**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician and notify the resident's representative when there is an accident involving the resident which results in injury and had the potential for requiring physician intervention for 1 (Resident #86) of 5 residents reviewed for falls. The facility failed to notify Resident #86's physician and FM that he had a fall on [DATE]. He was found unresponsive at the facility around 6:30 AM on [DATE] and subsequently passed away.An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:23 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of serious injuries, abuse, serious harm, and death.Findings Included: Review of Resident #86's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnosis that included muscle weakness, unsteadiness on feet, unspecified abnormalities of gait and mobility, cognitive communication deficit, and muscle wasting and atrophy. Review of Resident #86's death in facility MDS dated [DATE] reflected entry/discharge reporting: death in facility. Review of Resident #86's last quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 indicating cognition intact. Section GG for functional abilities indicated Resident #86 used a wheelchair. Functional abilities related to chair/bed transfer indicated partial moderate assistance. Walking 10 feet indicated resident required substantial assistance. MDS active diagnosis included muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility. MDS assessment did not reflect Resident #86 was on hospice or end of life care. Review of Resident #86's care plan last revised [DATE] (cancelled date due to death) reflected a focus initiated on [DATE], Resident is at risk for falls related to deconditioning, gait/balance problems with interventions that included follow facility fall protocol.Review of Resident #86's progress note dated [DATE] reflected he had an unwitnessed fall at approximately 05:45 PM. After the nurse got him off the floor and into his wheelchair, an assessment was performed and there was redness on the back of his head/neck area. There is no documented evidence in the medical record that family and physician were notified. Review of Resident #86's progress note dated [DATE] reflected nurse found him unresponsive around 06:33 AM. He was awakened but not responding. CPR was initiated until EMS arrived and took over. He was resuscitated at 07:40 AM and rushed to the hospital for treatment, where he passed away shortly after.Review of Resident #86's neurological notes and observations sheet documented on paper dated [DATE] reflected LVN A initiated neuros on [DATE] at 05:45 PM and 06:05 PM. The family and physician notification was incomplete/blank. The remainer of the neuro checks were incomplete or not done. During an interview on [DATE] at 11:19 AM with Resident #86's FM, they stated the facility did not notify them that Resident #86 had a fall on [DATE]. FM stated the facility notified them on [DATE] that Resident #86 was being sent to the hospital. FM stated they observed Resident #86 at the hospital with blood residue in both his nostrils, a cut outer upper right lip, and bruises on the right side of his face on [DATE]. FM stated Resident #86 passed away in the hospital on [DATE]. During an interview on [DATE] at 2:15 PM with LVN A, she stated that on [DATE] around 5:45 PM, she heard from staff and other residents that Resident #86 fell. LVN A stated she helped Resident #86 back into his wheelchair after his unwitnessed fall. LVN A stated Resident #86 told her that he felt weak when transferring from his bed to wheelchair and fell. LVN A stated she assessed Resident #86 and observed he had redness on the back of his head/neck area. LVN A stated she did not ask Resident #86 if he hit his head during his fall. LVN A stated she could not recall notifying the physician after Resident #86 had his fall. LVN A stated she did not notify Resident #86's FM of Resident #86's fall. During an interview on [DATE] at 2:30 PM with RN K, he stated he observed Resident #86 was responsive on [DATE] around 2:00 AM. RN K stated he observed Resident #86 on [DATE] around 6:00 AM, tapped on Resident #86's shoulder, and Resident #86 was not responding. RN K stated LVN A did not communicate with him that Resident #86 had a fall on [DATE]. During an interview on [DATE] at 3:07 PM with the ADON, she stated the DON was responsible for ensuring nurses notified residents' FMs and physician after an unwitnessed fall. She stated she was unsure if LVN A notified Resident #86's FM and physician of his fall. She stated nurses were responsible for notifying residents' families and physicians that they fell. She also knew the importance of notifying family and physician and said, So they were aware of the change in condition. Physician would not be able to intervene or initiate orders if they were unaware. Family would not be able to be aware of their resident hurting themselves. During an interview on [DATE] at 4:20 PM with the Physician, he stated he was not notified Resident #86 had a fall on [DATE]. He expected to be notified of residents' falls and said, Resident could be at risk of head bleeding and head trauma and respiratory issues. During an interview on [DATE] at 2:02 PM with the DON, she stated nurses were required to notify the physician and FM after an unwitnessed fall. She knew it was important to notify family and physician after unwitnessed fall and said, Important for physician to give orders. Important for family to know so they could respond to facility or hospital.Review of the facility Abuse and Neglect Clinical Protocol last revised in [DATE] reflected:- The nurse will report findings to the physician and monitor residents.Review of the facility Change in a Residents Condition or Status policy last revised [DATE] reflected:- Physician and representative must be notified when there is an incident or accident involving the resident. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 12:23 p.m. The DON was notified of the IJ and provided the IJ template.The POR F580 was approved [DATE] at 08:16 AM and reflected the following:Plan of Removal F580Immediate JeopardyOn [DATE], regulatory services determined that The Facility failed to meet the requirements of tag F580, resulting in an Immediate Threat to resident health and safety.Action:Action: Immediate Notification Protocol ImplementationStart Date: [DATE]Completion Date: [DATE]Responsible: Consultant Registered Nurse (RN)/Director of Nursing (DON)Target Audience: All licensed nursing staffDetails: DON was educated by Consultant RN on change of conditions and F580. An audit checklist was created by Consultant RN and DON; and used to review the last 72 Hour Report for keywords pain, fall, fever, all Vital Signs, blood glucose monitoring, weights, variances, and last 14 days incident reports. These were all printed for review and notations made on report. Any change of conditions found were worked by DON and Consultant RN to verify DON comprehension. A standardized notification checklist was implemented for all incidents involving changes in resident condition. The checklist includes time-stamped documentation of family and physician contact. Charge nurses must verify completion and submit to DON daily.Evaluation: Daily audits of incident reports and 24hr report for 14 days. Daily IDT review for compliance and documentation. Nurse staff comprehension was verified and documented on competency form with comprehension statement signed by nursing staff and either DON or Consultant RN.Action:Action: Staff Education on Notification RequirementsStart Date: [DATE]Completion Date: [DATE]Responsible: DON and Consultant RNTarget Audience: All licensed nursing staff and new hires ongoingDetails: Mandatory in-service training on F580 regulations and facility policy. Evaluation: Post-training competency quiz (pass rate 90%). Random chart audits for 30 days to verify proper notification, includes documentation of audit by printing and notations to 24hr report and progress notes and/or incident report reviewed. Action:Action: Policy Review and Quality Assurance Performance ImprovementStart Date: [DATE]Completion Date: [DATE]Responsible: Administrator & DONTarget Audience: All licensed nursing staff and IDTDetails: Facility policies on change in condition and fall response reviewed. Daily EMR audit specific to Incidents and Accidents for tracking family/physician contacts and documentation. Will be documented on Compliance Monitoring Audit. Evaluation: Monthly policy compliance audits. EMR usage reports reviewed monthly during QAPI X3 months or until a revised sustainable plan for safety is achieved. Comprehension verified and documented as above for nursing staff with same Post-training competency quiz (pass rate 90%) for all IDT members . The POR was monitored in the following ways :In an interview on [DATE] at 01:00 PM with the DON she confirmed that on [DATE] she was in-serviced by the CEO (Chief Executive Officer) prior to beginning the education with all licensed nursing staff. The ADON made the decision to return to work as a floor nurse and not continue the responsibilities as a ADON and was not in-serviced by the CEO, the MDS coordinator did receive the training at the same time as the DON the in-service stated that all licensed nursing staff will receive mandatory re-education with verbal discussion and sign in sheet on the facility's fall response protocol, change in condition procedures, and abuse/neglect clinical protocols. Nurses have been directed to notify DON when any resident refuses evaluation by EMS (emergency medical services) and a post-quiz will be used for determining understanding after education is provided. In an interview on [DATE] at 01:59 PM with the DON confirmed that she was in-serviced by the NC prior to in-servicing the facility nursing staff on regarding changes in resident conditions, falls, neuro fall risk assessments, and notification to RP and MD and DON, they reviewed facility policy on acute change condition protocol, and the importance of timely and accurate documentation and notification of changes in resident conditions and identifying and documenting and communicating the changes according to facility policy. The DON said she was aware that the changes in conditions must be reported, according to the facility policy to the DON, MD/NP and RP/family, She was aware and agreed to use the action tab for risk management and follow through with documentation. She received training and education relevant to acute care planning needs and to relay all information to the ADM, DON, ADON, and MDS to make sure all acute care planning needs will be met. She received training and education on completing required resident assessments and confirmed she is competent to perform the assessments necessary, they also discussed the of care planning and updating the resident's care plans to include falls.In an interview on [DATE] at 02:54 PM with the DON she stated for the moment they have to move forward with EMS assessments until she is absolutely comfortable with the nurses ability to assess residents to make sure that residents stay safe in the event of a fall, EMS is a fall back safety measure, she can provide staff education and make them do competencies all day long - the staff need to respond with a sense of emergency, and be able to reflect they have the knowledge of what they do, right now she is using EMS for assessments until staff exhibit they can do everything appropriately.In an interview on [DATE] at 01:31 PM with NC she confirmed that she in-serviced DON prior to the DON in-servicing the nursing staff regarding changes in resident conditions, falls, neuro fall risk assessments, and notification to RP and MD and DON, they reviewed facility policy on acute change condition protocol, and the importance of timely and accurate documentation and notification of changes in resident conditions and identifying and documenting and communicating the changes according to facility policy. The DON said she was aware that the changes in conditions must be reported, according to the facility policy to the DON, MD/NP and RP/family, She was aware and agreed to use the action tab for risk management and follow through with documentation. She received training and education relevant to acute care planning needs and to relay all information to the ADM, DON, ADON, and MDS to make sure all acute care planning needs will be met. She received training and education on completing required resident assessments and confirmed she is competent to perform the assessments necessary. They also discussed the of care planning and updating the resident's care plans to include fallsIn an interview on [DATE] at 11:45 AM DON stated most of the nurses are trained and retrained on neuro check and post fall evaluation. She stated they were trained on reporting to physician and family in a timely manner. DON stated the daily meeting the fall and other related issues evaluated, and necessary actions taken. There was no fall or incident of any significant changes in condition. Resident #3 had a fall on [DATE] and was reviewed and all the necessary steps were taken after the fall. She stated during the review it was revealed the care plans were not updated, not just for fall but also for various other issues. She stated the care plans were updated accordingly. The external NC will be supervising and monitoring the activities to ensure things are going in the right track.In an interview on [DATE] at 03:12PM with NC, she stated she in serviced and trained DON . She stated she had interviewed the nursing staff in the weekends as well to make sure they learnt everything that they supposed to. She stated she was happy with the outcome and