indicating no cognitive impairment. Resident #11 required partial/moderate assistance of one person for eating. Review of Resident #11's Care Plan, revised date 01/25/24 reflected: Focus: [Resident #11] is at risk for integument impairment. Resident had a history of a burn at right upper thigh from a hot liquids spill and is at risk for hot liquid spills. Goal: Resident will be free from skin breakdown through review date. Resident will be free from injury through the review date. Interventions: Resident requires set up/supervision with all meals to include ensuring a cap/lid are on all hot liquids. Focus: Resident has dx of Parkinson's, she has impaired muscle strength and coordination due to Parkinson tremors. She is at risk for hot liquid injury from hot beverages ie tea/coffee/cocoa. Goal: Resident will have no injury from hot liquids through review date. Interventions: Provide lid on hot beverages to prevent spills, staff to assist in opening the lids, setting up the tray for patient as needed. Focus: Resident had a history of a burn at right upper thigh from a hot liquids spill and is at risk for hot liquid spills. Goal: Resident will be free from injury through the review date. Interventions: Resident requires set up/supervision with all meals to include ensuring a cap/lid are on all hot liquids. Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Review of the facility Incident Log date range from 08/24/23 to 01/24/24 revealed the following: Person involved in Incident: Resident #11 Date of incident: 09/12/23 Name of Associate Assigned to Resident at the time of the incident: CNA K Location of Incident: Resident Room. Nature of Incident: Miscellaneous - Scalding Type of Injury/Impairment: Burn Part(s) of Body Injured: Hip (right) Initial Actions Take: Applied First Aid, Checked for Injury, Notify emergency contact. Severity Code: 2- Harm/Injury without outside treatment and/or observation Additional Facts not Refenced Above: On the night of 9/12/23, while assigned to CNA K and LVN X, Resident #11 requested a piece of pizza and tea between 4-5AM. CNA K obtained the water for the tea from the hot water dispenser in the kitchen. She delivered the food and tea to Resident #11and when exiting the room turned off the lights and closed the door per Resident #11's request. Resident #11 dropped her tea in bed which resulted in a burn on her right hip. CNA K answered the call light, observed the accident/spill and notified LVN X. First aid was provided, RP and physician were notified. During the investigation, it was determined that Resident #11 has a history of requesting her door to be closed and lights turned off during night hours. It was also discovered that Resident #11 CNA from 6-2 that she had requested CNA K to close the door and turn off the lights. Interventions: Resident #11 will be encouraged to keep light on when eating at night. Drinks to be served with a lid when drinking hot liquids. Follow up: (10/04/23 [Administrator]) During investigation - it was determined that the hot water dispenser has been dispensing water below the recommended serving temps for hot liquids. Review of Resident #11's Hot Liquids Safety Data Collection dated 09/12/23 revealed resident was at risk of hot liquid injury. Task: Resident to use cup with lid. Review of Resident #11's progress note documented by LVN X on 09/12/23 at 5:24 AM revealed the following: Situation: The Change in Condition/s reported on this CIC Evaluation are/were: Skin wound or ulcer. Skin Status Evaluation: Skin tear. Pain Status Evaluation: Does the resident/patient have pain? Yes. Neurological Status Evaluation: Nursing observations, evaluation, and recommendations are: On observation and assessment, the skin tear looked like a blister that had popped. It would need some kind of ointment to rub on in order to heel. Review of Resident #11's progress note documented by LVN X on 09/12/23 at 17:00 [5:00PM] revealed the following: F/U hot liquid injury. alert and oriented x3, v/s stable. burn area to right hip. treatment completed as ordered. medicated x2 for pain and effective. no distress noted. Review of Resident #11's wound physician note dated 09/13/23 revealed the following: Patient present with a wound on her right hip. Burn wound of the right hip full thickness. Etiology (quality) Burn. Wound Size (L x W x D): 11.5 x 5.5 x 0.3 cm. Surface Area: 63.25 cm². Cluster Wound: open ulceration area of 37.95 cm². Exudate: Moderate Serous. Granulation tissue: 20 %. Skin: 40 %. Site 1: Surgical excisional debridement procedure: Indication for procedure: Remove Necrotic Tissue and Establish the Margins of Viable Tissue, Remove Thick Adherent Eschar and Devitalized Tissue. Consent for procedure: Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 09/13/2023 to the patient who indicated agreement to proceed with the procedure(s). Procedure Notes: The wound was cleansed with normal saline and anesthesia was achieved using 2% lidocaine jelly. Then with clean surgical technique, 15 blade was used to surgically excise 6.32cm² of devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 10 percent to 0 percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below. Plan of care reviewed and addressed: The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 109 days. This estimate is made with an 80% degree of certainty. Review of Resident #11's progress note from Physician on 09/15/23 at 13:30 [1:30PM] revealed the following: *** Chief Complaint ***Acute Issue Pt [patient] is seen lying in bed [with] NAD exhibited. Pain reported to R [right] hip. 1st>>2nddegree burn from hot tea this am appx 0500 to R [right] thigh. Mixed intact bulla [fluid blister] [with] ruptured bulla [fluid blister] areas and exposed skin. Area is dry. Entire irregular shaped area appx 15cmx4cm. Pt reports increased pain to the area. Discussed plan [with] Pt [patient] and [family member] on the phone. Initially- Cleanse [with] NS [normal saline] and apply bacitracin [ointment] bid [twice a day], LOTA for now [with] loose brief on that time. If bullas rupture and wound begins to drain then we will need dressing. Dry at this time. Wound care team to f/u [follow-up] in am. Schedule her oxy 2.5mg q12h x 3 days and keep2.5mg q6h available, cont apap1000mg TID. Therapy Clarification from therapy regarding transfers/toileting. Going forward, the safest thing for [Resident #11] and the staff caring for her would be for [Resident #11] to be using a bed pan for toileting or a brief for incontinent episodes. She requires the hoyer lift for transfers, and it would not be feasible or safe to use the hoyer lift to transfer to the toilet or a bedside .Burn of skin - Onset: 09/12/2023. Review of facility Incident Investigation completed by Administrator, dated 09/15/23, revealed the following: Summary of Incident: On 09/12/23 between 3-5AM, [Resident #11] requested pizza and tea from [CNA K]. [CNA K] warmed up her leftover pizza and obtained her Tea from the kitchen. [CNA K] setup her tea (that had a lid) and pizza on her bedside table. [Resident #11], when attempting to grab her tea knocked it over and tea spilled on her right leg. This resulted in a second-degree burn. Investigation: 09/12/23 [Resident #11] expressed that her leg was hurting due to her spilling her tea on herself. On 09/15/23 [Resident #11] explained that [CNA K] brought her tea and she spilled it on herself. When asked what happened she said it spilled out of her hands when attempting to drink. She did mention that the room was dark and she could have grabbed the wrong end of the drink. Associated Interview: [CNA K] stated [Resident #11] requested that [I] bring her tea and pizza. [I] warmed up her left-over pizza and grabbed the water/tea bags. [I] placed it by her bed don the table and left the room. When [I] left she asked me to close the door and turn the light off. She did not call me back in the room until after she [split] the tea. [LVN X] stated [I] completed the incident report when [CNA K] came and got me telling me [Resident #11] spilled her tea. [I] notified the physician and family and performed the care as ordered. Visitor/Vendor Interview: 09/15/23 Spoke with resident family regarding the incident. She stated she did not have any concerns but wants to avoid the situation moving forward. [I] discussed interventions with her. She requested that we discuss next week as . she is pre-occupied. She was thankful that [I] I reached out and stated mom loves you and says [Administrator] will take care of me and knows we take good care of her mother. Timeline: Between 4-5:30AM: [Resident #11] request tea and pizza. Between 4-5:30AM: [CNA K] provides pizza and tea. Between 4-5:30AM: [Resident #11] spills her tea. Between 5:26AM: [CNA K] notifies [LVN X] Conclusion: Supporting statement. Unconfirmed After getting statements from all involved, [Facility] came to the conclusion that this was an accident that was the result of [Resident #11] request for her door to be closed and lights turned off potentially causing her to grab the wrong end of the cup/hands slipping. This is a consistent request of hers during night hours dating back to her days in assisting living. We are agreeance that staff should encourage [Resident #11] to leave a light on when eating/drinking. The water for the tea that [Resident #11] was drinking was obtained from our kitchen hot water brewer. The hot water brewer is set for 175 degrees. Dining Director reviewed brewing guidelines, confirmed brewer was within guidelines at 170. Immediate Actions Taken: Resident Evaluation and/or Treatment. Notifications of District/Regional Nurse and RVP/DDO. Notifications of Responsible Party, Notifications of Physician Post Investigation Actions: Care Plan updates, In-serviced/Associate Re-training, Tasks Updated, Family Updated. Review of Resident #11's wound physician note dated 11/29/23 revealed the following: Burn wound of the right hip (resolved on 11/29/23) Duration > (greater than) 74 days. Wound progress: Resolved. Anatomic location of previously existing wound examined today: Epithelialized and Resolved. Follow up only as needed. Observation and interview on 01/23/224 at 11:20 AM revealed Resident #11 lying in bed. Resident #11 stated she was doing well. Observed Resident #11 to have a sippy cup that had tea. Resident #11 denied any concerns regarding her care. Review on 01/24/24 at 10:15 AM of facility Resident Council Notes, dated 12/07/23, revealed an issue made by Resident#11 stating, Why am [I] being billed for wound care when I got burnt due to the negligence of the staff? Administrator visited Resident #11 personally and spoke to her about the bill and that she would not be charged for wound care. Follow-up observation and interview on 01/24/24 at 10:20 AM revealed Resident #11 lying in bed. Resident #11 stated last year in September 2023 she had asked CNA K for tea; she stated it was early in the morning. She stated CNA K came in her room and placed the tea on her bedside table, she stated the bedside table was above her within reach. She stated the tea was in a white styrofoam cup with a lid on. She stated CNA K turned off her lights and closed the door when she left. She stated the room was dark and could not see. She stated she tried to get her tea when she spilled it. Resident #11 stated she felt pain right away and she pushed her call light for help and a few second later CNA K entered her room. She stated CNA K called LVN X for help and they cleaned her up. She stated the burn caused a blister to her right hip. Resident #11 stated had a cover over her when the tea spilled and it still cause a burn. Resident #11 stated she received wound care for a couple of months. She stated the burn had healed. Observed Resident #11 skin to the right thigh with no visible wound or scar. Resident #11 stated she could not recall if she asked CNA K to turn off the light or to leave them on. She stated the following day CNA K entered her room and that made her upset and she notified the Administrator she no longer wanted CNA K to enter her room. She stated since the incident she had not seen CNA K. Resident #11 stated she only drinks her hot tea in her special cup with a lid on. Interview on 01/24/24 at 12:48 PM with Resident #11's Family Member-1 revealed in September 2023 she received a call from the facility notifying them of the burn that Resident #11 sustained. Resident #11's Family Member-1 stated she was informed Resident #11 had requested tea early in the morning and Resident #11 requested her lights to be turned off and when Resident #11 tried to get the tea it slipped on her. While on the phone with Resident #11's Family Member-1 another Family Member-2 got on the phone who stated when they asked the Administrator how hot the water was the Administrator responded with inappropriate temperature, Family Member-2 stated they were not satisfied with his response. Family Member-2 stated the water must had been really hot for it to cause a bad burn within second. Family Member-2 stated their concern is not just for Resident #11 but for all the resident in the facility who drink tea or coffee. Resident #11's Family Member-1 stated she did not make a big deal of the situation due to Resident #11 diagnosis of Parkinson and the incident could had been an accident. An attempt was made on 01/24/24 at 3:04 PM to contact LVN X; however, there was no response. Interview on 01/24/24/ at 3:28 PM with CNA K revealed she was the CNA assigned to Resident #11 when the burn incident happened. CNA K stated between 4-5 in the morning Resident #11 requested