will monitor and guide them to optimize their competencyThe following nurses were interviewed and observed working on PCC completing neuro checks and post fall evaluation. They were able to navigate the neuro check and post fall evaluation form on E H R (PCC). They were able to explain how to fill them out and the rationale and significance of the findings during the evaluation . They were able to identify a significant change and when to notify a physician /or call EMS Able to answer randomly asked post training quiz questions. See below:In an interview on [DATE] at 01:00 PM with RN O, - Full time started [DATE] During the interview stated: Got received the training [DATE] trained . Previously was doing neuro checks on paper form and then hand over to DON. Now got trained to do directly on the EH R.In an interview on [DATE] at 01:15 PM RN G - PRN -[DATE] During the interview stated: Trained on [DATE] and was trained on neuro check, post fall evaluation and incident report was to be completed. Neuro check to be continued for 3 days, she stated she was previously doing on paper , now on both , first on paper and then on PCC. Stated confident to do neuro and post fall evaluation. Neuro check initially every 15minutes.In an interview on [DATE] at 01:45 PM with LVN I Trained on [DATE]. During the interview stated: Interview over the phone, able to answer quiz questions. Able to explain neuro check and post fall process and procedures. Stated able to coordinate care independently.In an interview on [DATE] at 01:55 PM with LVN B, Trained on [DATE]. During the interview stated : She was doing after the fall evaluation and neuro check before too. Stated she was confident enough to conduct oneIn an interview on [DATE] at 02:35 PM with MDS Coordinator, LVN Trained on [DATE]. During the interview stated she received the trainings for the post fall procedures and how to enter the information in the E H R. In an interview on [DATE] at 02:35 PM with LVN P Interview over the phone. Nurse for 7 years. Done post fall evaluation and neuro checks before. Received the training on [DATE] from the facility. Stated she was able to conduct a post fall procedure independentlyReview of the facility's in-services and post-training quizzes reflected staff were reeducated and returned demonstration of competencies with F580 and facility protocols. Additionally, the following care plans/ assessments had been updated by the facility - Resident #65Resident #100Resident #66Resident #49Resident #27Resident #3Resident #7Resident #19Resident #11Resident #14Resident #6Resident #12These failures resulted in an identification of an Immediate Jeopardy (IJ) with the DON notified and IJ Template provided on [DATE] at 12:23 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and 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 protect a resident's right to be free from neglect for 1 (Resident #86) of 5 residents reviewed for resident neglect. The facility failed to ensure Resident #86 was free from neglect when nursing staff failed to conduct ongoing neuro checks and monitor for delayed complications after an unwitnessed fall with head injury that occurred on [DATE]; and document in the residents' chart changes in condition, notify the family and physician, and follow facility fall protocol per policy and residents person centered care plan. He was found unresponsive around 6:30 AM on [DATE] and subsequently passed away. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:00 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents at risk for serious injuries, abuse, serious harm, and death.Findings include: Review of Resident #86's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included muscle weakness, unsteadiness on feet, unspecified abnormalities of gait and mobility, cognitive communication deficit, and muscle wasting and atrophy. Review of Resident #86's last quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 indicating cognition was intact. Section GG for functional abilities indicated Resident #86 used a wheelchair. Functional abilities related to chair/bed transfer indicated partial moderate assistance. Walking 10 feet indicated resident required substantial assistance. MDS active diagnoses included muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility. MDS assessment did not reflect Resident #86 was on hospice or end of life care. Resident #86 had no falls since admission. Review of Resident #86's care plan reflected a focus initiated on [DATE], Resident is at risk for falls related to deconditioning, gait/balance problems with interventions that included follow facility fall protocol. Review of Resident #86's progress note, created by LVN A on [DATE], reflected he had an unwitnessed fall at approximately 05:45 PM. After the nurse got him off the floor and into his wheelchair, an assessment was performed and there was redness on the back of his head/neck area. There was no documented evidence in the medical record that neuros were conducted and completed, and family and physician were notified. Review of Resident #86's progress note, created by RN K on [DATE], reflected nurse found him unresponsive around 06:33 AM. He was awakened but not responding. CPR was initiated until EMS arrived and took over. He was resuscitated at 07:40 AM and rushed to the hospital for treatment, where he passed away shortly after. Review of Resident #86's fall risk evaluations reflected there was no fall risk/post fall evaluation for the fall that occurred on [DATE], and the last evaluation conducted was dated [DATE]. Review of Resident #86's progress notes and EMR reflected no documented follow up for delayed complications related to the fall (generally completed for up to 48 hours post fall) and no assessments by nurse or PT for observing resident rise from chair post fall (to test if decline in strength/abilities or changes in status). Review of Resident #86's neurological notes and observations sheet documented on paper dated [DATE] reflected LVN A initiated neuros monitoring on [DATE] at 05:45 PM and 06:05 PM. The family and physician notification was incomplete/blank. The remainder of the neuro checks were incomplete or not done. Review of Resident #86's death in facility MDS dated [DATE] reflected entry/discharge reporting: death in facility. During an interview on [DATE] at 11:19 AM with Resident #86's FM, they stated the facility did not notify them that Resident #86 had a fall on [DATE]. FM stated the facility notified them on [DATE] that Resident #86 was being sent to the hospital. FM stated they observed Resident #86 at the hospital with blood residue in both his nostrils, a cut to his outer upper right lip, and bruises on the right side of his face on [DATE]. FM stated Resident #86 passed away in the hospital on [DATE] at 8:57 a.m. During an interview on [DATE] at 2:15 PM with LVN A, she stated that on [DATE] around 5:45 PM, she heard from staff and other residents that Resident #86 fell. LVN A stated she helped Resident #86 back into his wheelchair after his unwitnessed fall. LVN A stated Resident #86 told her that he felt weak when transferring from his bed to wheelchair and fell. LVN A stated she could not recall notifying the physician after Resident #86 had his fall. LVN A stated she did not notify Resident #86's FM of Resident #86's fall. LVN A stated she notified the DON when the incident happened. LVN A stated she assessed Resident #86 and observed he had redness on the back of his head/neck area. LVN A stated she did not ask Resident #86 if he hit his head during his fall. LVN A stated she believed she initiated neurological monitoring on Resident #86. LVN A stated nurses were responsible for initiating and conducting ongoing neurological monitoring on residents every 30 minutes when they have an unwitnessed fall. LVN A stated the ADON and DON were responsible for ensuring nurses initiated and conducted ongoing neurological monitoring after a resident had an unwitnessed fall. LVN A stated she knew the importance of initiating and conducting ongoing neurological monitoring for residents with falls and said, To make sure their vitals were stable. Resident could be at risk of a blood clot. She could not recall if not initiating and conducting ongoing neuro checks after an unwitnessed fall and not notifying family and physician was neglect. She defined neglect as not taking care of a resident or abusing a resident. During an interview on [DATE] at 2:30 PM with RN K, he stated he observed Resident #86 was responsive on [DATE] around 2:00 AM. RN K stated he observed Resident #86 on [DATE] around 6:00 AM, tapped on Resident #86's shoulder, and Resident #86 was not responding. RN K stated LVN A did not communicate with him that Resident #86 had a fall on [DATE]. RN K stated he did not initiate and conduct neurological monitoring on Resident #86 because he did not know Resident #86 had a fall on [DATE]. RN K stated nurses were responsible for initiating and conducting ongoing neurological monitoring on residents if residents had an unwitnessed fall. RN K explained nurses were responsible for following the neurological monitoring frequency listed on the neurological monitoring sheet when initiating and conducting ongoing neurological monitoring. RN K stated the DON was responsible for ensuring the nurses initiated and conducted ongoing neurological monitoring after a resident had an unwitnessed fall. RN K stated he told the DON that LVN A needed to be put back on training due to not performing neurological monitoring on Resident #86 after the fall. RN K stated he knew the importance of initiating and conducting ongoing neurological monitoring for residents with falls and said, Because resident could have hit his head and had a brain injury and to know that resident did not have damage to his head and to determine if resident needs to go to the hospital. Resident could be at risk of brain injury. He believed not initiating and conducting ongoing neurological monitoring after a resident had an unwitnessed fall was neglect. He defined neglect as failure of NF not providing care and services to a resident. During an interview on [DATE] at 3:07 PM with the ADON, she stated she was unable to find Resident #86's neurological monitoring sheets after his fall on [DATE]. She stated Resident #86's neurological monitoring sheets were started on [DATE] by LVN A and were not finished. She stated RN K was supposed to continue Resident #86's neurological monitoring. She stated nurses were responsible for initiating and conducting ongoing neurological monitoring after a resident had an unwitnessed fall and followed the frequency on the neurological monitoring sheet. She stated the DON was responsible for ensuring nurses initiated and conducted ongoing neurological monitoring on residents and notified residents' FMs and physician after an unwitnessed fall. She stated she was unsure if LVN A notified Resident #86's FM and physician of his fall. She knew the importance of initiating and conducting ongoing neurological monitoring on residents after an unwitnessed fall and said, Because resident could have brain injury, brain bleeding, abnormal vital signs, pain or fracture from fall. Residents could be at risk of going unconscious, brain bleed that staff unaware of, fracture, stroke, and develop infection if not completing neuro checks on them. She also stated nurses were responsible for notifying residents' families and physicians that they fell. She also knew the importance of notifying family and physician and said, So they were aware of the change in condition. Physician would not be able to intervene or initiate orders if they were unaware. Family would not be able to be aware of their resident hurting themselves. Not initiating and conducting ongoing neurological monitoring after a resident had an unwitnessed fall was neglect. She defined neglect as not caring or not carrying out duties as a nurse, and not tending to the resident. During an interview on [DATE] at 3:26 p.m., LVN M stated nurses were responsible for initiating and conducting ongoing neurological monitoring after an unwitnessed fall. LVN M stated nurses were responsible for documenting neurological monitoring, submitting the completed sheets to the MR, and the MR uploads the sheets in the resident's EMR. LVN M stated the ADON or DON were responsible for ensuring nurses initiated and conducted ongoing neurological monitoring after a resident had an unwitnessed fall. LVN M stated he knew the importance of initiating and conducting ongoing neurological monitoring on residents after an unwitnessed fall and said, Because resident could be on blood thinners or for signs or symptoms of change in condition so they could be sent out to the hospital or they could have high blood pressure. Residents could be at risk of brain bleed, fracture, and other injuries. LVN M stated not initiating and conducting ongoing neurological monitoring after a resident had an unwitnessed fall was neglect. LVN M stated he defined neglect as when not showing up for the resident in a way they needed to be shown up for and not tending to residents' needs. During an interview on [DATE] at 4:20 PM with the Physician, he stated he was not notified Resident #86 had a fall on [DATE]. He expected to be notified of residents' falls. He stated nurses were required to initiate neurological monitoring after an unwitnessed fall and said, Resident could be at risk of head bleeding and head trauma and respiratory issues. During an interview on [DATE] at 10:35 AM with the DON, she stated she did not believe the fall protocol was followed in this case. She stated it is the expectation that post fall assessments are completed and documented after a fall and that the nurse