hot tea. She stated she got the hot water from the 2nd floor service kitchen hot water brewer and then added the tea bag. She stated she placed a lid on the cup and took it to Resident #11 room. CNA K stated she placed the teacup on the resident bedside table, within reach. She stated she notified Resident #11 of the hot tea being placed on the bed side table. She stated Resident #11 requested for the door to be closed. She stated the room was not dark, there was natural light, Resident #11 had a bedside lamp on and the bathroom light was on and the door was slightly open. She stated she continued to do her rounds when Resident #11 pushed her call light on. CNA K stated she went in the room and Resident #11 told her she had spilled her tea. She stated she called for LVN X and they cleaned Resident #11. She stated Resident #11 sustained a burn. CNA K stated she could not recall how hot the water of the tea was. CNA K stated she was in-serviced on safety measure. CNA K stated they had a service kitchen on the 2nd floor and 3rd floor, and staff obtain hot water from the hot water brewer. She stated they used the hot water brewer to make hot beverages. Interview on 01/24/24 at 3:36 PM with the ADON revealed when Resident #11 had the burn incident, she was not the nurse on duty. The ADON stated the incident happened during the night shift. She stated she was told Resident #11 requested hot tea and when Resident #11 tried to get the cup it spilled on her. The ADON stated she could not recall if she had been in-serviced on the incident; however, they put interventions in place. She stated the interventions were if Resident #11 request any hot liquids it should be given in a special cup with a lid (sippy cup). The ADON stated Resident #11 required wound care for a couple of months. She stated the wound had healed. She stated staff obtain hot water from the kitchen coffee machine hot water brewer. She stated she was unsure who was supposed to check for hot beverage temperatures. She stated they had not been told to check temperatures for hot liquid beverages. The ADON stated upon admission they complete a hot liquid assessment on any new admission residents. The ADON stated Resident #11 was the only resident who required interventions. Interview on 01/24/24 at 3:51 PM with CNA N revealed Resident #11 told her about the hot tea spilling on herself. CNA N stated Resident #11 sustained a burn. She stated when Resident #11 told her about the incident she went and spoke to CNA K. She stated CNA K stated she provided hot tea to Resident #11 and the resident spilled it on herself. CNA N stated they were in-serviced on ensuring Resident #11 gets her special cup when she requests hot beverages. She stated the 2nd floor and 3rd flood had a service kitchen which had a coffee machine with hot water Bunn dispenser. She stated they all get the hot water from the hot water Bunn dispenser when they prepare hot beverages. She stated the water that comes from the hot water Bunn dispenser was hot. She stated when someone request hot liquid beverages and she gets hot water from the hot water Bunn dispenser she waits about 10-15 minutes to let it cool down. Observation of facility 2nd floor service kitchen on 01/24/24 at 4:00 PM with the RD revealed a coffee machine with a Bunn hot water dispenser was observed. The RD stated staff obtain hot water from the coffee machine (Bunn hot water dispenser) to prepare hot beverages. The RD stated she had been checking the hot water temperature today (01/24/24) every 30 minutes due to the hot water valve being replaced today (01/24/24). Observed the RD grabbed a coffee mug and poured hot water inside the coffee mug from the Bunn hot water dispenser. Then grabbed the facility thermometer, it took her about 5 to 10 seconds to place the thermometer inside the hot water. The hot water temperature was 188 degrees Fahrenheit. The RD stated dietary staff had not been told to check Bunn hot water dispenser or hot beverage temperatures. She stated they only checked food temperatures when serving. Observed 2nd floor service kitchen temperature logbook revealed no temperature checks for hot beverages. Interview on 01/24/24 at 4:13 PM with LVN B stated she was the nurse assigned to Resident #11 the day after the incident. She stated she could not recall the dates. LVN B stated she observed Resident #11 burn the 1st day and it had a blister to the right hip. LVN B stated they did not start wound care until the blistered popped. She stated Resident #11 did complain of pain and they provided her with pain medication. She stated Resident #11 did not go to the hospital, she stated she was treated inhouse. She stated they provided wound care for a month or two until it healed. She stated she was not sure how Resident #11 burned herself; however, it happened during the night shift, she stated the night nurse on duty completed an incident report. LVN B stated she was in-serviced on how to prevent hot liquids incidents. She stated the interventions they put in place for Resident #11 was to provide her with her special up with a lid, make sure Resident #11 was able to hold the cup and make sure the water was not hot. LVN B stated she tests the hot water by placing a drop on her skin. LVN B stated she was unsure of any hot water dispenser temperature log and believed it was the dietary staff responsibility to check and log the temperatures. Interview on 01/24/24 at 4:25 PM with the DON revealed Resident #11 requested hot tea during the 10:00 PM-6:00 AM shift. She stated CNA K gave Resident #11 her tea and turned off the lights and closed the door. The DON stated when Resident #11 tried to drink the tea she spilled it over her. She stated staff immediately assisted Resident #11 and cleaned her up. She stated Resident #11 sustained a burn to her right hip. She stated Resident #11 received wound care and was on pain medication. She stated Resident #11 wound had healed and no longer required wound care. The DON stated they educated the staff on how to protect resident with hot liquid beverages, to check water temperatures and provide Resident #11 sippy cup to prevent any spills. She stated they also educated Resident #11 to not drink hot beverages in the darkness. The DON stated the hot beverages should be within temperatures and if hot beverages are too hot the CNAs must notify the dietary staff. The DON stated dietary staff should be logging hot beverages temperatures. The DON stated the water temperatures had been controlled and they had hot liquid temperature logs in each service kitchen. Interview on 01/24/24 at 4:46 PM with the Administrator revealed in September 2023 during the night shift Resident #11 requested pizza and hot tea from CNA K. He stated CNA K obtained the tea from the service kitchen hot water dispenser. He stated CNA K provided the tea in a cup with a lid and turned off the light and closed the door per Resident #11 request. The Administrator stated Resident #11 grabbed the cup of tea and spilled it on herself and resulted on a burn. He stated Resident #11 pushed the call button, CNA K came in and she called for the nurse and they performed care. He stated Resident #11 required wound care and further stated the wound had healed. The Administrator stated he conducted a full investigation and it was determined it was an accident. He stated they in-serviced all staff on using lids when drinking hot beverages, hot beverages to be monitor by the dietary department. He stated the dietary department kept a log of the temperatures. Observation and interview on 01/24/24 beginning at 4:51 PM with Dining Service Director revealed the dietary staff were not required to check the temperatures from the coffee machine hot water Bunn dispenser. She stated the maintenance staff conduct a monthly check; however, she was notified by the RD today (01/24/24) that dietary staff should monitor the hot water Bunn dispenser much closer. Observed 3rd floor service kitchen with the Dining Service Director, a coffee machine with hot water Bunn dispenser was observed. The Dining Service Director was observed to check the hot water Bunn temperature. She grabbed a coffee mug and poured hot water inside the coffee mug from the coffee machine hot water Bunn dispenser. Then grabbed the facility thermometer, it took her about 5 to 10 seconds to place the thermometer inside the hot water. The hot water temperature was 173 degrees Fahrenheit. The Dining Service Director stated she was unsure if dietary staff had been in-serviced on hot beverages, she stated she would have to ask. She stated the dietary did not have a log for the hot beverage temperature. Follow-up temperature check of facility 2nd floor service kitchen on 01/24/24 at 5:00 PM with the RD revealed the hot water temperature was 176 degrees Fahrenheit. The RD stated it was within the brewing temperatures but not serving temperatures. Interview on 01/24/24 at 5:16 PM with the Administrator revealed his expectations were for hot beverages to be within the serving guidelines 175-180 degrees Fahrenheit. A few minutes later the Administrator returned to the conference room and stated he misunderstood the question and stated hot beverages should be within the brewer temperatures 175-180 degrees Fahrenheit and serving guidelines temperatures would be 155 degrees Fahrenheit. Interview on 01/24/24 at 5:25 PM with the Maintenance Director revealed the facility had a third-party contractor who checks the facility hot water. He stated the commercial kitchen hot water are inspected quarterly. He stated they have not been told to kitchen hot water dispenser daily, he further stated it was not a requirement for the maintenance department to check temperatures. He stated normally the Dietary Manager would notify them if they had an issue in the kitchen and he would contact the third-party contractor to come inspect the issue. He stated the service kitchen on the 2nd and 3rd floor hot water dispensers had temperature fluctuations. He stated he was not asked to adjust the hot water brewer temperatures in September 2023 or as of today (01/24/24). The Maintenance Director asked if he needed to adjust the hot water brewer temperatures, because he was able to adjust them. Interview on 01/25/25 at 9:10 AM with the Administrator revealed he could not locate the in-services they completed on 09/12/23. He stated he had begun in-servicing all staff starting today (01/25/24). The Administrator stated the dietary staff did not have a log for the hot beverage temperature. Review of The American Burn Association Scald Injury Prevention Educator's Guide, https://ameriburn.org/wp-content/uploads/2017/04/scaldinjuryeducatorsguide.pdf reflected the following: .Time and Temperature Relationship to Severe Burns Water Temperature Time for a third degree burn to occur 155 degree F 1 second 140 degrees F 5 seconds Based upon the time of the exposure and the temperature of the water, the severity of the harm to the skin is identified by the degree of burn, as follows . Second- degree burns involved the first two layers of skin. These may present as deep reddening of the skin, pain, blister, glossy appearance from leaking fluid, and possible loss of some skin. Review of the facility's Safe of Hot liquids policy, revised February 2020, reflected the following: Residents shall be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission, quarterly and on change of condition. Appropriate precautions shall be implemented to maximize choice of beverages while minimizing the potential for injury. A. The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. B. Residents who prefer hot beverages with meals (i.e., coffee, tea, soups, etc.) will not be restricted from these options. Instead, associated shall conduct regular Hot Liquids Safety Data Collections as indicated, and document the risk factors for scalding and burns in the care plan. D. Once risk factors for injury from hot liquids are identified, appropriate interventions shall be implemented to minimize the risk from burns. Such interventions may include: 1. Maintaining a hot liquid serving temperature of not more than 155 degrees Fahrenheit; 2. Serving hot beverages in a cup with a lid; 3. Encourage residents to sit at a table while drinking or eating hot liquids; 4. Providing protective lap covering or clothing to protect skin from accidental spills; and 5. Associate supervision or assistance with hot beverages Review of the facility's Safe Holding and Serving Temperature for Hot Beverages policy, revised 03/01/16, provided by the Administrator on 01/25/24 reflected the following: . 2. Coffee needs to be brewed at (recommended temperature per machine) 195 to 205 degrees Fahrenheit to extract the full flavor 4. Skin on the arms and legs - being less sensitive than the mouth - can suffer a burn before the danger is realized. The elderly who are immobilized in a wheelchair and confused resident are more susceptible. 5. Because of this susceptibility, follow these safety precautions: a. Serve the hot beverages between 140-155 degrees Fahrenheit. Dietary should record hot beverage temperatures for every meal c. Residents should be supervised while drinking hot beverages. d. A staff member should pour the hot beverages, in a manner that protects the resident's safety. Fill hot beverage mugs to 75% of less of their capacity. An Immediate Jeopardy was identified on 01/25/24. The Administrator was notified of the Immediate Jeopardy on 01/25/24 at 11:50 AM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 01/25/24 3:39 PM and reflected the following: -1. On 1/25/2024, the Director of Clinical Services (DCS) completed a new hot risk data collection for resident # 1 [Resident #11]. The DCS reviewed the plan of care and no additional interventions were needed. On 1/24/2024, the Dining Service Director took the hot water/coffee dispenser out of service. On 1/25/2024, the Maintenance Director contacted a third-party vendor to complete an onsite preventative maintenance check. On 1/25/2024, a Registered Dietician revised the Meal Inspection-Test Trays Form that is completed at minimum 3 times a month to include the serving temperature of coffee and hot water. -2. All residents have the potential to be impacted. On 1/25/2024 a dining service manager completed rounds to temp current serving temperatures for hot coffee and hot water on current operating dispenser in the main kitchen. This was documented on a log. -3. On 1/25/2024, a Registered Dietician completed re-education to Dining Service associates the food temperature log to include the hot coffee and hot water temperature log. On 1/25/2024, a third party Registered Dietician completed re-education to the in-house Registered Dietician and Dining Service Manager on the revised Meal Inspection- Test Trays Form that includes the hot coffee and hot water serving temperature. On 1/25/2024 to 1/26/2024, the Registered Dietician and/or designee re-educated Dining Services, Certified Nursing Assistants (C.N.As), and Nurses on the Safe Holding and Serving Temperatures for Hot Beverages and Service of Hot Beverage Guidelines. The dining service associates, C.N.A and Nurses not available on 1/25/2024 will receive re-education by the registered dietician or designee before their next scheduled shift and this will include new hires hired after 1/25/2024. Competency will be validated on a post-test. -4. The Certified Dining Manager (CDM) or designee will audit the food temperature log 5 x a week for 90 days to verify that serving temps of hot water and hot coffee are being documented and do not exceed 155 degrees. The CDM or des[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one 1 (Resident #1) of 6 residents reviewed for quality of care. The facility failed to follow physician orders for Resident #1 to monitor blood pressure and blood sugars after a medication error was discovered and resident had to be sent to the emergency department. An Immediate Jeopardy (IJ) existed from [DATE] - [DATE]. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. These failures placed the resident at risk of not receiving adequate care and services, and decreased quality of life. Review of Resident #1's face sheet dated [DATE] reflected an [AGE] year-old female admitted to the facility with diagnoses that included: scalp laceration (cut on the head), Parkinson's Disease (central nervous system disorder that affects movement), muscle weakness, abnormality of gait and mobility, Hyperlipidemia (high cholesterol) and history of falling. Review of Resident #1's MDS reflected a BIMS of 9 indicating moderate impairment of cognitive ability. Review of Resident #1's December MAR reflected resident received the following medications at 9:00 am on [DATE]: glipizide XL10 MG (medication to treat Diabetes) and Carvedilol 25 MG (blood pressure medication). Review of Resident #1's orders reflected a physician order dated 12//4/2023 at 11:00 am to Monitor BP and HR every hour for the next 6 hours r/t medication error and Monitor blood sugar every hour for the next 12 hours r/t medication error. Record review of Resident #1's December MAR reflected no blood pressure entry for 4pm and no blood sugar checks for 3 pm and 4 pm. During interview on [DATE] at 2:35 pm with LVN D, he stated he was the nurse for Resident #1 on [DATE] on the 2-10 pm shift. He stated he was not able to check Resident #1's blood pressure at 4 pm or Resident #1's blood sugar at 3pm and 4pm because Resident #1 was off the unit, and he could not find her. He stated he looked in her room, looked in her husband's room and asked staff but he could not locate resident. He stated he did not think to call the doctor and let them know he had not been able to find the resident or check her BP or blood sugar. He stated Resident #1 returned to the unit for dinner and he checker her BP and blood sugar then. He stated her sugar was a little low, but she was getting ready to eat dinner, so he waited and checked it again after she ate. He stated he continued to check her sugar as ordered and provide interventions as needed until his shift ended and then he gave report to LVN E who came on shift at 10pm. He stated he informed LVN E of the medication error and that Resident #1's blood sugar needed to be checked every hour. During an interview on [DATE] at 11:06 am, FM stated the facility did not check Resident #1's blood pressure and blood sugar like they were supposed to and then after midnight on[DATE], the facility checked her sugar, and it was in the 30's so Resident #1 was sent to the ER due to low blood sugar. FM stated Resident was in the hospital on IV medications for several days to try and stabilize her blood sugar. FM stated Resident #1's room was on the 2nd floor, and they went up to the activity room on the 3rd floor to make ornaments. She stated no staff came looking for Resident #1 and no staff called her or her another FM to see where Resident #1 was located. During an interview on [DATE] at 4:47 pm, the facility NP stated she was in the building on [DATE] and was notified of a medication error for Resident #1. She went and saw/assessed Resident #1 who was alert and in bed with family in the room. She stated she was concerned about hypotension (low blood pressure) and hypoglycemia (low blood sugar) with Resident #1 due to the medication errors. She stated her expectation when she gives orders to staff is that they will be followed. She stated she was not aware that some of the blood sugar checks, and blood pressure checks that she had ordered had been missed by the nursing staff. She stated she found out the resident had been sent to the hospital, so she found out on her own by reviewing the records that some of the blood sugar checks and blood pressure checks had been missed by the nursing staff. She stated she was concerned about the missed checks because I had not been notified that this happened and there was no documentation as to why it was not done. She further stated her concerns with the missed blood sugar checks would be exactly what happened. She became hypoglycemic. We should have been keeping a real close eye on her. It was not ideal that she ended up in the hospital. During an interview on [DATE] at 8:58 am, LVN E stated she was the nurse for Resident #1 on [DATE] on the 10 pm to 6 am shift. She stated she received report from LVN D and was made aware of Resident #1's medication error and the need to monitor Resident #1's blood sugar. She stated she saw the order in the system when she opened her computer a few minutes after 11. She stated she did not check Resident #1's blood sugar as ordered at 11pm because she got busy passing pain medications and I didn't think there was anything wrong with checking it later. She stated she saw the resident on rounds before 11 and she had crackers in her hand, so she didn't think she needed to check it. She stated she could not remember when she checked on the resident again, but she found her unresponsive and checked her sugar and it was in the 30's. She tried to give her orange juice and it was just running out of her mouth. She stated she called the DON to let her know and then called 911. She stated nurses are supposed to follow doctors orders and if they can't, they need to notify the DON or Doctor. She stated by not following orders and missing a blood sugar check a resident could potentially go into a coma - they need to check it to make sure it is stable - if it goes too low a resident could go into a state of shock or coma. During an interview on [DATE] at 9:36 am, LVN D stated when he got report at shift hand off, Resident #1 was sitting at the end of the hall with her family and then family took her off the unit and he didn't know where she was. He stated he looked around and asked some staff but did not attempt to call the family. I didn't think of calling the family to see where she was. He stated by not checking her blood sugar She could have tanked - her blood sugar could have gone so low that she could have lost consciousness and injured herself or could have even died. During an interview on [DATE] at 12:57 pm, the DON stated she had called LVN E at 11pm on [DATE] to make sure she knew Resident #1 needed to be monitored and to check her sugar. She stated LVN E told her she had just gotten report and was aware that Resident #1's blood sugar had been dropping and needed to be monitored. The DON stated Resident #1's blood sugar should have been checked at 11 pm on [DATE] and said, why should she wait if she knew there had been a problem? She stated she received a call on [DATE] at 12:37 am from LVN E and was informed that Resident #1 was found unresponsive, and her blood sugar was thirty something. She stated LVN E told her she had just taken her sugar and tried to give the resident some orange juice, but she was not able to. The DON stated she told LVN E to call the on-call doctor and see if she could get an order for glucagon. The DON stated, I got the impression that this all had just happened, not that she had checked her sugar an hour ago. The DON stated she called LVN E back at 12:45 and I asked her if she had gotten ahold of the doctor yet and she said no, so I told her to call 911 and send the resident out. The DON stated nurses are supposed to follow doctors orders and if they are not able to they need to call the doctor and notify the DON. Review of Facility policy Change of Condition for Skilled Nursing Communities, revised 8/23 reflected. When a resident is evaluated or assessed as having a change in condition, the licensed nurse should document notification to the family/resident representative, the Healthcare Provider (HCP) and other licensed nurses in order to facilitate the appropriate plan of care. 2. Upon receiving a Stop and Watch documentation or observing a difference in the resident's usual physical, emotional or cognitive patterns the licensed nurse should:2g) Implement treatment interventions, received orders and document HCP recommendations as indicated.

**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 of significant medications errors for one of five residents (Resident #1) reviewed for any significant medication errors, in that: The facility gave Resident #1 medications belonging to another patient on 12/3/2023 and 12/4/2023 resulting in Resident #1 blood sugar dropping and being transferred to the emergency department. An Immediate Jeopardy (IJ) existed from 12/03/23 - 12/05/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure placed residents at risk of experiencing non-therapeutic side effects from medications which could cause injury and/or death. Findings included : Review of Resident #1's face sheet dated 12/8/2023 reflected an [AGE] year-old female admitted to the facility with diagnoses that included: scalp laceration (cut on the head), Parkinson's Disease (central nervous system disorder that affects movement), muscle weakness, abnormality of gait and mobility, Hyperlipidemia (high cholesterol) and history of falling. Review of Resident #1's MDS reflected a BIMS of 9 indicating moderate impairment of cognitive ability. Review of Resident #1's MAR reflected the resident received the following medications at 9:00 am on 12/4/2023: glipizide XL10 MG (medication to treat Diabetes) and Carvedilol 25 MG (blood pressure medication). Review of Resident #1's orders reflected a physician order dated 12/4/2023 at 11:00 am to Monitor BP and HR every hour for the next 6 hours r/t medication error and Monitor blood sugar every hour for the next 12 hours r/t medication error . During an interview with LVN A on 12/8/2023 at 1:32 pm she stated she was working on 12/3/2023 in the evening when Resident #1 arrived as a new admission with a packet from the hospital. She stated she took the packet and handed it to her supervisor, RN B. LVN A stated RN B put all the medication orders in the system and then LVN A verified them to make sure they were correct. She stated she looked at the medication list but somehow I missed looking at the name of the resident on the medication list, but I checked the face sheet and history, and they all had the right name. I missed that there was a different name on the paper with the meds. She stated, I am supposed to look at all the names on everything; all the paperwork in the packet including the medication list. I did not do this. I made an assumption that everything in the packet was for that resident. (resident #1) She stated the facility practice was to have two nurses check medications to make sure they were correct, and she was the second witness for Resident #1's medication orders after RN B put them in the system. She stated not checking names on medication lists could lead to med errors and residents could get very sick . During an interview on 12/8/2023 at 2:13 pm, RN C stated she was working on 12/4/2023 when a FM for Resident #1 came to her and asked her to print out Resident #1's med list. She printed it out and a short while later, the FM came back and notified RN C that Resident #1 was not on any of the medications on the list. RN C stated she opened Resident #1 chart binder and reviewed the discharge med