assessing the fall or PT assess the resident's ability to rise from his/her wheelchair. She stated a negative outcome of not following the fall protocol/ procedures are negative deficits are increased up to and including death. DON stated LVN A completed neurological checks for the time left on her shift (only 1 hour) and were documented on paper not on the resident's chart as it should have been. She stated the checks that should have occurred after LVN A left were not completed. During an interview [DATE] at 11:13 AM with LVN A, she stated Resident #86 was able to stand and self-transfer from his bed to his wc on a normal day. She stated after his fall on [DATE] redness was noted to his head and she suspected head injury. LVN A stated after the fall Resident #86 refused to go to the hospital and instead went outside. LVN A stated she documented the fall in the nursing progress notes but did not do an incident report as the charge nurse on duty, and only provided an oral report to the DON. She stated she was aware of the care plan intervention but did not have the knowledge of the facility's fall protocol or procedures and was not aware of the assessments she had to complete. LVN A also stated she lacked the knowledge of using the EMR system for the facility and only received 3 days of training before being allowed on the floor as the charge nurse. She stated therefore she did not know how to properly document the assessments required after a fall and lacked the knowledge of what assessments were required. LVN A stated she only completed checks on Resident #86 for the 1 hour she had left on her shift and left at 7pm. She stated those were documented on paper and not the resident's chart. In an interview on [DATE] at 12:57 PM with the ADON, she stated it was the expectation that all falls were documented on the EMR and post fall assessments and incident reports completed. She stated she is not sure why it was not documented in there by LVN A. ADON stated that if LVN A does not know how to conduct the assessments from the EMR system that it was her expectation that LVN A asked for assistance. ADON stated the nurse doing the assessment on the resident post fall should also do the wc stand up assessment to test any decline in strength or abilities. She stated the care plan reflects the care that is supposed to be provided to residents, and it was not followed in this case since following the fall protocol was an intervention. ADON stated post fall assessments include neuro checks, vitals such as pulse, respirations, checking motor skills, pupils reaction, overall alertness and any changes to baseline. She stated a potential negative outcome to the resident if the fall protocols and procedures are not followed would be the resident can have a brain bleed, internal issues they are not aware of, fractures, or infections from fractures. In an interview on [DATE] at 03:00 PM with the DON, she reiterated that the fall protocol was not followed as it pertained to the incident on [DATE] with Resident #86. The DON stated that it was her expectation that the nurses were competent in following a resident's care plan because failure to follow it would result in the residents not getting the care they need. She stated it was her expectation that if a nurse encounters something they do not know how to do such as assessments, placing orders, or working in the EMR that they ask for help. She stated staff should be reaching out to her to get instructions on how to do it. In an interview on [DATE] at 03:38 PM with the ADM, she stated it was her expectation that before a nurse goes to the floor to work with residents she is provided competencies that include training on where you go in the EMR to generate assessments, knowledge on the facility's policies and procedures, and know that they must ask questions if there is something they don't know. The ADM stated that failure to have competent nurse staffing, not completing assessments, following care plans, or facility policy results in residents not having the opportunity to be provided appropriate care. She stated that as the new ADM she is providing the facility with her expectations on the education that must be completed to ensure residents are being provided the appropriate care, and ongoing education that will be provided to direct care staff. Review of the facility Care Plans, Comprehensive Person Centered last revised [DATE] reflected:Policy statement: A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. - The Interdisciplinary Team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. - The comprehensive person-centered care plan will: o describe the services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being.o Incorporate identified problem areas.o Identify the professional services that are responsible for each element of care. - Assessments of the residents are ongoing and care plans are revised as information about the resident and the resident's conditions change. Review of the facility Abuse and Neglect Clinical Protocol last revised in [DATE] reflected:- Neglect, as defined at S483.5, means the failure of the facility, its employees or service providers to- provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or- emotional distress.- The nurse will report findings to the physician and monitor residents. Review of the facility Change in a Residents Condition or Status policy last revised [DATE] reflected:- Physician and representative must be notified when there is an incident or accident involving the resident. Review of the facility Falls-Clinical Protocol last revised [DATE] reflected:- A nurse shall assess and document/ report the following: vital signs, musculoskeletal function, observing changes in normal range of motion, weight bearing etc., change in cognition or level of consciousness, neurological status, pain.- Monitoring and follow up: the staff with the physician's guidance will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. Review of facility Assessing Falls and Their Cause policy revised [DATE] reflected: Purpose- to provide guidelines for assessing a resident fall and to assist staff in identifying causes of the fall. - After a fall- observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall and will document findings in the medical record. - Document any observed signs or symptoms of swelling, bruising, deformity, and/or decreased mobility and any changes to level responsiveness/ consciousness and overall function. Note the presence or absence of significant findings. - Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report should be completed by the nursing supervisor on duty at the time and submitted to the DON.Performing a post fall evaluation:- After a first fall, a nurse and/or physical therapist will watch the resident attempt to rise from a chair without using his or her arms, walk several paces, and return to sitting, and will document the results ofthis effort. If the individual has no difficulty or unsteadiness, no further evaluation is needed at that time. If the individual has difficulty or is unsteady in performing this test, additional evaluation may be initiated as warranted. These failures resulted in an identification of an Immediate Jeopardy (IJ) On [DATE] at 05:00 PM. The ADM was notified of the IJ and provided the IJ template on [DATE] at 5:00 p.m. The POR F600 was approved [DATE] at 06:07 PM and reflected the following:Plan of Removal (POR)Immediate Jeopardy - F600: Neglect On [DATE], an abbreviated survey was initiated at The Facility. On [DATE], The surveyor determined that the Facility was in Immediate Jeopardy (IJ) due to noncompliance with Tag F600 - Neglect, resulting in the death of Resident #86. The facility failed to follow its own policies and procedures regarding post-fall assessments, including conducting ongoing neurological checks, notifying the resident's family, and notifying the physician after an unwitnessed fall on [DATE]. Resident #86 was found unresponsive the following morning and passed away shortly thereafter.Date of Immediate Jeopardy Notification: [DATE]Tag: F600 - The facility must ensure residents are free from neglect.Immediate Jeopardy Summary:On [DATE], Resident #86 experienced an unwitnessed fall and hit his head. The facility failed to conduct ongoing neurological checks, notify the family, and notify the physician. The resident was found unresponsive the following morning and passed away shortly after. Interviews and documentation revealed systemic failures in communication, assessment, and adherence to facility protocols, constituting neglect.Actions to Remove Immediate JeopardyAction 1: Immediate Staff Education and Re-EducationDescription: DON(Director of Nursing) will be re-educated by CEO (Chief Executive Officer) prior to beginning of education with all licensed nursing staff, including PRN and possible agency staff prior to next shift worked. ADON (Assistant Director of Nursing) and MDS (Minimum Data Set) Nurse will be initially educated by DON after DON education. All licensed nursing staff will receive mandatory re-education with verbal discussion and sign in sheet on the facility's fall response protocol, change in condition procedures, and abuse/neglect clinical protocols. Nurses have been directed to notify DON when any resident refuses evaluation by EMS(emergency medical services). A Post- Quiz will be used for determining understanding after education is provided. Start Date: [DATE]Completion Date: [DATE]Responsible: Director of Nursing (DON)/MDS Coordinator/ADONAction 2: Implementation of Neuro Check Audit SystemDescription: A neuro check audit log will be implemented to ensure all required neurological assessments are completed and documented following any fall, especially unwitnessed ones or known head injuries. All licensed nursing staff have been notified by mass group messaging app- response in acknowledgement has been requested. If no response- DON/Designee will complete calls to each nurse who fails to acknowledge and send report of follow up call to administrator for tracking purposes. ADON will be responsible for maintaining Neuro log. DON has educated ADON on completing and maintaining Neuro Audit Log, including how to fill out audit form during clinical review in morning clinical meeting. ADON will provide overview of log during fall review component of morning clinical meeting; it will only be completed on residents with unwitnessed falls or with known head injuries. Should the ADON be unavailable, DON will maintain and provide overview. Start Date: [DATE]Completion Date: [DATE]Responsible: Assistant Director of Nursing (ADON)/DONAction 3: Mandatory Notification Protocol EnforcementDescription: All nursing staff will be required to notify the physician and family immediately following any fall. A notification checklist is included in the incident report form to ensure compliance. This is a checklist only and does not require competencies to be completed for training. Only notification of implementation- via secure messaging app with read receipts turned on. It will also be added to the Neuro audit logs for review each morning during the clinical meeting. Initial notice was provided via mass group messaging app. Re-education on fall protocol, neuro implementation, log and risk management checklist will be provided from DON to Designee and then to all other licensed nursing staff (including new hires and possible agency) prior to next shift worked. A comprehensive post-Quiz with included topics will be used for determining understanding after education is provided. Nursing has also been reminded of policy to complete walking rounds and review of shift change over (24 hour report) and group acknowledgement has been required as above. When nursing is observed out of compliance by DON/ADON, 1 on 1 disciplinary action will ensue.Start Date: [DATE]Completion Date: [DATE]Responsible: DON/DesigneeAction 4: Daily Clinical Review of All FallsDescription: The interdisciplinary team will conduct daily reviews of all falls to verify that neuro checks, notifications, and documentation are complete and timely. IDT consists of entire leadership team depending on availability: Administrator, DON, ADON, therapy, social services, activities, dietary and housekeeping/maintenance. This will be documented on an Audit Log daily until system maintenance is achieved and plan is completed per QAPI below. Start Date: [DATE]Completion Date: [DATE]Responsible: DON, ADON, AdministratorAction 5: Quality Assurance and Performance Improvement (QAPI) IntegrationDescription: The incident and corrective actions were reviewed during ad hoc QAPI meeting. A root cause analysis will be conducted, and long-term strategies will be developed to prevent recurrence. A second ad hoc took place on [DATE] via teleconference to directly review policy on nursing communication; committee agreed that policy changes do not need to take place at present; nursing will be held accountable by disciplinary action for variance from required walking rounds and review of 24 hour report during shift change over. Will continue to be reviewed in monthly QAPI x3 or until revised plan is reached to sustain ongoing maintenance. Start Date: [DATE]Completion Date: [DATE]Responsible: CEO/Administrator The POR was monitored in the following ways: In an interview on [DATE] at 12:20 PM with CEO and DON, they notified surveyors LVN A had resigned effective [DATE] and would no longer be coming in. In an interview on [DATE] at 01:00 PM with the DON she confirmed that on [DATE] she was in-serviced by the CEO (Chief Executive Officer) prior to beginning the education with all licensed nursing staff. The ADON made the decision to return to work as a floor nurse and not