list from the hospital and the name on the med list was for another patient from the hospital, not Resident #1. She stated the med list was signed by two nurses on Sunday night 12/3/2023. RN C stated she alerted the DON who alerted the facility NP who was in the building and the NP assessed Resident #1. RN C stated the NP gave new orders to stop all current medications and to monitor the resident's BP, HR, and blood sugar for any changes in condition . During an interview on 12/11/2023 at 11:06 am, Resident #1s FM stated she was reviewing the hospital paperwork with RN C and found the error in the paperwork from the hospital and pointed it out to RN C who then alerted the DON, AD and NP. She stated the facility did not check Resident #1's blood pressure and blood sugar like they were supposed to and then after midnight on 12/5/2023, the facility checked her blood sugar, and it was in the 30's so Resident #1 was sent to the ER due to low blood sugar. The FM stated Resident #1 was in the hospital on IV medications for several days to try and stabilize her blood sugar. During an interview on 12/11/2023 at 3:13 pm RN B stated he was the nursing supervisor working on the evening on 12/3/2023 and he put in the medication orders for Resident #1 and then LVN A verified them. He stated Resident #1 arrived from the hospital with a packet with records and medication orders. He stated he verified the name on the history and physical and face sheet, then found the med orders and put them in. He stated he never noticed the name on the discharge medication list was not Resident #1. He stated they were supposed to verify names on all documents from the hospital. He stated he put the medication orders in the system and then LVN A verified them. He stated the facility policy was to have two nurses check the orders and they did that, but neither one of them saw the name on the medication list was not Resident #1. He stated by not checking the name it resulted in a med error for Resident #1 and she ended up going to the emergency department with low blood sugar. During an interview via a text message exchange on 12/11/2023 from 3:41 pm to 4:07 pm, the CCO for the on-call NP group stated their group had provided NP on call services to the facility. She stated when the facility called for admission orders for new residents, the on-call NP would review the orders verbally with a nurse from the facility. She stated, The nurse reads the orders out load verbally and we just approve/deny them. We do not get visibility for the discharge orders from the hospital. She said they were just provided verbally by the facility nurses and the on-call NPs did not actually put any medication orders in the system, the facility nurses do. During an interview on 12/11/2023 at 4:47 pm, the facility NP stated she had been in the building on 12/4/2023 and had been notified of a medication error for Resident #1. She stated she went and saw/assessed Resident #1 who was alert and in bed with family in the room. She stated she had been concerned about hypotension (low blood pressure) and hypoglycemia (low blood sugar) with Resident #1 due to the medication errors. She stated her expectation when she gave orders to staff was that they will be followed. She stated she was not aware that some of the blood sugar checks, and blood pressure checks that she had ordered had been missed by the nursing staff. She stated she had heard the resident had been sent to the hospital, so she found out on her own by reviewing the records that some of the blood sugar checks and blood pressure checks had been missed by the nursing staff. She stated she was concerned about the missed checks because I had not been notified that this happened and there was no documentation as to why it was not done. She further stated her concerns with the missed blood sugar checks would be exactly what happened. She became hypoglycemic. We should have been keeping a real close eye on her. It was not ideal that she ended up in the hospital. During an interview on 12/8/2023 at 12:13 pm, the AD stated as part of the order verification process upon admission the name on the orders should be verified that they are for the resident being admitted . He further stated that if that verification was not done, then there could be a medication error just like with Resident #1 and a resident could get very sick. During an interview on 12/8/2023 at 12:27 pm, the MD stated the facility had notified her of the medication error and they held an emergency QAPI meeting. She stated the hospital sent the discharge packet and had another patient's medication orders in it. She stated it was a HIPAA violation and error on the hospital's part. She stated the two nurses failed to recognize the medication orders had a different name on it than Resident #1's name and the root cause was human error. She further stated it was not a systemic error, it was an error from outside the organization and it was reported back to the hospital. She stated most med errors had little to no consequences and an individual's reaction to a med error was dependent on the individual. She stated she felt it was managed appropriately; even at the change of condition. She also stated There is always a risk of significant effect, hospitalization, and a rare complication, death. During an interview on 12/28/23 at 2:30 p.m., the ADM stated the hospital sent the wrong medication orders during Resident #1's discharge to the facility. The ADM stated the orders were primarily for Resident #1, but the last few pages were for another resident. The ADM stated the facility conducted an investigation and implemented interventions and preventions to ensure a similar incident would not occur in the future. The ADM stated Resident #1 was still residing at the facility. During an interview on 12/28/23 at 2:42 p.m., the NP stated when Resident #1 came to the facility from the hospital on [DATE], the discharge medication orders that were attached to the discharge paperwork were for someone else. The NP stated the nurse did not check Resident #1's discharge medication orders to ensure they were for Resident #1 and inputted the orders into Resident #1's EHR. The NP stated Resident #1 received blood pressure and blood sugar medications, which she normally did not take because she was not diabetic. The NP stated on 12/4/23, the nurse caught the error , but already administered the medications to Resident #1. The NP stated following the medication administration, nurses were assigned to check Resident #1's blood sugar and blood pressure levels. The NP stated there were some vital checks the nurses did not complete for whatever reason. The NP stated when Resident #1's blood sugar and blood pressure were checked during the night shift of 12/4/23, the nurse found Resident #1's blood sugar level was critically low . The NP stated staff sent Resident #1 to the hospital for the critically low blood sugar levels. The NP stated Resident #1 developed a secondary infection in the hospital. The NP stated Resident #1's blood sugar levels were stabilized, and she had no issues since returning from the hospital. The NP stated Resident #1's vital checks for blood sugar were conducted for a short-term because Resident #1 no longer received blood sugar and blood pressure medications. The NP stated staff no longer checked Resident #1's blood sugar levels when she returned from the hospital because she was not diabetic and did not take any medication that would affect her blood sugar levels. The NP stated staff routinely checked Resident #1's blood pressure levels. During an interview on 12/28/23 at 3:45 p.m., CNA F stated he worked for the facility for 7 years. CNA F stated he was in-serviced on BS and BP levels by the ADON and the ADON taught him s/s of hypoglycemia, how to check, how to respond in the event, and notifying the nurse on duty if a resident had a low BP. CNA F stated he checked residents' vitals immediately. CNA F stated residents' BP was checked every shift by a CNA. CNA F stated residents' BS was checked by the LVNs. During an observation and interview on 12/28/23 at 3:50 p.m., revealed LVN G was checking and verifying a newly admitted resident's hospital discharge medication orders. LVN stated he worked at the facility for 8 months. LVN stated he was in-serviced on BP and BS by the DON. LVN stated he learned how to report irregular levels. LVN stated vitals were checked every shift. LVN stated the BS was checked according to orders. LVN stated the BP was checked every shift. LVN stated vitals were checked by a CNA and BP was checked by LVNs. LVN stated charge nurses verified hospital discharge medication orders with the resident's name. During an interview on 12/28/23 at 3:58 p.m., RN H stated he worked at the facility for a month. RN stated he was in-serviced on the BP and BS levels during orientation. RN stated he learned how to check BP and BS levels and what to do in the event of hypoglycemia. RN stated residents' vitals were checked by CNAs every shift unless on BP meds. RN stated BS checks were done by LVNs, who also administered BS meds. RN stated he was trained on verifying residents' hospital discharge medication orders with the correct resident and sign and date verification whenever newly admitted and during night shift as well. During an interview on 12/28/23 at 4:02 p.m., LVN I stated she was in-serviced on BP and BS by the ADON. LVN stated she learned how to check the BP according to orders. LVN stated she checked the BS of residents with diabetes. LVN stated if residents' had irregular levels, she was trained to notify the MD. LVN stated she verified residents' hospital discharge medication orders to make sure match with residents and second verified to make sure correct verification. LVN stated CNAs checked vitals every shift. LVN stated LVNs checked the BS according to orders. During an interview on 12/28/23 at 4:06 p.m., CNA J stated she worked for the facility for two months. CNA stated she was in-serviced on BP and BS. CNA stated she could not remember who in-serviced her on the training topics. CNA stated she learned the signs and symptoms of hypoglycemia and how to respond and notify a nurse when there were signs and symptoms. CNA stated CNAs checked residents' BP every shift and whenever residents were admitted . CNA stated LVNs checked residents' BS. During an interview on 12/28/23 at 4:17 p.m., MA K stated she worked at the facility for two years. MA stated she was in-serviced on checking BP and how to verify orders by the DON and ADM. MA stated residents' BP were checked twice a day. MA stated if a resident had low BP, she was trained to notify a charge nurse, hold the residents' medicine, and check the resident's BP again. During an interview on 12/28/23 at 4:11 p.m., the ADON stated she in-serviced all nurses and taught them how to verify hospital discharge orders and made sure the nurses correctly matched the residents to the residents' discharge orders. ADON stated CNAs, MAs , and LVNs were also taught how to recognize signs and symptoms of hypoglycemia. ADON stated CNAs were also taught on how to report the signs and symptoms of hypoglycemia. ADON stated IDT meetings were conducted daily with the nurses, her, and the DON who verify and check to make sure hospital discharge medication orders correctly matched residents and were documented on the IDT checklist. ADON stated she was in-serviced by the DON on the processes. ADON stated the CNAs checked residents' BP once every shift and according to the physician's orders. ADON stated LVNs checked residents' BS twice a day, before meals and according to the physician's orders. ADON stated Resident #1 was no longer being checked for BS after she returned to the hospital because she was not taking any diabetic medication. During an observation and interview on 12/18/23 at 4:40 p.m., revealed Resident #1 was sitting in her wheelchair. Resident #1 was clean, comfortable, and her call light was sitting on her bed. Resident #1 was interacting with her family. Resident #1 and her family stated staff checked Resident #1's BP twice a day. Record review of Resident #1's December 2023 MAR/TAR revealed she received medications within required timeframes and that were active physician's orders. During an interview on 12/28/23 at 5:25 p.m., the ADM stated LVN E was suspended pending the investigation and then terminated after he completed the investigation. During an interview on 12/29/23 at 10:52 a.m., the ADM stated the facility made own POC. ADM stated there was monitoring that had been taking place daily for two weeks and then three times weekly for 12 weeks since 12/5/23. ADM stated QAPI had been conducting audits of the monitoring for the next three months and based on the audit results. ADM stated the facility had no other incidents since Resident #1's admission on [DATE]. Record review of the facility's QAPI meeting attendance sheet, dated 12/5/23, reflected there was a QAPI meeting. The members who attended the meeting were the Executive Director/Healthcare Administrator, Director of Clinical Services, Infection Preventionist, RDCS, DDO, VP of Clinical Services, and MD. The meeting topic was regarding discharge orders entered from hospital did not match Resident #1. The incident was reported to ED/HCA, DCS, POA, and SSA. The incident investigation report was completed. The root cause analysis was completed and determined the admitting nurse and verifying nurse did not confirm name on Resident #1's orders. Resident #1 had 9 BIMS score. The clinical admission orders were