continue the responsibilities as a ADON and was not in-serviced by the CEO. The MDS coordinator did receive the training at the same time as the DON. The in-service stated that all licensed nursing staff will receive mandatory re-education with verbal discussion and sign in sheet on the facility's fall response protocol, change in condition procedures, and abuse/neglect clinical protocols. Nurses have been directed to notify DON when any resident refuses evaluation by EMS (emergency medical services) and a post-quiz will be used for determining understanding after education is provided. In an interview on [DATE] at 01:59 PM with the DON confirmed that she was in-serviced by the NC prior to in-servicing the facility nursing staff on changes in resident conditions, falls, neuro fall risk assessments, and notification to RP and MD and DON. They reviewed facility policy on acute change condition protocol, and the importance of timely and accurate documentation and notification of changes in resident conditions and identifying and documenting and communicating the changes according to facility policy. The DON said she was aware that the changes in conditions must be reported, according to the facility policy to the DON, MD/NP and RP/family. She was aware and agreed to use the action tab for risk management and follow through with documentation. She received training and education relevant to acute care planning needs and to relay all information to the ADM, DON, ADON, and MDS to make sure all acute care planning needs will be met. She received training and education on completing required resident assessments and confirmed she is competent to perform the assessments necessary. They also discussed the care planning and updating the resident's care plans to include falls.In an interview on [DATE] at 02:54 PM with the DON she stated for the moment they have to move forward with EMS assessments until she is absolutely comfortable with the nurses' ability to assess residents to make sure that residents stay safe in the event of a fall. EMS is a fall back safety measure. She can provide staff education and make them do competencies all day long - the staff need to respond with a sense of emergency, and be able to reflect they have the knowledge of what they should do. Right now she is using EMS for assessments until staff exhibit they can do everything appropriately.In an interview on [DATE] at 01:31 PM with NC she confirmed that she in-serviced DON prior to the DON in-servicing the nursing staff regarding changes in resident conditions, falls, neuro fall risk assessments, and notification to RP and MD and DON. They reviewed facility policy on acute change condition protocol, and the importance of timely and accurate documentation and notification of changes in resident conditions and identifying and documenting and communicating the changes according to facility policy. The DON said she was aware that the changes in conditions must be reported, according to the facility policy to the DON, MD/NP and RP/family. She was aware and agreed to use the action tab for risk management and follow through with documentation. She received training and education relevant to acute care planning needs and to relay all information to the ADM, DON, ADON, and MDS to make sure all acute care planning needs will be met. She received training and education on completing required resident assessments and confirmed she is competent to perform the assessments necessary. They also discussed the care planning and updating the resident's care plans to include fallsIn an interview on [DATE] at 11:45 AM DON stated most of the nurses are trained and retrained on neuro check and post fall evaluation. She stated they were trained on reporting to physician and family in a timely manner. DON stated that during their daily meeting falls and other related issues were evaluated, and necessary actions were taken. There was no fall or incident of any significant changes in condition. Resident #3 had a fall on [DATE] and was reviewed and all the necessary steps were taken after the fall. She stated during the review it was revealed the care plans were not updated, not just for fall but also for various other issues. She stated the care plans were updated accordingly. The external NC will be supervising and monitoring the activities to ensure things are going in the right track.In an interview on [DATE] at 03:12PM with NC, she stated she in serviced and trained DON . She stated she had interviewed the nursing staff on the weekend as well to make sure they learned everything that they were supposed to. She stated she was happy with the outcome and will monitor and guide them to optimize their competency.The following nurses were interviewed and observed working on PCC completing neuro checks and post fall evaluation. They were able to navigate the neuro check and post fall evaluation form on E H R (PCC). They were able to explain how to fill them out and the rationale and significance of the findings during the evaluation . They were able to identify a significant change and when to notify a physician /or call EMS, additionally staff were able to answer randomly asked post training quiz questions. See below:In an interview on [DATE] at 01:00 PM with RN O, - Full time started [DATE] During the interview she stated: she received the training [DATE]. She stated she was previously doing neuro checks on paper form and then would hand it over to DON. Now she got trained to do the documentation directly on the EH R. She stated she knew to immediately report ANE to the ANE coordinator who was the ADM. In an interview on [DATE] at 01:15 PM RN G - PRN -[DATE] During the interview stated: she received training on [DATE] and was trained on neuro check, post fall evaluation and incident report was to be completed. Neuro check to be continued for 3 days, she stated she was previously doing charting on paper , now on both , first on paper and then on PCC. Stated she is confident in doing neuro and post fall evaluations. She stated neuro check are complet[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assure that all nursing staff possess the competencies, and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being for 1 (Resident #86) of 5 residents reviewed. - The facility failed to ensure nursing staff were competent to conduct ongoing neuro checks, notify the family, and notify the physician after Resident #86 had an unwitnessed fall and hit his head on [DATE]. He was found unresponsive around 6:30 AM on [DATE] and subsequently passed away.- The facility failed to ensure nursing staff were competent to complete a fall risk assessment/ post fall evaluation For Resident #86 following a fall [DATE] (last one documented dated [DATE]).- The facility failed to ensure LVN A had competency on fall risk policies, procedures, conducting assessments, and knowledge of EMR system used. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 12:23 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents who have a fall at risk for a significant change in condition up to and including death. Findings included: Review of Resident #86's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included muscle weakness, unsteadiness on feet, unspecified abnormalities of gait and mobility, cognitive communication deficit, and muscle wasting and atrophy. Review of Resident #86's death in facility MDS dated [DATE] reflected entry/discharge reporting: death in facility. Review of Resident #86's last quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 indicating cognition intact. Section GG for functional abilities indicated Resident #86 used a wheelchair. Functional abilities related to chair/bed transfer indicated partial moderate assistance. Walking 10 feet indicated resident required substantial assistance. MDS active diagnosis included muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility. MDS assessment did not reflect Resident #86 was on hospice or end of life care. Review of Resident #86's care plan last revised [DATE] (cancelled date due to death) reflected a focus initiated on [DATE], Resident is at risk for falls related to deconditioning, gait/balance problems with interventions that included follow facility fall protocol. Review of Resident #86's progress note dated [DATE] reflected he had an unwitnessed fall at approximately 05:45 PM. After the nurse got him off the floor and into his wheelchair, an assessment was performed and there was redness on the back of his head/neck area. There is no documented evidence in the medical record that neuros were conducted, and family and physician were notified. Review of Resident #86's progress note dated [DATE] reflected nurse found him unresponsive around 06:33 AM. He was awakened but not responding. CPR was initiated until EMS arrived and took over. He was resuscitated at 07:40 AM and rushed to the hospital for treatment, where he passed away shortly after. Review of Resident #86's fall risk evaluations reflected there was no fall risk/post fall evaluation for the fall that occurred on [DATE], and the last evaluation conducted was dated [DATE]. Review of Resident #86's progress notes and EMR reflected no documented follow up for delayed complications related to the fall (completed for up to 48 hours post fall) and no assessments by nurse or PT for observing resident rise from chair post fall (to test if decline in strength/abilities or changes in status). Review of Resident #86's neurological notes and observations sheet documented on paper dated [DATE] reflected LVN A initiated neuros on [DATE] at 05:45 PM and 06:05 PM. The family and physician notification was incomplete/blank. The remainer of the neuro checks were incomplete or not done. During an interview on [DATE] at 11:19 AM, with Resident #86's FM, they stated the facility did not notify them that Resident #86 had a fall on [DATE]. The FM stated the facility notified them on [DATE] that Resident #86 was being sent to the hospital. The FM stated they observed Resident #86 at the hospital with blood residue in both his nostrils, a cut outer upper right lip, and bruises on the right side of his face on [DATE]. FM stated Resident #86 passed away in the hospital on [DATE]. During an interview on [DATE] at 2:15 PM with LVN A, she stated that on [DATE] around 5:45 PM, she heard from staff and other residents that Resident #86 fell. LVN A stated she helped Resident #86 back into his wheelchair after his unwitnessed fall. LVN A stated Resident #86 told her that he felt weak when transferring from his bed to wheelchair and fell. LVN A stated she could not recall notifying the physician after Resident #86 had his fall. LVN A stated she did not notify Resident #86's FM of Resident #86's fall. LVN A stated she assessed Resident #86 and observed he had redness on the back of his head/neck area. LVN A stated she did not ask Resident #86 if he hit his head during his fall. LVN A stated she believed she initiated neurological monitoring on Resident #86. LVN A stated nurses were responsible for initiating and conducting ongoing neurological monitoring on residents every 30 minutes when they have an unwitnessed fall. LVN A stated the ADON and DON were responsible for ensuring nurses initiated and conducted ongoing neurological monitoring after a resident had an unwitnessed fall. LVN A stated she knew the importance of initiating and conducting ongoing neurological monitoring for residents with falls and said, To make sure their vitals were stable. Resident could be at risk of a blood clot. During an interview on [DATE] at 2:30 PM with RN K, he stated he observed Resident #86 was responsive on [DATE] around 2:00 AM. RN K stated he observed Resident #86 on [DATE] around 6:00 AM, tapped on Resident #86's shoulder, and Resident #86 was not responding. RN K stated LVN A did not communicate with him that Resident #86 had a fall on [DATE]. RN K stated he did not initiate and conduct neurological monitoring on Resident #86 because he did not know Resident #86 had a fall on [DATE]. RN K stated nurses were responsible for initiating and conducting ongoing neurological monitoring on residents if residents had an unwitnessed fall. RN K stated the DON was responsible for ensuring the nurses initiated and conducted ongoing neurological monitoring after a resident had an unwitnessed fall. RN K stated he told the DON that LVN A needed to be put back on training due to not performing neurological monitoring on Resident #86 after the fall. RN K stated he knew the importance of initiating and conducting ongoing neurological monitoring for residents with falls and said, Because resident could have hit his head and had a brain injury and to know that resident did not have damage to his head and to determine if resident needs to go to the hospital. Resident could be at risk of brain injury. During an interview on [DATE] at 3:07 PM with the ADON, she stated she was unable to find Resident #86's neurological monitoring sheets after his fall on [DATE]. She stated Resident #86's neurological monitoring sheets were started on [DATE] by LVN A and were not finished. She stated RN K was supposed to continue Resident #86's neurological monitoring. She stated nurses were responsible for initiating and conducting ongoing neurological monitoring after a resident had an unwitnessed fall. She stated the DON was responsible for ensuring nurses initiated and conducted ongoing neurological monitoring on residents and notified residents' FMs and physician after an unwitnessed fall. She stated she was unsure if LVN A notified Resident #86's FM and physician of his fall. She knew the importance of initiating and conducting ongoing neurological monitoring on residents after an