reviewed and audited on 12/5/23. Record review of the facility's resident roster, dated 12/7/23, reflected residents' medication orders and names were verified and matched . An audit was completed by the ADM. Record review of the facility's in-services reflected staff were trained on the following: Medications and admissions on 12/4/23, 12/5/23 at 1:00pm, and 12/7/23: Medication errors, medication administration (including 6 rights of medication, medication reconciliation on admission including verifying name of resident, blood glucose management including documentation of ongoing monitoring, CNAs signs and symptoms of hypoglycemia, and initialing next to resident's name on discharge orders. Record review of 49 knowledge-based exams reflected staff were tested from 12/5/23 through 12/10/23 on the following: What is hypoglycemia Signs of low blood sugar What to do when they believe a resident had low blood sugar Values that were considered low blood sugar What is given to raise up a resident's blood sugar How often resident's physician order section of the medical record and electronic orders were to be reviewed Where the 24-hour physician order audit form was located and completed by a nurse What a charge nurse verifies in reviewing each order Purpose of performing medication reconciliation Medication reconciliation helps identify what factors How many nurses needed to complete medication reconciliation for a new admission Second charge nurse responsibilities Information to be gathered for an admission/readmission to reconcile the medication list Common signs and symptoms of hypoglycemia How to respond when symptomatic and unresponsive residents with hypoglycemia Record review of Resident #1's blood pressure log reflected staff assessed and documented levels daily since readmission on [DATE] (12/12/23 - 12/29/23). Review of the facility policy admission and Data Collection and Orders last revised 02/23 reflected #2 The charge nurse who admits the resident is responsible for completing the Nursing admission Data Collection, verifying orders are present for admission, additional corresponding data collections and reviewing the information sent by the discharging community, hospital and/or attending physician. and #5 The charge nurse should contact the attending physician after the resident has been admitted to the community and resident data is collected. a) Orders should be reviewed with the physician and verified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident receives adequate supervision and assistive devices to prevent elopement for one resident (Resident #4) of two reviewed with dementia who exhibited exit-seeking behaviors. Resident #4 was able to exit facility on 07/19/2023 around 1:00 PM and was left unsupervised and exposed to environmental hazards for a period of time. A past non-compliance Immediate Jeopardy was identified on 08/25/2023. The IJ was determined to have been removed due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure could place residents with dementia who have exhibited exit-seeking behaviors at risk for severe injury or death. Findings included: Record review of Resident #4's face sheet dated 07/20/2023 revealed an [AGE] year-old female resident admitted on [DATE] from acute care hospital with Diagnoses which included syncope and collapse, fall which required acute-care hospitalization in period just prior to facility admission date of 07/05/2023, dementia without behavioral, psychotic, mood, or anxiety disturbance, seizures and epilepsy, among other diagnosis. Primary language of Resident #4 was noted to be of Eastern European dialect per face sheet dated 07/20/2023. Record review of Resident #4's MDS dated [DATE] revealed BIMS score of 07/15, which indicated severe cognitive impairment (a deterioration or loss in intellectual capacity), wandering behavior had not been exhibited. Resident #4 required supervision level of assistance for walking in room, walking in corridor, locomotion on unit, and locomotion off unit. Resident #4 had not had any falls since 07/05/2023. Resident #4 had been admitted for OT and PT services and those services were provided during facility stay. Record review also revealed that no physical restraints were used during stay. Record review of Resident #4's Care Plan entry for Fall Risk revealed that Resident #4 focus area for fall risk was initiated on 07/05/2023, that a Goal of Resident #4 not sustaining serious fall injury was initiated on 07/19/2023, that fall interventions of OT eval (evaluate) and treat as ordered and PT evaluate and treat as ordered were established on 07/05/2023 and that other fall interventions were initiated on 07/19/2023. The Care Plan revealed wandering/elopement seeking behaviors with initiation of focus area, goal, and interventions added to Care Plan on 07/19/2023include the following: Ensuring the environment is clutter free and hazardous items are away from Resident #4, collaboration of staff to help with monitoring Resident #4, relocating Resident #4 to a room close to nurse's station, asking family members to come sit with Resident #4, providing one on one supervision. Use of wander guard (an electronic device worn as a bracelet or anklet which interfaces with an alarm if resident gets too close to an exit door) did not appear as an intervention for elopement risk on Care Plan. Resident #4 Care Plan revealed initiation of entry on 07/19/2023 with focus area of blisters to both left and right heel due to frequent ambulation; goal and interventions for blisters were initiated on 07/20/2023 and included intervention of encouraging Resident #4 to wear shoes and socks when ambulating, monitoring healing of the blisters, and monitoring feet for signs and symptoms of infection every shift, notification of medical provider if blisters opened. Care plan for Resident #4 focus area of ADL self-care performance deficit, initiated 07/05/2023 indicated an intervention initiated on 07/19/2023 of making sure shoes were comfortable and not slippery. Record review of Tulip intake revealed that on 07/19/2023 at 1:15 PM, the facility learned of an incident in which Resident #4 had eloped from the building. Resident #4 with no injuries found, completion of change of condition documentation, utilization of wander guard system/process and management of wander guard alarm, notification of physician and family, one on one care initiation, auditing like-residents, and providing hydration. The report indicated in-service of staff on change of condition process, utilization of elopement binder/procedure, wander guard system/process and management, and notifications. Record review of an e-mail (electronic mail) from the ADM dated 07/20/2023 at 12:57 PM, uploaded to Tulip, stated that Resident #4 was first noted to exit seek on 07/06/2023. Further information indicated that Resident #4 had been gone approximately 25 minutes, was a short term rehab (rehabilitation) resident, and had been wearing a wander guard. The e-mail stated that Charge Nurse (no name specified) and Aide (no name specified) saw her 15-20 minutes prior to being reported missing. Record review of PIR, submitted on 07/27/2023 at 5:08 PM, indicated that Resident #4 had a wander guard placed on 07/06/2023 when Resident #4 was initially identified as an exit-seeker. and that Resident #4 was first found to be missing by Social Services Director on 07/19/2023 (no stated time). Record review of facility Incident Investigation Incident report, Summary of Incident, dated 07/20/2023 reflected that Social Services Director had gone to Resident #4's room on 07/19/2023 (no time indicated) and did not find Resident #4 there. Social Services Director then (no time indicated) informed Charge Nurse A that Resident #4 was not in her room and a missing resident procedure was initiated (no time indicated). Record review of (facility) Incident Investigation report, Associate Interview section, dated 07/20/2023, Charge Nurse A statement indicated that Charge Nurse A, assigned to Resident #4, was notified around 1 PM that Resident #4 was missing and that Charge Nurse A had last seen Resident #4 approximately 20 minutes prior. Record review of facility Incident Investigation report, Associate Interview section, dated 07/20/2023, CNA F revealed that she has seen Resident #4 approximately 15-20 minutes prior (no time given) to the time that she was found missing (no time given). Record review of facility Incident Investigation report, Summary of Incident, dated 07/20/2023, indicated that Resident #4 was found outside the community (by not stated person) and was returned without any visible injuries (time not stated). Record review of facility Incident Investigation report, Resident Interview, dated 07/20/2023 indicated that Resident #4 was attempting to go home. Record review of facility Incident Investigation report, Post Investigation Actions, dated 07/20/2023 indicated that the following actions would be taken: care plan updates, in-services/associate retraining, audits (non-specified), wander guard system adjustment, 24/7 one on one care initiation with Resident #4. Record review of Form Scoring Report to identify residents at risk for elopement printed on 07/19/2023 at 14:23:54 CT indicted that elopement assessment for Resident #4 indicated Not at Risk for Elopement on 07/05/2023. No further assessment of elopement was indicated on this report for Resident #4. Record review of Form Scoring Report to identify a resident at risk for elopement printed 07/19/2023 at 14:25:51 CT indicated that Resident #4 was identified as Potential Elopement Risk on 07/06/2023 and on 07/19/2023. Record review of 07/19/2023 at 12:35 PM in-services included utilization of Elopement Binder to assist nursing staff familiarity with residents at risk for elopement, and Incident Reporting - Elopement. Sign in sheets reflecting date/time of in-service and nursing staff in attendance were contained with in-service content. Record review of 07/19/2023 at 4:20 PM in-service regarding resident Change of Condition related to Elopement/Missing Resident included nursing staff sign-in sheet and reference to attached policy. Instruction to notify administrative staff if an elopement/missing resident incident takes place was noted on staff sign-in sheet for this in-service. An in-service dated 07/20/2023 at 08:00 AM entitled Elopement Notifications to HCA was noted to be held for Therapy Department. Sign in sheet of this in-service reflected Therapy Department staff signatures and defined elopement, indicated presence/access of elopement binder at each nurse's station, and the statement that wander guards should be disabled by a licensed nurse only. An example of elopement followed the definition of elopement on 07/20/2023 at 08:00 AM in-service sign-in sheet for Therapy Department. The written example of elopement reflected Leaving skilled nursing to first floor AL without signing out/notifying staff. Elopement was defined on Therapy Department in-service sign in sheet dated 07/20/2023 at 08:00 AM as A situation in which a resident leaves the premises or a safe area without the community's knowledge and supervision which may represent a risk to the resident's health and safety. Concierge staff in-service sign-in sheet dated 07/20/2023 at 08:00 AM entitled Elopement Notifications to HCA reflected the same items covered in meeting as those of Therapy Department. In-service dated 07/20/2023 at 08:00 AM entitled Elopement Notifications to HCA with sign-in sheets was held for House (miscellaneous staff working in the facility) and for Dining Department and reflected items covered as: elopement definition, elopement example, elopement binder access and utilization, notification of administrative staff if an elopement occurs, and disabling of wander guard system by licensed nurse only. Record review of hard copies of 7/19/2023 and 07/20/2023 in-service sign in sheets were reviewed during investigation on 08/23/2023 through 08/25/2023. Record review of Nursing Progress Note dated 07/06/2023 at 8:55 PM by Charge Nurse B revealed that Resident #4 was exit-seeking and that wander guard had been applied to right wrist. Record review of Nursing Progress Note dated 07/14/2023 at 2:16 PM by Charge Nurse C revealed that Resident #4 made several attempts to elope, requires redirection, and has a wander guard in place. Record review of Nursing Progress Note dated 07/15/2023 at 9:21 PM by Charge Nurse D revealed that Resident #4 was wandering around the unit, wander guard in place at all times. Record review of Nursing Progress Notes of 07/16/2023 at 9:14 PM by Charge Nurse E revealed that Resident #14 had attempted to elope six times (period of time not stated). Record review of Nursing Progress Note dated 07/18/2023 at 6:30 PM revealed that Charge Nurse A had been contacted by receptionist from the first floor stating that she noted resident in the parking lot and brought her back into the building, and that resident continued exit-seeking behaviors that evening. Record review of Progress Note dated 07/20/2023 from APRN revealed that Resident #4 had an episode of elopement today and was found in a housing community nearby. She was brought back to her room and vitals were stable. Her face was flushed and she was given cold towels and ice water. She denies pain. She did have some blisters on her feet from where her shoes rubbed but no injuries. Patient reported that she was trying to get home. She had a wander guard in place that was functioning but was still able to elope. Patient (Resident #4) to get 24-hour sitter