unwitnessed fall and said, Because resident could have brain injury, brain bleeding, abnormal vital signs, pain or fracture from fall. Residents could be at risk of going unconscious, brain bleed that staff unaware of, fracture, stroke, and develop infection if not completing neuro checks on them. She also stated nurses were responsible for notifying residents' families and physicians that they fell. She also knew the importance of notifying family and physician and said, So they were aware of the change in condition. Physician would not be able to intervene or initiate orders if they were unaware. Family would not be able to be aware of their resident hurting themselves. During an interview on [DATE] at 4:20 PM, with the Physician, he stated he was not notified Resident #86 had a fall on [DATE]. He expected to be notified of residents' falls. He stated nurses were required to initiate neurological monitoring after an unwitnessed fall and said, Resident could be at risk of head bleeding and head trauma and respiratory issues. During an interview on [DATE] at 10:35 AM, with the DON, she stated she did not believe the fall protocol was followed in this case. She stated it is the expectation that post fall assessments are completed and documented after a fall and that the nurse assessing the fall or PT assess the resident's ability to rise from his/her wheelchair. She stated a negative outcome of not following the fall protocol/ procedures are negative deficits are increased up to and including death. DON stated LVN A completed neurological checks for the time left on her shift (only 1 hour) and were documented on paper not on the residents chart as it should have been, she stated the checks that should have occurred after LVN A left were not completed. During an interview [DATE] at 11:13AM, with LVN A, she stated Resident #86 was able to stand and self-transfer from his bed to his WC on a normal day. She stated after his fall on [DATE] redness was noted to his head and she suspected head injury. LVN A stated after the fall Resident #1 refused to go to the hospital and instead went outside. LVN A stated she documented the fall in the nursing progress notes but did not do an incident report as the charge nurse on duty, and only provided an oral report to the DON. She stated she was aware of the care plan intervention but she did not have the knowledge of the facilities fall protocol or procedures and was not aware of the assessments she had to complete. LVN A also stated she lacked the knowledge of using the EMR system for the facility and only received 3 days of training before being allowed on the floor as the charge nurse, she stated therefore she did not know how to properly document the assessments required after a fall and lacked the knowledge of what assessments were required. LVN A stated she only completed checks on Resident #86 for the 1 hour she had left on her shift and left at 7pm, she stated those were documented on paper and not the resident's chart. In an interview on [DATE] at 12:57 PM, with the ADON, she stated it was the expectation that all falls were documented on the EMR and post fall assessments and incident reports completed, she stated she is not sure why it was not documented in here by LVN A. The ADON stated that if LVN A does not know how to conduct the assessments from the EMR system that it was her expectation that LVN A asked for assistance. The ADON stated the nurse doing the assessment on the resident post fall should also do the WC stand up assessment to test any decline in strength or abilities. She stated the care plan reflects the care that is supposed to be provided to residents, and it was not followed in this case since following the fall protocol was an intervention. The ADON stated post fall assessments include neuro checks, vitals such as pulse, respirations, checking motor skills, pupil reaction, overall alertness and any changes to baseline. She stated a potential negative outcome to the resident if the fall protocols and procedures are not followed would be the resident can have a brain bleed, internal issues they are not aware of, fractures, or infections from fractures. In an interview on [DATE] at 03:00 PM, with the DON, she reiterated that the fall protocol was not followed as it pertained to the incident on [DATE] with Resident #86. The DON stated that it was her expectation that the nurses were competent in following a residents care plan because failure to follow it would result in the residents not getting the care they need. She stated it was her expectation that if a nurse encounters something they do not know how to do such as assessments, placing orders, or working in the EMR that they ask for help. She stated staff should be reaching out to her to get instructions on how to do it. In an interview on [DATE] with the ADM she stated it was her expectation that before a nurse goes to the floor to work with residents she is provided competencies that include training on where you go in the EMR to generate assessments, knowledge on the facilities policies and procedures, and know that they must ask questions if there is something they don't know. The ADM stated that failure to have competent nurse staffing, not completing assessments, following care plans, or facility policy results in residents not having the opportunity to be provided appropriate care. She stated that as the new ADM she is providing the facility with her expectations on the education that must be completed to ensure residents are being provided the appropriate care, and ongoing education that will be provided to direct care staff. Review of the facility Abuse and Neglect Clinical Protocol last revised in [DATE] reflected:- The nurse will report findings to the physician. Review of the facility Change in a Residents Condition or Status policy last revised [DATE] reflected:- Physician and representative must be notified when there is an incident or accident involving the resident. Review of the facility Falls-Clinical Protocol last revised [DATE] reflected:- A nurse shall assess and document/ report the following: vital signs, musculoskeletal function, observing changes in normal range of motion, weight bearing etc., change in cognition or level of consciousness, neurological status, pain.- Monitoring and follow up: the staff with the physician's guidance will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. Review of facility Assessing Falls and Their Cause policy revised [DATE] reflected: Purpose- to provide guidelines for assessing a resident fall and to assist staff in identifying causes of the fall. - After a fall- observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall and will document findings in the medical record. - Document any observed signs or symptoms of swelling, bruising, deformity, and/or decreased mobility and any changes to level responsiveness/ consciousness and overall function. Note the presence or absence of significant findings. - Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report should be completed by the nursing supervisor on duty at the time and submitted to the DON.Performing a post fall evaluation:- After a first fall, a nurse and/or physical therapist will watch the resident attempt to rise from a chair without using his or her arms, walk several paces, and return to sitting, and will document the results ofthis effort. If the individual has no difficulty or unsteadiness, no further evaluation is needed at that time. If the individual has difficulty or is unsteady in performing this test, additional evaluation may be initiated as warranted. These failures resulted in an identification of an Immediate Jeopardy (IJ) the ADM and DON were notified and provided the IJ Template on [DATE] at 12:23 PM. The POR F726 was approved [DATE] at 08:16 AM and reflected the following:Plan of RemovalImmediate ThreatOn [DATE], HHSC determined that Coral Rehab failed to meet the requirements of tag F726, resulting in an Immediate Threat to resident health and safety.Action:Action: Competency Assessment and Temporary ReassignmentStart Date: [DATE]Completion Date: [DATE]Responsible: DON & Consultant RNTarget Audience: RNs, LVNs and new hiresDetails: Immediate assessment of staff competency in fall protocols and EMR use. Staff with deficiencies reassigned until retraining is complete. DON trained by Consultant RN prior to initiating staff training; verified on competency check list; signed by Consultant RN. ADON demoted and disciplinary action provided for direct violation of policy and notification of DON. Re-education followed using competency checklist. Evaluation: Competency checklist signed by DON. Staff reassigned only after passing post-training evaluation. No staff reassignments were necessary; both staff which required re-education for this instance have resigned and resignation was accepted immediately. And, ADON as above. Action:Action: Targeted Training Start Date: [DATE]Completion Date: [DATE]Responsible: DON & Consultant RNTarget Audience: RNs, LVNs and new hiresDetails: Training on clinical fall protocol, fall risk assessments, neuro checks, and EMR documentation. New hires will continue to be educated using competency checklist ongoing. Evaluation: 7-day and 30-day follow-up competency re-check. Documented on Competency Monitoring spreadsheet. Action:Action: Policy Review and Quality Assurance Performance ImprovementStart Date: [DATE]Completion Date: [DATE]Responsible: Administrator, DON and Consultant RNTarget Audience: Interdisciplinary TeamDetails: Enforcement of disciplinary actions for protocol violations. Review of policies and procedures for fall protocol and EMR documentation. Post-training competency quiz (pass rate 90%) based on Fall protocol and EMR documentation requirements. Evaluation: Incident trend analysis X 3 months in QAPI The POR was monitored in the following ways: In an interview on [DATE] at 12:20 PM with CEO and DON, they notified surveyors LVN A had resigned effective [DATE] and would no longer be coming in. In an interview on [DATE] at 01:00 PM with the DON she confirmed that on [DATE] she was in-serviced by the CEO (Chief Executive Officer) prior to beginning the education with all licensed nursing staff. The ADON made the decision to return to work as a floor nurse and not continue the responsibilities as a ADON and was not in-serviced by the CEO, the MDS coordinator did receive the training at the same time as the DON the in-service stated that all licensed nursing staff will receive mandatory re-education with verbal discussion and sign in sheet on the facility's fall response protocol, change in condition procedures, and abuse/neglect clinical protocols. Nurses have been directed to notify DON when any resident refuses evaluation by EMS (emergency medical services) and a post-quiz will be used for determining understanding after education is provided. In an interview on [DATE] at 01:59 PM with the DON confirmed that she was in-serviced by the NC prior to in-servicing the facility nursing staff regarding changes in resident conditions, falls, neuro fall risk assessments, and notification to RP and MD and DON. They reviewed facility policy on acute change condition protocol, and the importance of timely and accurate documentation and notification of changes in resident conditions and identifying and documenting and communicating the changes according to facility policy. The DON said she was aware that the changes in conditions must be reported, according to the facility policy to the DON, MD/NP and RP/family. She was aware and agreed to use the action tab for risk management and follow through with documentation. She received training and education relevant to acute care planning needs and to relay all information to the ADM, DON, ADON, and MDS to make sure all acute care planning needs will be met. She received training and education on completing required resident assessments and confirmed she is competent to perform the assessments necessary. They also discussed the of care planning and updating the resident's care plans to include falls.In an interview on [DATE] at 02:54 PM with the DON she stated for the moment they have to move forward with EMS assessments until she is absolutely comfortable with the nurses ability to assess residents to make sure that residents stay safe in the event of a fall, EMS is a fall back safety measure. She can provide staff education and make them do competencies all day long - the staff need to respond with a sense of emergency, and be able to reflect they have the knowledge of what they do, right now she is using EMS for assessments until staff exhibit they can do everything appropriately.In an interview on [DATE] at 01:31 PM with NC she confirmed that she in-serviced DON prior to the DON in-servicing the nursing staff regarding changes in resident conditions, falls, neuro fall risk assessments, and notification to RP and MD and DON, they reviewed facility policy on acute change condition protocol, and the importance of timely and accurate documentation and notification of changes in resident conditions and identifying and documenting and communicating the changes according to facility policy. The DON said she was aware that the changes in conditions must be reported, according to the facility policy to the DON, MD/NP and RP/family, She was aware and agreed to use the action tab for risk management and follow through with documentation. She received training and education relevant to acute care planning needs and to relay all information to the ADM, DON, ADON, and MDS to make sure all acute care planning needs will be met. She received training and education on completing required resident assessments and confirmed she is competent to perform the assessments necessary. They also discussed the of care planning and updating the resident's care plans to include fallsIn an interview on [DATE] at 11:45 AM DON stated most of the nurses are trained and retrained on neuro check and post fall evaluation. She stated they were trained on reporting to physician and family in a timely manner. DON stated during their staff daily meeting falls and other related issues are evaluated, and necessary actions are taken. There was no fall or incident of any significant changes in condition. Resident #3 had a fall on [DATE] and was reviewed and all the necessary steps were taken after the fall. She stated during the review it was revealed the care plans were not updated, not just for fall but also for various other issues. She stated the care plans were updated accordingly. The external NC will be supervising and monitoring the activities to ensure things are going in the right track.In an interview on [DATE] at 03:12PM with NC, she stated she in serviced and trained the DON. She stated she had interviewed the nursing staff in the weekends as well to make sure they learned everything that they were supposed to. She stated she was happy with the outcome and will monitor and guide them to optimize their competencyThe following nurses were interviewed and observed working on PCC completing neuro checks and post fall evaluation. They were able to navigate the neuro check and post fall evaluation form on E H R (PCC). They were able to explain how to fill them out and the rationale and significance of the findings during the evaluation. They were able to identify a significant change and when to notify a physician /or call EMS Able to answer randomly asked post training quiz questions. See below:In an interview on [DATE] at 01:00 PM with RN O - Full time started [DATE] During the interview stated: Got received the training [DATE] trained. Previously was doing neuro checks on paper form and then hand over to DON. Now got trained to do directly on the EH R.In an interview on [DATE] at 01:15 PM RN G - PRN -[DATE] During the interview stated: Trained on [DATE] and was trained on neuro check, post fall evaluation and incident report was to be completed. Neuro check to be continued for 3 days, she stated she was previously doing on paper, now on both, first on paper and then on PCC. Stated confident to do neuro and post fall evaluation. Neuro check initially every 15minutes.In an interview on [DATE] at 01:45 PM with LVN I Trained on [DATE]. During the interview stated: Interview over the phone, able to answer quiz questions. Able to explain neuro check and post fall process and procedures. Stated able to coordinate care independently.In an interview on [DATE] at 01:55 PM with LVN B, Trained on [DATE]. During the interview stated: She was doing after the fall evaluation and neuro check before too. Stated she was confident enough to conduct oneIn an interview on [DATE] at 02:35 PM with MDS Coordinator, LVN Trained on [DATE]. During the interview stated she received the trainings for the post fall procedures and how to enter the information in the E H R. In an interview on [DATE] at 02:35 PM with LVN P Interview over the phone. Nurse for 7 years. Done post fall evaluation and neuro checks before. Received the training on [DATE] from the facility. Stated she was able to conduct a post fall procedure independentlyReview of the facility's in-services and post-training quizzes reflected staff were reeducated and returned demonstration of competencies with clinical fall protocol, fall risk assessments, neuro checks, and EMR documentation and use.Additionally, the following care plans/ assessments had been updated by the facility - Resident #65Resident #100Resident #66Resident #49Resident #27Resident #3Resident #7Resident #19Resident #11Resident #14Resident #6Resident #12 These failures resulted in an identification of an Immediate Jeopardy (IJ) and the ADM and DON were notified on [DATE] at 12:23 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to have evidence that all alleged violations are thoroughly investigated for 1 (Resident #1) of 5 residents reviewed for incidents. The facility failed to initiate and complete a thorough investigation of Resident #1's injury of unknown origin. Staff observed Resident #1 had discoloration to his buttocks area on 09/10/25. Staff confirmed Resident #1's discoloration was an acute (sudden) femur (thigh) fracture on 09/11/25. An IJ was identified on 09/18/25. The IJ template was provided to the facility on [DATE] at 7:10 p.m. While the IJ was removed on 09/21/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of their corrective systems. This failure could place residents at risk of untreated medical problems, worsening injuries, mental anguish, and reduced quality of life. Findings include:Review of Resident #1's admission Record, dated 09/18/25, reflected he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses that included bilateral (both sides) primary osteoarthritis (a chronic, degenerative condition characterized by the progressive breakdown of joint cartilage and underlying bone) of hip, pain in left and right hip, age-related osteoporosis (the condition of bones becoming weak and brittle), schizoaffective disorder (a mental illness that combines symptoms of schizophrenia and a mood disorder), vascular dementia (a type of dementia that happens when blood vessels in the brain are damaged or blocked), muscle weakness, lack of coordination, and cognitive communication deficit. Resident #1 was discharged to the hospital on [DATE]. Review of Resident #1's Annual MDS Assessment, dated 09/11/25, reflected a BIMS of 3/15, which indicated he had severe cognitive impairment. Resident #1 required substantial/maximal assistance with transfers. Review of Resident #1's Care Plan, last revised 08/07/25, reflected he had potential for complications related to schizophrenia and bipolar disorder and was at risk for falls. Review of Resident #1's Progress Notes reflected:-A note created by the ADON on 09/11/25 at 6:45 a.m., Writer was called to room d/t resident c/o pain, while repositioning resident in bed for brief change. Writer noted dark discoloration to left buttock area.NP on call notified. New order: Left lateral hip x-ray stat (immediately) confirmation. DON and Guardian notified.-A note created by RN A on 09/11/25 at 7:33 p.m., Resident was transferred out to hospital per order.MPOA was called and notified. DON aware. Review of Resident #1's Radiology Results, dated 09/11/25 at 10:36 a.m., reflected he was x-rayed and had a mild displaced comminuted right proximal femoral (thigh) fracture. Review of Resident #1's Physician Note, dated 09/11/25, reflected, He was evaluated per nursing request following complaints of right hip pain with movement. Per nursing report, [Resident #1] verbalized pain during repositioning in bed for a brief change .On exam, dark discoloration was noted over the left buttock area. A stat right hip x-ray was ordered, which revealed an acute mildly displaced comminuted fracture of the right proximal femur. [Resident #1 denied any recent fall or trauma, and no recent falls have been reported or documented. The ADON, DON, and facility Administrator were notified for further investigation.[Resident #1] was sent to the emergency department for further evaluation and management. Review of Resident #1's Medical Provider Progress Note, dated 09/16/25, reflected Resident #1 presented to the hospital from the facility after a mechanical fall. The fall occurred on 09/11/25 and resulted in a right intertrochanteric area of the femur. During an interview on 09/18/25 at 10:32 a.m., the ADON stated the day before Resident #1 was sent to the hospital (09/10/25), CNA B notified her that she observed Resident #1 had dark purple discoloration to his left buttocks and experienced pain when she turned him. The ADON stated she also made the same observation as CNA B during her assessment of Resident #1 and notified the DON, who informed her to notify the on-call NP. The ADON stated Resident #1 told her that he fell and could not elaborate on the incident. The ADON stated the on-call NP ordered a stat x-ray on Resident #1's left hip area on 09/10/25 and the results on 09/11/25 revealed he had a right hip fracture. The ADON stated she notified the on-call NP and DON of the results and sent Resident #1 to the hospital per on-call NP orders. The ADON stated Resident #1's right hip fracture was an injury of unknown origin because the facility did not know how he sustained the discoloration and fracture. The ADON stated the ADM was responsible for investigating injury of unknown origin. The ADON stated she knew it was important to investigate injury of unknown origin and said, To investigate and make sure resident safety and determine how incident occurred. Residents could be at risk of neglect I would say. During an interview on 09/18/25 at 10:57 a.m., CNA B stated she observed Resident #1 had a purple bruise on his left buttocks when she was changing his brief and repositioning him in bed last week (09/10/25). CNA B stated she notified the ADON of Resident #1's bruise. CNA B stated Resident #1's left buttocks bruise was an injury of unknown origin because the facility did not know how he sustained the bruise. CNA B stated the nurses and DON were responsible for investigating injury of unknown origin. CNA B stated she knew it was important to investigate injury of unknown origin and said, Because the reason is really important.so it won't happen again. Residents could be at risk of getting more sick and stop walking .During an interview on 09/18/25 at 12:39 p.m., the DON stated the ADON told her on 09/10/25 that Resident #1 complained of pain, the ADON assessed Resident #1 and observed he had a bruise. The DON stated she instructed the ADON to notify the doctor and order an x-ray. The DON stated the ADON or RN A told her that Resident #1's mobile x-ray results reflected he had a fracture. The DON stated she instructed the ADON or RN A to notify the NP. The DON stated Resident #1's bruise and fracture was an injury of unknown origin because the facility did not know how he sustained the bruise and fracture. The DON stated she expected her staff to notify the ADM if there was any injury of unknown origin. The DON stated her and the ADM were responsible for investigating injury of unknown origin. The DON stated the CEO oversaw to ensure her and the ADM investigated injury of unknown origin. The DON stated she informed the ADM of Resident #1's injury of unknown origin on 09/11/25. The DON stated she did not investigate and did not know why she did not investigate Resident #1's injury of unknown origin. The DON stated she knew it was important to investigate injury of unknown origin and said, So that if it is possible abuse, it doesn't reoccur. Residents could be at risk of death and a multitude of things. During an interview on 09/18/25 at 2:20 p.m., the NP stated he reviewed Resident #1's x-ray results, found he had an acute femur fracture, and ordered him to be sent to the hospital for further evaluation and treatment on 09/11/25. The NP stated he also observed Resident #1 had blue, yellow and purple colored bruises on his left buttocks on 09/11/25. The NP stated Resident #1's bruises and fracture could be an injury of unknown origin because the facility did not know how he sustained the bruise and fracture. The NP stated he expected the facility staff to thoroughly investigate Resident #1's incident and determine the likely source and cause of the injury and said, If there were bruises, obviously something happened. The NP stated he believed Resident #1's acute femur fracture was indicative of some kind of trauma to that area of his body. The NP stated Resident #1's incident would have kicked off an investigation and did not know why there was not an initiated investigation. During an interview on 09/18/25 at 3:33 p.m., RN A stated the ADON told her on 09/11/25 that CNA B notified her during the night of 09/10/25 that Resident #1 was moaning and groaning when CNA B was providing care. RN A stated it was not typical for Resident #1 to moan and groan on the night of 09/10/25. RN A stated Resident #1's mobile x-ray results revealed on 09/11/25 that he had a right hip fracture. RN A stated Resident #1's fracture was an injury of unknown origin because the facility did not know how he sustained the fracture. RN A stated the ADM was responsible for investigating injury of unknown origin. RN A stated she knew it was important to investigate injury of unknown origin and said, So they can do appropriate and immediate investigation to see what happened. Residents could be at risk of abuse and neglect and also for their safety. During an interview on 09/18/25 at 5:17 p.m., the ADM stated she was not notified that Resident #1 had a bruise on his buttocks. The ADM stated the surveyor's interview was the first time she was hearing Resident #1 had a bruise on his buttocks. The ADM stated Resident #1's bruise on his buttocks was an injury of unknown origin because the facility did not know how he sustained the bruise. The ADM stated she expected staff to notify her and the DON if there was an injury of unknown origin. The ADM stated her and the DON were responsible for investigating injury of unknown origin. The ADM stated the CEO was responsible for ensuring her and the DON investigated injury of unknown origin. The ADM stated she knew it was important to investigate injury of unknown origin and said, Because there might be others who might be at harm's way and might be at risk of harm to those harming them. Review of the facility's Abuse Investigations policy, revised December 2024, reflected, Policy Statement:All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management.Policy Interpretation and Implementation:1. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident.17. Inquiries concerning abuse reporting and investigation should be referred to the Administrator or to the Director of Nursing Services.The ADM was notified on 09/18/25 at 7:13 p.m. that an IJ had been identified and an IJ template was provided. The following POR was approved on 09/20/25 at 1:50 p.m.: POR Immediate Jeopardy - Failure to Investigate Alleged Violations The facility failed to have evidence that all alleged violations were thoroughly investigated.On 9/18/25 at 7:10 p.m. the surveyors determined that the facility was in Immediate Jeopardy due to: Facility failed to report an injury of unknown origin in accordance with State and Federal regulations.Resident#1 was discharged to hospital on 9/11/25 and remains in the hospital .Immediate interventions when notified of IJ are the following: On 9/18/25, the Administrator and DON were in-serviced by contracted consultant regarding investigation and timely reporting of any injury of unknown origin within 2 hours of receiving report of incident. The facility's policy and procedures regarding reporting abuse, neglect and exploitation was reviewed and explained in detail by a contracted consultant on 9/18/25. Included in this training was the course of action that must be taken anytime an alleged abuse, neglect or exploitation allegation is made. Both DON and Administration demonstrated understanding of policy and procedures by verbalizing understanding and signing the acknowledgement on an in-service document. A flow chart was provided by consultant to DON and administrator as visual aid in facilitating reporting to Department of Health and Human Services. Skin sweep completed by designated nurses to assess each resident for any injuries. All findings were reported to the DON and Administrator. All nursing staff, including new hires, current full-time, PRN, agency nursing staff, were in-serviced by DON/designee on 9/18/25, 9/19 and 9/20 on identifying and reporting requirements for injuries of unknown origin. All nursing staff, including new hires, current full-time, PRN and agency staff, were given a T/F test regarding investigating and reporting injuries of unknown origin. Administrator and DON will discuss with IDT members during our daily morning meeting and stand down meeting all findings and will ensure compliance is met and sustained.Start Date 9/18/25Completion date 9/20/25Responsible for POR - Director of Nursing ServicesTargeted Audience - Interdisciplinary Team The surveyor monitored the POR on 09/20/25 as followed: During interviews from 09/20/25 at 3:15 p.m. through 09/20/25 at 4:55 p.m., LVN F, RN A, LVN G, CNA H, CNA I, CNA J, and LVN L stated they were in-serviced and provided competency before their shifts by the DON/designee on identifying and immediately reporting requirements for injuries of unknown origin. They knew to immediately notify the ADM, DON, and Charge nurse. They also completed skin sweeps to assess each resident for any new injuries. During an interview on 09/21/25 at 12:15 p.m., the DON stated her and the ADM were in-serviced by the contracted consultant on reporting and investigating injuries of unknown origin within two hours of receiving report of the incident. The DON stated her and the signed an acknowledgement of the in-service received to demonstrate understanding the facility's policy and procedures. The DON stated her and the ADM received a flow chart as a visual aid in facilitating reporting to the SSA. The DON stated skin sweeps were completed by designated nurses to assess each resident for injuries and there were no abnormal findings reported to her and the ADM. The DON stated staff were also in-serviced and tested for competency on identifying and reporting requirements for injuries of unknown origin. The DON stated her and the ADM will discuss with IDT members during daily meetings all findings to ensure compliance was met and sustained. Review of the facility's In-Services, 09/18/25-09/20/25, reflected the ADM and DON were reeducated by a contracted consultant on reporting and investigating injuries of unknown origin within two hours of receiving report of the incident. The ADM and DON signed an acknowledgement of the in-service received. Staff were also in-serviced and tested for competency by the DON/designee on identifying and reporting requirements for injuries of unknown origin. Review of the facility's Reporting Abuse, Neglect, and Exploitation policy, reviewed on 09/18/25, reflected the policy was reviewed and explained in detail by the contracted consultant. A flow chart was provided as a visual aid for the ADM and DON in facilitating reporting to the SSA. Review of the facility's Skin Assessments completed by the DON and other charge nurses, 09/18/25-09/20/25, reflected all 70 residents were assessed and did not have injuries of unknown origin. The ADM was notified on 09/21/25 at 1:18 p.m. that the IJ had been removed. While the IJ was removed, the facility remained at a scope level of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure the resident environment remains free of accident hazards and each resident receives adequate supervision for 1 (Resident #1) of 5 residents reviewed for incidents. The facility failed to monitor and supervise Resident #1, who was cognitively impaired and a fall risk. Resident #1 complained of pain and had discoloration to his buttocks area on 09/10/25. Resident #1 sustained an acute (sudden) femoral (thigh) fracture and was sent to the hospital for surgery on 09/11/25. An IJ was identified on 09/18/25. The IJ template was provided to the facility on [DATE] at 7:10 p.m. While the IJ was removed on 09/21/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of their corrective systems. This failure could place residents at risk of untreated medical problems, worsening injuries, mental anguish, and reduced quality of life.Findings included:1.Review of Resident #1's admission Record, dated 09/18/25, reflected he was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses that included bilateral (both sides) primary osteoarthritis (a chronic, degenerative condition characterized by the progressive breakdown of joint cartilage and underlying bone) of hip, pain in left and right hip, age-related osteoporosis (the condition of bones becoming weak and brittle), schizoaffective disorder (a mental illness that combines symptoms of schizophrenia and a mood disorder), vascular dementia (a type of dementia that happens when blood vessels in the brain are damaged or blocked), muscle weakness, lack of coordination, right eye blindness, and cognitive communication deficit. Resident #1 was discharged to the hospital on [DATE]. Review of Resident #1's Annual MDS Assessment, dated 07/07/25, reflected a BIMS of 3/15, which indicated he had severe cognitive impairment. Resident #1 had no falls since his admission. Resident #1 also required substantial/maximal assistance with chair/bed-to-chair transfers. Review of Resident #1's Care Plan, last revised 08/07/25, reflected he had potential for complications related to schizophrenia and bipolar disorder and was at risk for falls related to vision. Staff were required to follow the facility's fall protocol. Resident #1 also required 2-person assistance. There was no notes related to mechanical lift assistance with Resident #1's transfers. Review of Resident #1's Progress Notes reflected:-A note created by the ADON on 09/11/25 at 6:45 a.m., Writer was called to room d/t resident c/o pain, while repositioning resident in bed for brief change. Writer noted dark discoloration to left buttock area.NP on call notified. New order: Left lateral hip x-ray stat (immediately) confirmation. DON and Guardian notified. -A note created by RN A on 09/11/25 at 7:33 p.m., Resident was transferred out to hospital per order.MPOA was called and notified. DON aware. There were no documented notes related to an accident/incident before Resident #1 complained of pain and staff observed the discoloration to his buttocks before 09/11/25. Review of Resident #1's skin observation, pain level, and change in condition assessments, dated 09/11/25, reflected they were a system error and the documents were incomplete. Review of Resident #1's Radiology Results, dated 09/11/25 at 10:36 a.m., reflected he was x-rayed and had a mild displaced comminuted right proximal femoral (thigh) fracture. Review of Resident #1's Physician Note, dated 09/11/25, reflected, He was evaluated per nursing request following complaints of right hip pain with movement. Per nursing report, [Resident #1] verbalized pain during repositioning in bed for a brief change .On exam, dark discoloration was noted over the left buttock area. A stat right hip x-ray was ordered, which revealed an acute mildly displaced comminuted fracture of the right proximal femur. [Resident #1 denied any recent fall or trauma, and no recent falls have been reported or documented. The ADON, DON, and facility Administrator were notified for further investigation.[Resident #1] was sent to the emergency department for further evaluation and management. Review of Resident #1's Medical Provider Progress Note, dated 09/16/25, reflected Resident #1 presented to the hospital from the facility after a mechanical fall. The fall occurred on 09/11/25 and resulted in a right intertrochanteric area of the femur.2. Review of Resident #2's admission Record, dated 09/18/25, reflected he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses including muscle weakness, repeated falls, lack of coordination, cognitive communication deficit, and unsteadiness on feet. Review of Resident #2's Quarterly MDS, dated [DATE], reflected a BIMS score of 15/15, which indicated he was cognitively intact. During an interview on 09/18/25 at 10:32 a.m., the ADON stated the day before Resident #1 was sent to the hospital (09/10/25), CNA B notified her that she observed Resident #1 had dark purple discoloration to his left buttocks and experienced pain when she turned him during perineal care. The ADON stated she also made the same observation as CNA B during her assessment of Resident #1. The ADON stated she did not believe Resident #1 had any accidents or incidents before her and CNA B's observation on 09/10/25. The ADON stated Resident #1 told her that he fell and could not elaborate on the incident . The ADON stated she notified the DON, who instructed her to conduct a skin assessment report and notify the on-call NP. The ADON stated she did not complete the skin assessment and that it should have been completed. The ADON stated the on-call NP ordered a stat x-ray on Resident #1's left hip area. The ADON stated the x-ray results revealed on 09/11/25 that Resident #1 had a right hip fracture. The ADON stated she notified the on-call NP and DON of Resident #1's x-ray results and the on-call NP instructed her to send Resident #1 out to the hospital. The ADON stated Resident #1's right hip fracture and discoloration was an injury of unknown origin because the facility did not know how he sustained the discoloration and fracture. The ADON stated CNAs and nurses were responsible for following the facility's fall protocol if a severely cognitive resident reported they fell and had a new skin issue. The ADON stated CNAs and nurses were also expected to notify the ADM, DON, and NP of the alleged incident. The ADON stated her and the DON were responsible for overseeing and ensuring staff followed fall protocol. The ADON stated she knew the importance of following fall protocol and said, To ensure resident safety, to assess the resident and see if the resident had any injuries, and to monitor resident for change in condition. If the fall protocol were not followed, resident could be at risk of neglect.During an interview on 09/18/25 at 10:57 a.m., CNA B stated she observed Resident #1 had a purple bruise on his left buttocks when she was changing his brief and repositioning him in bed last week (09/10/25) during perineal care. CNA B stated Resident #1 told her that he fell in the morning and evening of 09/10/25 and no one listened to him. CNA B stated Resident #1 could not elaborate on the incident. CNA B stated she notified the ADON. CNA B stated Resident #1's left buttocks bruise was an injury of unknown origin because the facility did not know how he sustained the bruise. CNA B stated the CNAs were expected to notify the nurse and ADM if a severely cognitive resident reported they fell and had a new skin issue. CNA B stated nurses were expected to follow the facility's fall protocol if a severely cognitive resident reported they fell and had a new skin issue. CNA B stated the DON was responsible for overseeing and ensuring staff followed fall protocol. CNA B stated she knew the importance of following fall protocol and said, It's a resident's right. We are supposed to care about them. We need to literally report the incident right away. Residents could be at risk of getting hurt and something else could happen to them.During an interview on 09/18/25 at 12:23 p.m., Resident #1's RP stated the ADON notified her on 09/11/25 that Resident #1 had a fracture that was caused by an unwitnessed fall. The RP stated the ADON did not elaborate on how Resident #1's unwitnessed fall occurred. During an interview on 09/18/25 at 12:39 p.m., the DON stated the ADON told her on 09/10/25 that Resident #1 complained of pain, the ADON assessed Resident #1 and observed he had a bruise. The DON stated she instructed the ADON to notify the doctor and order an x-ray. The DON stated she notified the ADM. The DON stated she could not figure out how Resident #1 