and plans to dc (discharge) home tomorrow with family. Record review of Missing Resident Drill Forms and sign-in sheets reflected drills conducted on 07/20/2023 at 12:30 PM, day shift, and 3:20 PM, evening shift. Record review of Missing Resident Drill Form reflected drill done on night shift at 07/21/2023 at 11:25 PM. Missing Resident Drill Forms Summary reflected that wander guard alarms were ignored and that wander guard alarms were not loud enough/staff reporting trouble hearing alarms. Record review of Root Cause Analysis developed during facility ad hoc (when necessary) QAPI meeting on 07/20/2023 at 1:00 PM indicated root cause analysis of elopement to be the need for wander guard enhancements. Interview with RN A on 08/23/2023 at 3:07 PM, revealed that RN A was working on day of Resident #4 elopement on 07/19/2023. RN A stated that Resident #4 was wearing a wander guard at time of elopement. RN A stated that Resident #4 had been placed on one-to-one supervision on several occasions during facility stay for exit-seeking. RN A stated that prior to elopement incident on 07/19/2023, staff would silence wander guard alarms. Since the elopement incident of 07/19/2023, RN A stated that only licensed nurses can now silence alarms. RN A stated that he believed that Resident #4 had been gone 5-10 minutes before she was found outside on 07/19/2023. Interview with CNA F was done on 08/24/2023 at 11:18 AM. CNA F stated that she was working on 07/19/2023 when elopement incident with Resident #4 occurred. CNA F stated that everybody was looking for her (Resident #4). CNA F stated that she did not know how Resident #4 got outside. CNA F stated that Resident #4 was not gone long but was not able to state how long Resident #4 was gone. Interview with Social Worker on 08/25/23 at 1:17 PM revealed that Resident #4 was found by a neighbor (unknown name) that lived near the facility. The neighbor realized that Resident #4 was confused and called the facility to report her location. It was then that she was brought back to the facility by two staff members who went to pick her up and walk her back to facility. Social Worker stated that she did not believe that Resident #4 was injured during incident, Social Worker stated that she felt that Resident #4 was just dehydrated, flushed, and sweating. Social Worker stated that Resident #4 was given water when she returned to facility. Social Worker stated that police were not involved in search and that Resident #4 was gone for about 15-20 minutes. Interview with Family Member #4 was conducted on 08/23/2023 at 5:26 PM. Family Member #4 stated that she was made aware on 07/19/2023 afternoon that Resident #4 had left the facility. Family member #4 stated that facility had called her three times during Resident #4's stay from 07/05/2023 to 07/20/2023 to report that resident was missing. Resident #4 Family Member #4 stated that Resident #4 worn a bracelet, applied by facility staff, that would help prevent elopement. Family Member #4 stated that Resident #4 had a strong will to leave the facility and on the fourth attempt she got outside. Resident #4 Family Member #4 stated that facility offered to find placement for Resident #4 in a Memory Care Unit after 07/19/2023 elopement incident. Family Member #4 stated that she brought Resident #4 to her house the next day and has hired 24-hour caregivers for Resident #4. Family Member #4 stated that after the elopement incident, she was told that the facility gave her water right away because it was hot outside and facility staff believed that Resident #4 may have been dehydrated. Family Member #4 stated that she was not aware of any other harm caused by the elopement. Family Member #4 stated that staff accounts of incident led her to believe that Resident #4 was missing for 15-30 minutes at approximately 1:30 PM on 07/19/2023. Interview with ADM on 08/25/2023 at 10:57 AM, revealed that Resident #4, during her stay from 07/05/2023 to 07/20/2023, had eloped to the outside of building one time and another time was found in a stair well. Actions taken after 07/19/2023 elopement incident included: root cause development, routine checks of wander guard when placed on residents and during duration of use by residents (order to check appears every shift on resident's treatment record to prompt nurses to check), and weekly door checks, with documentation log kept by maintenance, for properly working delayed egress mechanism. Per interview with ADM on 08/25/2023 at 10:57 AM, further actions taken after 07/19/2023 elopement incident included Missing Resident drills in immediate days following elopement and initiation of monthly Missing Resident drills. ADM stated that radios were now kept at nurse's station for enhanced communication. ADM stated that Security Guard now has a golf cart to check the premises when a resident is reported missing, and an emergency response warning is sent out to law enforcement officials when a resident is missing. ADM stated in interview on 08/23/2023 at 10:57 AM interview that elopement binders which include a copy of resident face sheet with photograph would be kept at each nurse's station and receptionist desk at entrance to facility. ADM further stated during 08/25/2023 at 10:57 AM interview that wander guard enhancements had been made which increased the alarm volume for staff when a resident wearing a wander guard gets close to the exit doors. Observations were conducted of live Missing Resident Drills on 08/23/2023 at 1630 (430pm) on floor 2 and on floor 3 with DON. No facility staff were observed silencing alarm. Two staff members on one floor were observed to continue other tasks during alarm period and drill and DON acknowledged that all staff should stop what they are doing and participate when there is a missing resident. DON stated on 08/24/2023 that a facility-wide elopement drill had been conducted since investigator observed drills of day prior, with good results. No sign-in sheet of this drill was produced when requested from DON for record review. Record review of facility Elopement Risk Policy dated 10/2022 defined elopement as a situation in which a resident leaves the premises or a safe area without the community's knowledge and supervision which may represent a risk to the resident's health and safety. Policy detail revealed that residents accepted for admission should be assessed upon admission into the Community and appropriate interventions should be established to respond to the resident's potential exit/elopement seeking behavior. Policy detail included completion of Elopement Risk Data sheet with photograph and placement in Elopement Risk Binder at Nurses Station, communication elopement risk to associates, elopement risk assessment on admission, quarterly, and as needed, and interventions will be documented in resident's Plan of Care. Policy on initiating wander guards, Resident Monitoring System policy, dated 10/2022, stated that Physician Orders should be placed for use of monitoring system, notification of Resident/Legal Representative, application according to manufacturer's instructions, monitoring of resident's comfort related to the device, verification of proper functioning. Policy revealed that placement of device should be checked every shift and documented, monitoring system should be inspected monthly and documented, and that recommendation will be made to physician for discontinuance of it has been determined that less restrictive measures can be accommodated. Record review of Elopement System Alarm Activation Policy, dated 10/2022, for wander guard alarms was reviewed. Policy stated that staff should go immediately to site of activation, alarmed door should remain alarming, the unsupervised resident should be identified or every resident with an elopement device should be accounted for, alarm will be reset by designated personnel, and if resident is unable to be located, Missing Resident policy will be enacted. Record review of Missing Resident Policy, dated 06/2017, revealed that a missing resident requires immediate attention. Missing Resident Policy, dated 06/2017, revealed that the following steps should be taken: verify if resident has signed out, obtain the time of last sighting, determine clothing that resident was wearing as well as cognitive and emotional status, obtain height and weight and other descriptive characteristics of missing resident. Missing Resident Policy, dated 06/2017, stated that the Missing Resident Response Worksheet should be initiated followed by a thorough interior search of the building. Security would then be notified to begin search of outside grounds, using security vehicle if needed. ADM and DON are to be notified as well medical provider. Lastly, provide the Missing Resident Profile with a picture of resident to local law enforcement. When a resident is located, per Missing Resident policy, dated 06/2017, the resident should be reviewed for injuries, an incident report should be completed, medical provider should be notified and resident will be transferred to higher level of care if needed. Resident will be assigned one-on-one supervision until reassessment determined future placement needs. On 08/25/2023 at 05:50 PM, a past non-compliance IJ was identified. The ADM was notified and provided the IJ template.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the residents' rights to be free from abuse for two (Resident #2 and Resident #3) of four residents reviewed for abuse, in that: -Resident #2 was not protected from alleged abuser CNA A after making a verbal complaint againt CNA A; measures were not taken to remove access by the alleged perpetrator to the alleged victim, resulting in intimidation and mental abuse. -Resident #3 was not protected from further abuse, in the form of mental abuse and potential physical abuse, when alleged perpetrator continued to have access to Resident #3 in the facility, causing Resident #3 mental distress. An IJ was identified on 08/25/2023 at 5:50 PM. While the IJ was removed on 8/27/2023 at 10:50 AM, the facility remained out of compliance at a severity level of actual harm with the potential for more than minimal harm that was not in immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for physical abuse or mental abuse by allowing perpetrators or potential perpetrators of abuse to continue. Findings included: Record review of Resident #2's face sheet, dated 07/20/2023, revealed a [AGE] year-old female with facility admission date of 07/07/2023 with diagnoses of right intertrochanteric fracture of right femur (fracture of the large bone of the right thigh in the hip area), fracture of right humerus (large bone of the upper arm), and major depressive disorder (persistently low or depressed mood), among other diagnoses. She was admitted to the facility for Physical and Occupational Therapy services after an acute care stay at a local hospital. Record review of Resident #2's MDS (standardized assessment tool that measures health status in nursing home residents) dated 07/14/2023 indicated a BIMS (assessment which measures cognitive functioning) score of 15/15, indicating resident had full cognition (full intellectual capacity), and revealed that Resident #2 had felt down, depressed, or hopeless nearly every day over the previous 2 weeks at the time the assessment was conducted. The MDS indicated that Resident #2 was not having hallucinations or delusions, she did not have any behavioral symptoms such as hitting or kicking, did not have any verbal symptoms, such as cursing or screaming at others, and did not have any behavioral symptoms directed toward others. Resident #2 required extensive assistance for bed mobility, including turning side to side in bed and positioning self while in bed, and she was always incontinent of urine and bowel. Record review of Resident #2's Care Plan, entry effective 07/21/2023, revealed that resident required extensive assistance of one person to roll over in the bed. Resident #2 had an ADL (activities of daily living, including hygiene, toileting/continence, other activities) self-care deficit and required assistance of at least one person for assistance with ADL's. Record review of Form 3613-A, Provider Investigation Report, dated and signed by ADM on 07/24/2023, revealed On 07/17/2023, (Resident #2) made the following grievance: . The Investigation did find that (CNA A) circled around Monday morning (07/17/2023) to ask (Resident #2) what went wrong during the care and why a grievance was made. (Resident #2) had grievances regarding (CNA A) peri-care on the morning of 7/15/2023. revealed that head to toe assessment of Resident #2 was done on 07/17/2023 at 10:00 AM. revealed that provider investigation findings were inconclusive. Record review of 07/17/2023 provider investigation facility form entitled (Corporate Name) Incident Investigation Form - Applicable to Skilled Nursing, Timeline section, indicated that incident involving Resident #2 and CNA A occurred at 4:00 AM on 07/16/2023, that Resident #2 made grievance on 07/16/2023 at 7-8:00 AM, and that RN A followed up with Resident #2 regarding her grievance on 07/16/2023 in the evening. Record review of form entitled (Corporate Name) Incident Investigation Form - Applicable to Skilled Nursing, dated 07/17/2023, Timeline section, indicated that RN A discussed grievance with CNA A on 07/17/2023 day shift; this same document/Timeline section, revealed that CNA A followed up with Resident #2 regarding grievance on 07/17/2023 during the day shift. Record review of (Corporate Name) form entitled Incident Investigation Form - Applicable to Skilled Nursing, dated 07/17/2023 and signed by ADM, revealed that Resident #2 stated CNA A was 'rough' during peri-care and Resident #2 was scared of CNA A. Record review of (Corporate Name) Incident Investigation form, dated 07/17/2023, revealed quoted statements from CNA A and PT A regarding the grievance and reapproach of Resident #2 by CNA A and the reapproach of Resident #2 as witnessed by PT A. Date/time of statements was not indicated. In this document, CNA A stated I went in to change her brief and she never said there was a problem .She didn't want me to change her pad and I do not know why. I went and talked to her on Monday because I thought everything was okay .and I wanted to know what was/went wrong. PT A statement included I did witness CNA A approach Resident #2 on Monday. I wouldn't say it was aggressive but it was inappropriate .I do not think CNA A understood how she was coming off to Resident #2. I do not think CNA A was trying to intimidate Resident #2 but trying to figure out why Resident #2 complained about her. A statement that CNA C's memory and opinion was congruent with PT A's statement was included on this form. A statement which read Pending CNA B interview followed these statements. No statement for CNA B, nurse aide for Resident #2 when allegations were first verbalized after incident, per Timeline section on (Corporate Name) Incident Investigation Form - Applicable to Skilled Nursing, was documented at time of investigation. Record review of (Corporate Name) Incident Investigation Form - Applicable to Skilled Nursing, dated 07/17/2023, revealed in Immediate Actions Taken: Resident was evaluated and/or treated, Associate accused/suspected was suspended, Notification was made to (Corporate) District/Regional Administrative Officers, Responsible Party was notified, Physician was notified; this same form indicated that Post Investigation Actions included In-services/Associate Re-training and Other Action (specified without detailed description as Corrective Action: CNA A) was taken. Record review of (Corporate Name) Incident Investigation Form - Applicable to Skilled Nursing, dated 07/17/2023, Conclusion, indicated that Provider findings were inconclusive and unfounded, as indicated by checked boxes; boxes associated with Confirmed or Unconfirmed were left blank. Record review of the Provider Investigation indicated that four safe surveys were conducted on four residents on unknown date by unknown person and there were no safety concerns expressed. Record review of documents in Provider Investigation indicated that Abuse and Neglect in-service was held on 07/17/2023 at 4:35 PM and signed by 15 staff persons. a Peri-care in-service was held on 07/17/2023 at 3:00 PM and signed by 15 staff persons. In-service on customer service dated 07/17/2023 at 4:35 PM revealed sign-in sheet signed by 15 staff persons. CNA A's signature did not appear on in-service sign in sheets dated 07/17/2023. During interview with Resident #2 on 08/23/2023 at 12:40 PM, Resident #2 stated that CNA A was rough with her on a night shift on 07/15/2023 or 7/16/2023. Resident #2 was able to identify CNA A by first name. Resident #2 stated that CNA A turned the light on in her room and woke her up and stated that she needed to change her brief and bedding as everything was wet. Prior to changing the brief, Resident #2 stated that CNA A had asked her to roll over. Resident #2 stated that she complied with CNA A request and rolled over. Resident #2 stated that CNA A then took her hands and shoved her over further, which indicated to Resident #2 that the CNA A was angry that she had not rolled over far enough on her own. Resident #2 stated she told CNA A that the action of shoving her over really hurt as this was her side (of her body) with fractures. Resident #2 stated she told CNA A not to change the wet pad that was underneath her on the bed as she just wanted CNA A to leave her room. Resident #2 stated CNA A left the wet pad under her and left the room. Interview with RN A on 8/23/2023 at 12:50 PM, revealed RN A was informed about the abuse allegation after Resident #2 reported it to morning CNA B when she came on duty on the morning shift of 07/16//2023 at approximately 7:00 AM. RN A stated that he spoke with Resident #2 immediately after he was informed of the grievance which had been conveyed from Resident #2 to CNA B. RN A stated that Resident #2 stated to him on 07/16/2023 at approximately 7:00 AM that CNA A was rough with her care when she attempted to change Resident #2's brief and wet bed in the early morning hours of 07/16/2023 after entering the room and turning on the light. Resident #2 stated to RN A during grievance follow-up on 07/16/2023 that she felt scared of CNA A. RN A stated CNA A is very passionate about her work and gets offended when she is accused of improper care. RN A denied that CNA A had been accused of abuse prior to the event with Resident #2. RN A stated that CNA A approached Resident #2 in a common area the following day, 07/17/2023, and stated to her That isn't what I did, referring to grievance expressed by Resident #2. RN A stated that CNA A came across in the wrong way as she attempted to relay verbally to Resident #2 that she had not been rough. RN A stated that CNA A is very efficient, works fast, and any rough behavior would not have been intentional. Resident #2 is no longer assigned to receive care from CNA A per RN A. RN A stated that he reported the incident to ADM right away after speaking with Resident #2 on 07/16/2023. Interview with Family Member #1 on 08/23/2023 at 3:51 PM, revealed that Family Member #1 and Resident #2 had spoken to the ADM on unknown date, about the allegation, in the days following the allegation. Family Member #1 stated that Resident #2 had a palpable fear that she was being retaliated against when she overheard an unknown Nurse Aide asking another staff person Who would report my friend? Family Member #1 stated that the penalty for CNA A regarding incident with Resident #2 was attending an in-service and this concerned Family Member #1, as he stated he did not feel this was a sufficient response from the facility regarding the incident. Family Member #1 stated that he did not feel the facility response was adequate based on the treatment that Resident #2 received from CNA A, and that she was left feeling scared after she alleged the mistreatment. Interview with Physical Therapist by phone on 08/24/2023 at 1:00 PM, revealed that Physical Therapist was with Resident #2 providing therapy services when Resident #2 was approached by CNA A. Physical Therapist stated that she does not remember the exact date/time. Physical Therapist stated during interview that CNA A approached Resident #2 during PT session and stated I heard you had a complaint about me, what did I do wrong?' to which Resident #2 replied 'I felt you were a little rough with me when you rolled me in the bed' . CNA A replied, according to Physical Therapist in interview, 'Well I have to roll you in order to change you' . Physical Therapist stated that she and Resident #2 felt this to be an uncomfortable situation and it caused Resident #2 distress, per Physical Therapist. Physical Therapist stated that Resident #2 told her that she did not want CNA A to come back in her room. Interview with CNA C on 08/24/2023 at 12:32 PM, revealed that she witnessed, on unknown date/time, Resident #2 as she was confronted by CNA A regarding grievance. CNA C stated that Resident #2 stated to her, at a time after she was approached by CNA A, 'She (CNA A) came up to me and accused me of reporting her' . CNA C stated that she told Resident #2 that wasn't very nice of her. CNA C stated that Resident #2 stated 'that scared me', in reference to the action of CNA A approaching her . CNA C stated that Resident #2 then stated 'I hope she doesn't come back to my room. I'm afraid of her roughing me up.' Interview with ADM on 08/24/2023 at 2:17 PM, by phone revealed that CNA A was suspended for a couple of days. ADM stated that when it came down to it, it was a he said-she said. ADM stated that CNA A was coached, after the incident on 07/17/2023, not to reapproach residents if they make accusations which involved her. ADM stated that in addition to a couple days suspension, beginning on 07/17/2023, CNA A was in-serviced on Customer Service, Peri Care (incontinent care), and Abuse/Neglect. A phone interview on 08/25/2023 at 10:52 AM with ADM, stated he was not made aware of grievance until 07/17/2023. ADM stated during phone interview on 08/24/2023 at 2:17 PM that he was made aware of Resident #2 grievance on 07/17/2023 and took action to investigate and address grievance beginning on this date. ADM stated that to his knowledge, RN A did not notify him of the grievance on 07/16/2023. ADM acknowledged that he is the facility Abuse Coordinator and that staff have been trained to report allegations of abuse or neglect to him immediately. Observation on 08/25/2023 at 2:31 PM, included incontinent peri-care and brief change for bed-bound resident by CNA G and CNA H. There were no concerns during observation. Record review of Resident #3's face sheet dated 08/11/2023 revealed a [AGE] year old female with diagnoses of depression, dementia without behavioral disturbance (decreased ability to remember without behavioral symptoms directed at others or oneself), psychotic disturbance, mood disturbance, and anxiety, among other diagnoses. Record review of Resident #3's MDS (standardized assessment tool that measures health status in nursing home residents dated 08/23/23 revealed a BIMS score of 7/15, which indicated severely impaired cognition (a deterioration or loss in intellectual capacity). Record review of Resident #3's Care Plan dated 08/11/2023 revealed that Resident #3 required staff assistance with bathing/showering, assistance with activities of daily living, and assistance to dress. The Care Plan indicated that Resident #3 had alteration in mood with interventions listed including administering medications, ordering behavioral health consults, and encouraging the resident to express feelings. Record review of Tulip submitted on 08/22/2023 at 4:12 PM, by ADM revealed that Resident #3 alleged that a nurse aide was rough with her during a shower with facility first learning of incident on 08/22/2023 at 3:30 PM, the report indicated that the perpetrator was unidentified. Resident #3's allegation of abuse revealed that Actions and Notifications taken by the facility included: assessing resident, notifying family and physician, conducting safe surveys, taking statements, and conducting in-services regarding showers, customer service, abuse, neglect, and exploitation. Provider investigation documents were requested at entrance to facility on 08/23/2023 at 11:02 AM by email to Executive Director and ADM. Executive Director stated at entrance conference that RN A would be facility contact person for anything needed to investigate intakes and Executive Director would also be available. ADM would be available by phone, per Executive Director. Executive Director stated that although intake was reported one day prior, the investigation regarding was under way. ADM was interviewed by phone on 8/23/2023 at 10:50 AM. ADM stated that incident which involved Resident #3 was reported to State intake the day prior, on 08/22/2023. ADM stated that Nurse Aide, whom had perpetrated abuse on Resident #3 during a shower, remained unidentified. ADM stated that ADON was sent in to do physical assessment on Resident #3 after allegation of abuse was communicated to him as the result of a Care Plan Meeting on 08/22/2023. During Care Plan Meeting on 08/22/2023, Family Member #2 communicated that Resident #3 had stated to him that a nurse aide was rough with her during a shower on either 08/20/2023 or 08/21/2023. ADM stated during interview of 08/23/2023 that Resident #3 Family Member is not worried that abuse occurred. Interview with Resident #5 on 8/23/2023 at 1:00 PM, revealed her own experience in the facility, then she advised that her roommate, Resident #3, had verbalized a concerning incident to her that she felt Resident #3 would want to discuss with HHS representative. Resident #5 revealed that her roommate had told her that she had been mistreated during a shower. Because her roommate, Resident #3, had been upset about the event, Resident #5 verbalized that she thought her roommate would want to discuss the concern. Resident #5 stated that she did not witness alleged abuse but had heard about it from her roommate, Resident #3. Resident #5 did not witness the alleged perpetrator to her knowledge. Resident #5 stated that she did not know what day the alleged abuse had taken place or what date/time Resident #3 had first told her about the event. Interview with Resident #3 on 08/23/2023 at 1:15 PM revealed that Resident #3 did not know the name of the staff person who had showered her on date of alleged abuse and was unable to give the date or day of the week that the shower had been given. Resident #3 described the event which had occurred in the shower: alleged perpetrator was assisting Resident #3 with her shower and asked her to turn around as she stood; alleged perpetrator was going to wash off her back side. Resident #3 stated that when she did not turn around in a timely manner, the alleged perpetrator physically turned her body around, knocking her against the shower wall. Not able to recall the date/time of the incident, Resident #3 provided a verbal description of the alleged perpetrator which included: of African or Hispanic descent, female, curly dark hair, and wearing a copper-colored hair accessory. Resident #3 stated that she told her roommate and her son after the alleged abuse took place. Resident #3 stated that she had further seen the alleged perpetrator since the date/time of the incident; Resident #3 stated that one sighting occurred at the nurse's station (date/day of week unknown) and second sighting was in the dining room as alleged perpetrator poured drinks (date/day of week unknown). Resident #3 stated that when she saw alleged perpetrator in the dining room it made her cry, and some of the staff asked her what was wrong and attempted to console her. Resident #3 stated that she had not had another shower since the alleged abuse occurred. Resident #3 became teary as she recounted the shower event, during her interview. Resident #3 stated that the alleged abuse made her feel awful and that she never had anyone treat her the way that she was treated during that shower. Request for Provider Investigation or documents which indicated progress toward investigation, , requested verbally from DON on 08/23/2023 at 3:00 PM. DON was unable to provide any investigation documents for review. CNA C was interviewed on 08/24/2023 at 12:45 PM. CNA C stated that she was aware of Resident #3 having a complaint about someone being rough with her in the shower. CNA C stated that she had no knowledge of a perpetrator or when the alleged abuse occurred, CNA C that Resident #3 is a day shower (showers on the 2:00 PM to 10:00 PM shift) and she had not showered Resident #3. Interview with RN B was held on 08/24/2023 at 1:40 PM. RN B stated that she had worked on 8/22/2023 and 08/23/2023 and was the primary nurse for Resident #3 on those days. RN B stated that she and ADON had done a skin assessment on Resident #3. RN B stated that an allegation had prompted the skin assessment but she did not know what was being alleged. RN B stated during interview on 08/24/2023 at 1:40 PM that she had heard that someone had been rough with Resident #3 during a shower and backed her up against the wall of the shower. RN B stated that she did not know who the assigned nurse aides were for Resident #3 on 08/22/2023 or 08/23/2023 or if she had had a shower on those dates. RN B stated that she had not witnessed abusive treatment toward Resident #3. Interview with ADON was done on 08/24/2023 at 2:08 PM and revealed that he and RN B did a head to toe skin assessment with Resident B on 08/22/2023. Resident #3 became agitated during skin assessment, ADON stated during 08/24/2023 interview, so skin assessment had to be done slowly and with measures taken to allow Resident #3 to calm during the procedure. ADON stated during 08/24/2023 interview that he and RN B were able to do a thorough skin assessment and did not find evidence of abuse. ADON stated that skin assessment was done at the end of the day on 08/22/2023 and he did not know who the alleged perpetrator was or who had showered Resident #3 when alleged abuse occurred. ADON stated that Nurse Aides do showers three times weekly per resident and that no Shower Aides are used in the facility. Provider Investigation documents requested on 08/24/2023 from RCS by text (her preferred method of contact for requesting documents per RCS, who was in facility on 08/24/2023 and 08/25/2023). Verbal request to RCS was made for Provider Investigation documents on 08/24/2023 at 2:02 PM. RCS stated advised investigator to speak with ADM regarding investigation documents and no Provider Investigation documents were obtained from RCS at this time. Provider Investigation documents for were requested from ADM by phone on 08/24/2023 at 2:10 PM. Email containing four safety surveys conducted with four residents on unknown date/time were received on 08/24/2023 at 2:13 PM. No other progress on investigation was submitted and a perpetrator remained unidentified for the alleged abuse regarding Resident #3. Executive Director was interviewed on 08/25/2023 at 09:55 AM and stated that the investigation regarding, Resident #3, had been started. Executive Director stated that interviews had been started with staff. Executive Director stated during interview on 08/25/2023 at 09:55 AM that there was no alleged perpetrator. Executive Director stated that Resident #3 is confused and unable to give a description of alleged perpetrator. ADM was interviewed on 08/25/2023 at 10:57 AM by phone regarding intake 445774. ADM stated that 5-day investigation report would be submitted to State intake on Tuesday, August 29, 2023. ADM stated that after initially receiving grievance on 08/22/2023, the facility staff began checking all other residents. ADM stated that family and physician were notified on 08/22/2023. ADM stated that in-services are being initiated and interviews are being completed on 08/25/2023. Resident identified perpetrator to ADM as African American female with short curly hair. ADM stated that CNA E had given Resident #3 a shower earlier in the week. ADM stated that he had spoken with various staff regarding incident or if there were any concerns regarding staff working on Resident #3's hall. Point Click Care software based electronic medical record was accessed on 08/23/2023 to aide in investigation. It was revealed in PCC that a shower had been documented on 08/22/2023, 2:00 PM to 10:00 PM shift. Shower entry in PCC was documented as Resident #3 requiring some assistance RN A was asked to identify the staff member that had documented the shower, along with their initials, on 08/22/2023 and RN A was unable to identify. Executive Director stated that he would be able to identify the staff member initials in PCC; it was requested to Executive Director that this staff member be identified and interviewed by HHS representative if they were present in the facility. CNA D was interviewed on 08/23/2023 at 2:19 PM. CNA D could not verify yes or no during interview if entry in PCC was her identification and entry when shown; CNA D stated that she was assigned to Resident #3 on date of Resident #3's last documented shower, which PCC documentation indicated to have occurred on 08/22/2023 on the 2:00 PM to 10:00 PM shift. CNA D stated that she had worked on 08/22/2023 and was assigned to Resident #3 on the 2:00 PM to 10:00 PM shift. CNA D stated that although a shower is documented as having been given, with codes 3, 2 documented in the entry (corresponding key indicated that Resident #3 required physical help in part of bathing activity, code 3, and by one person, code 2) she did not give a shower to Resident #3 as entry indicated. CNA D stated that Resident #3 had refused her shower on 08/22/2023. Two of three documented initials on entry matched CNA D. Shower entry in PCC prior to 08/22/2023 was on 08/19/2023 on the 2:00 PM to 10:00 PM shift; it was revealed that the 8,8 codes that were used in the entry indicated that the activity did not occur per documentation entry codes listed on same PCC page. Other shower entries for Resident #3 indicated that on 08/17/2023 on the 2:00 PM to 10:00 PM shift, Resident #3 was given a shower, required physical help in part of bathing activity by one person (codes 3 and 2) and that initials of person documenting belonged to a male nurse aide. Entry on 08/15/2023 indicated that activity did not occur for Resident #3 and entry on 08/14/2023 indicated that activity did not occur. There were no further shower entries in PCC electronic medical record for Resident #3 for August 2023. Second interview with Resident #3 occurred on 08/25/2023 at 10:10 AM. Resident #3 recounted the events verbally as she did during first interview; Resident #3 recounting of the shower event did not change from her first interview on 08/23/23 to her second interview on 08/25/25. Resident #3 description of the perpetrator did not change from the first interview to the second interview. During interview on 08/25/2023 at 10:10 AM, Resident #3 stated that DON had come by to see her (unknown day/date). Resident #3 stated that DON advised her to speak with ADM and find out if he had spoken with alleged perpetrator. Attempted to call Family Member #2 on 08/23/2023 at 3:30 PM. Sims message (digital phone number of caller) was only available option after Family Member #2 did not answer, and phone number was sent for call back. Attempted to interview Family Member #2 on 08/24/2023 at 10:39 AM, Sims message sent (call back number sent). Attempted to call Family Member #3 on 08/23/2023 at 4:09 PM. Message left requesting call back. Attempted to call CNA B for interview on 08/23/2023 at 3:37 PM as RN A had provided phone number for facility staff person who frequently worked with Resident #3; no answer; voicemail was not an option. Attempted to call CNA B a second time for interview on 08/23/2023 at 2:27 PM, no answer to phone call and voicemail was not an option. CNA B was not working in the facility on investigation days per RN A. Record review of facility's policy titled Abuse, Neglect, and Exploitation dated October 2022 reflected Residents have the right to be free from abuse, neglect, mistreatment, misappropriation, and exploitation. Record review of facility's ANE Policy, dated October 2022, reflected The facility should attempt to take necessary steps to verify residents are protected from subsequent episodes of abuse. Upon learning of alleged abuse, neglect, mistreatment, or exploitation, the ADM or supervisor on duty should attempt to take necessary steps to verify residents are protected from subsequent episodes of abuse, neglect, mistreatment, or exploitation .and take necessary steps to protect the residents. If the investigation is conducted by a designee, the designee should report the results of the investigation to the ADM, no time frame for reporting to ADM is specified. On 8/25/23 at 05:50 PM, an Immediate Jeopardy (IJ) was identified. The ADM was notified and provided the IJ template, and a Plan of Removal (POR) was requested at that time The Facility Plan of Removal (POR) was accepted on 08/27/2023 at 10:45 AM. Monitoring of the plan of Removal included the following: Plan of Removal On 8/25/2023, at 5:45PM, [Facility] was notified of an immediate jeopardy for F600 (Free from abuse and neglect) regarding: - The facility failed to prevent further mistreatment of Resident #2 while the investigation was in progress - The facility failed to investigate a report of abuse by Resident #3 to prevent further abuse F600 Abuse and Neglect 1. Two residents were identified as being affected by deficient practice. All residents have the potential to be affected. Resident #2 discharged on 8/24/2023. On 8/25/2023, Resident #3's alleged perpetrator was put on formal suspension pending further investigation. The CNA has not been in the community since noon on 8/24/23. On 8/25/2023, director of clinical services completed skin assessment and pain data collection. No concerns or pain noted. Beginning on 8/26/23 through 8/27/2023, the regional director of clinical services provided re-education to licensed nurses and CNAs regarding showers, customer service and abuse and neglect. Licensed nurses and CNAs not available will be re-educated prior to the next shift or during orientation for new hires by the DCS or designee. 2. Beginning on 8/25/2023 and continuing through 8/26/23, DCS and/or designee conducted interviews with all current residents regarding potential abuse and/or neglect. No additional allegations of abuse or neglect were identified. Beginning on 8/25/2023 and continuing through 8/26/23, DCS and/or designee conducted pain data collections on current residents, which includes verbal and non-verbal pain. Beginning on 8/25/2023 and continuing through 8/26/23, the administrator and designee reviewed current residents' last 45 days (8/25/2023 back through 7/11/2023) of progress notes, grievances, and incidents/accidents to ensure all residents were free from abuse and neglect. No additional allegations of abuse or neglect were identified. 3. On 8/25/2023 through 8/26/2023, licensed nurses and CNAs were re-educated by the director of clinical services/designee regarding: o o Abuse, neglect, and exploitation policy including retaliation with post-test o o Reporting any suspected allegation of abuse-to-abuse coordinator (Administrator) and/or backup abuse coordinator (executive director) immediately o o Staff, residents, and/or visitors may file a formal grievance and/or concerns o o Completing a grievance form and providing to the administrator/executive director and/or designee o o When a resident voices pain during care, associates will halt care, and notify a licensed nurse to address the resident's concerns Licensed nurses and CNAs not available will be re-educated prior to the next shift by the DCS or designee. On 8/25/2023, the healthcare administrator and executive director completed re-education by Regional Director of Clinical Services (RDCS) regarding completing thorough investigations dealing with abuse, neglect, or exploitation, including suspension of alleged perpetrators pending completion of the investigation. On 8/26/2023, RN weekend supervisor was re-educated by executive director and/or designee on reporting potential allegations of abuse and/or neglect to the abuse coordinator and/or backup abuse coordinator immediately. 4. Starting on 8/25/2023, progress notes, incidents/accidents, and grievances will be reviewed daily Monday-Friday by an interdisciplinary team (executive director, healthcare administrator, DCS, ADCS, [TRUNCATED]