sustained the bruise and explained Resident #1 was a mechanical lift transfer. The DON stated the ADON told her that Resident #1 told her that he ended up on the floor on 09/10/25. The DON stated the ADON or RN A told her that Resident #1's mobile x-ray results reflected Resident #1 had a fracture. The DON stated she instructed the ADON or RN A to notify the NP. The DON stated Resident #1's bruise and fracture was an injury of unknown origin because the facility did not know how he sustained the bruise and fracture. The DON stated she expected her staff to notify her and the ADM, start clinical duties, such as taking vitals, initiating and conducting neurological monitoring, and notifying the resident's physician, RP and family, and immediately follow the facility's fall protocol if a severely cognitive resident reported they fell and had a new skin issue. The DON stated she was responsible for overseeing and ensuring staff followed the facility's fall protocol. The DON stated she did not know if her staff followed the facility's fall protocol. The DON stated she knew the importance of following fall protocol and said, So you don't end up with injuries. So you don't have poor resident outcomes. Residents could be at risk of pain, decreased quality of life, and including death.During an interview on 09/18/25 at 1:11 p.m., Resident #2 stated he was Resident #1's roommate. Resident #2 stated Resident #1 was blind. Resident #2 stated he observed staff mostly transfer Resident #1 using 1-person assistance and sometimes 2-person assistance. Resident #2 stated he believed it was possible a staff member helped Resident #1 off the floor if he fell. Resident #2 stated staff picked up and turned Resident #1 and did not think staff used a Hoyer lift for Resident #1 during transfers. During an interview on 09/18/25 at 2:20 p.m., the NP stated he reviewed Resident #1's x-ray results, found he had an acute femur fracture, and ordered him to be sent to the hospital for further evaluation and treatment on 09/11/25. The NP stated he was not notified of any incidents/accidents involving Resident #1 before 09/11/25. The NP stated Resident #1 might be able to get up on his own. The NP stated he also observed Resident #1 had blue, yellow and purple colored bruises on his left buttocks on 09/11/25. The NP stated Resident #1's bruises and fracture could be an injury of unknown origin because the facility did not know how he sustained the bruise and fracture. The NP stated he expected the facility staff to thoroughly investigate Resident #1's incident and determine the likely source and cause of the injury and said, If there were bruises, obviously something happened. The NP stated he expected the facility staff to follow the facility's fall protocol, initiate and conduct ongoing neurological monitoring, and perform physical assessments if a severely cognitive resident reported they fell and had a new skin issue. The NP stated he was not notified by the ADON that Resident #1 told her that he fell. The NP stated he believed Resident #1's acute femur fracture was indicative of some kind of trauma to that area of his body. The NP stated he was not notified that Resident #1's Medical Provider Progress Notes reflected Resident #1 had a mechanical fall. The NP explained emergency medical services might have been told Resident #1 had a mechanical fall by the facility staff. The NP defined mechanical fall and said, Falling from bed, wheelchair or Hoyer lift, or any other piece of equipment. During interviews on 09/18/25 from 3:03 p.m. through 3:26 p.m., CNA C and MA D stated Resident #1 was a 2-person Hoyer lift transfer. During an interview on 09/18/25 at 3:33 p.m., RN A stated the ADON told her on 09/11/25 that CNA B notified her during the night of 09/10/25 that Resident #1 was moaning and groaning when CNA B was providing care. RN A stated it was not typical for Resident #1 to moan and groan on the night of 09/10/25. RN A stated Resident #1's mobile x-ray results revealed on 09/11/25 that he had a right hip fracture. RN A stated Resident #1's fracture was an injury of unknown origin because the facility did not know how he sustained the fracture. RN A stated she would follow the facility's fall protocol and document the incident and notify reporting parties if a severely cognitive resident reported they fell and had a new skin issue. RN A stated the ADON and DON were responsible for overseeing and ensuring nurses followed the facility's fall protocol. RN A stated she knew the importance of following fall protocol and said, So we don't get anything left out. So we have it on record of incident, interventions done, and always good to do fall incident report. Resident could be at risk of more serious injury. During an interview on 09/18/25 at 5:17 p.m., the ADM stated she was not notified that Resident #1 had a bruise on his buttocks last week (09/10/25). The ADM stated the surveyor's interview was the first time she was hearing Resident #1 had a bruise on his buttocks. The ADM stated Resident #1's bruise on his buttocks was an injury of unknown origin because the facility did not know how he sustained the bruise. The ADM stated she expected staff to notify her and the DON if there was an injury of unknown origin. The ADM stated her and the DON were responsible for investigating injury of unknown origin. The ADM stated the CEO was responsible for ensuring her and the DON investigated injury of unknown origin. The ADM stated she knew it was important to investigate injury of unknown origin and said, Because there might be others who might be at harm's way and might be at risk of harm to those harming them. The ADM stated she expected staff to check residents' care plans for their transfer status and said, That's where it needs to be documented. It's important to follow the care plan because it's a care plan for a reason and could cause injury to the resident if not followed. The DON must train CNAs to look at care plan and follow care plan notes for transfer status. The ADM stated it was not acceptable for nurses to give transfer status information to CNAs. The ADM stated the CNAs should be looking at residents' EMR and the DON should be educating the CNAs on transfer status search and task performance. During interviews on 09/18/25 from 4:20 p.m. through 4:49 p.m., CNA C, RN A and MA D stated Resident #1 was a Hoyer lift because they were verbally told by a former nurse who was employed at the facility that he required the Hoyer lift for transfers and were told that anyone who cannot bear any weight were automatically a Hoyer lift. They also stated they looked at Resident #1's EMR and the previous Hoyer lift list that was no longer used to determine Resident #1's transfer status. They knew it was important to know a resident's transfer status for security and to prevent injuries because residents could be at risk for injury or skin tear. Review of the facility's In-Services, 08/01/25-09/18/25, reflected none related to fall protocol, transfers, and accidents/incidents. Review of the facility's Change in a Resident's Condition or Status policy, revised December 2010, reflected staff were required to notify the RP and physician of accidents or incidents involving the resident. Review of the facility's Accidents: Assessment, Management and Interventions policy, undated, reflected, Policy: It is the policy of facility to complete a fall risk assessment for all residents upon admission, readmission, quarterly, after every fall and significant change and as needed. Purpose: To ensure that all residents are properly assessed and appropriate interventions are put place to prevent falls.Procedure: .10. All interventions must be indicated on the falls care plan and on the CNA nursing instructions in EMR. Review of the facility's Assessing Falls and Their Causes policy, revised March 2018, reflected, Purpose: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Preparation: 1. Review the resident's care plan to assess for any special needs of the resident.Steps in the Procedure: After a Fall: 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 2. Obtain and record vital signs as soon as it is safe to do so. 3. If there is evidence of injury, provide appropriate first aide and/or obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. 5. Notify the resident's attending physician and family in an appropriate time frame. a. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone. 6. Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall and will document findings in the medical record. 7. Document any observed signs or symptoms of pain, swelling, bruising.and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 8. Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing Services. Defining Details of Falls:1. After an observed or probable fall, clarify the details of the fall.2. For each individual, distinguish falls in the following categories.Identifying Causes of a Fall or Fall Risk: 1. Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident.3. Continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found.6. If the cause if unknown by no additional evaluation is done, the physician or nursing staff should note why (e.g., workup already done, finding a cause would not change the approach, etc ). The ADM was notified on 09/18/25 at 7:13 p.m. that an IJ had been identified and an IJ template was provided. The following POR was approved on 09/20/25 at 1:54 p.m.: PORImmediate Jeopardy - Safe Environment Requires Nursing Facilities environment to be free of accident hazards, and for residents to receive adequate supervision and necessary assistance devices to prevent accidents. On 9/18/25 at 7:10 p.m. the surveyors determined that the facility was in Immediate Jeopardy due to: Facility failed to ensure the resident environment remained as free of accident hazards as possible and provide adequate supervision to prevent accidents. Resident #1 on 9/11/25 was discharged to the hospital and remains in the hospital. Immediate interventions when notied of IJ are the following: All Nursing Staff including all new hires, current full-time, PRN, or agencynurse/aides, will be in serviced prior to initiating their shift by current DON/designee regarding utilizing Kardex in Point Click Care as a guide for resident's care needs. DON/designee will demonstrate to these staff members how to access and utilize the Kardex system. The DON/ designee will then require each nursing member to provide a return demonstration on how to access and interpret the Kardex system. An audit was completed on all residents regarding their transfer status. The facility currently has a total of 20 residents requiring a 2-person Hoyer lift transfer. Audit also completed on transfer ability on every resident's care plan and Kardex to ensure accuracy. A skin assessment was completed by DON and other charge nurses to ensure all 70 residents do not have injuries of unknown origin. There were no injuries of unknown origin found. Transfer check-off utilizing gait belt and Hoyer lift methods with all nursing staff including all new hire nursing staff, current full-time, PRN and agency will be completed by physical therapy personnel/designees. No nursing staff, including new hires, full-time, PRN or agency staff members will report to their shift until they have been successfully checked off. Returned demonstration is being provided by all fulltime, new hires, PRN, and agency nurses and aides. Kardex will be printed out and placed at each nurse's station for access should the computer system go down. When change in condition and transfer level changes, the Kardex will be updated by MDS Nurse/Designee. Any changes that a resident may experience causing a status change in their transferring ability will be immediately reported to the DON or designee for immediate care plan and Kardex updating.DON, MDS Nurse and administrator will audit care plans and Kardex weekly for consistency and accuracy x's 3 months. This process will be reviewed monthly in the QAPI meeting for compliance and sustainability. Start date 9/18/25 Completion date 9/20/25 Responsible for POR - Director of Nursing Services Targeted Audience - IDT team The surveyor monitored the POR on 09/20/25 as followed:During interviews from 09/20/25 at 1:58 p.m. through 4:55 p.m., CNA E, LVN F, RN A, LVN G, CNA H, CNA I, CNA J, the MDS Nurse, the ADON, LVN K, and LVN L stated they were in-serviced and provided return demonstrations before their shifts by the DON/designee on accessing and utilizing residents' EMR and physical records at the nursing station as a guide for resident care needs. They also knew the MDS nurse updated residents' EMR and physical records. They also knew any change in residents' condition was to be immediately reported to the DON or designee. They also completed skin assessments to ensure all resident did not have injuries of unknown origin. They also completed transfer checkoffs and return demonstrations of utilizing gait belt and Hoyer lift methods with physical therapy personnel/designees. During observations from 09/21/25 at 9:30 a.m. through 09/21/25 at 9:45 a.m., CNA M, CNA N, and CNA O utilized residents' EMR and proper gait belt and Hoyer lift transfer techniques during resident transfers. During an interview with the DON on 09/21/25 at 12:15 p.m., she stated in-services staff before their shifts regarding utilizing residents' EMR as a guide for residents' care needs and demonstrated how to access and utilize the system. The DON stated she then had each staff member provide a return demonstration on how to access and interpret the system. The DON stated she and the other charge nurses completed skin assessments to ensure all 70 residents did not have injuries of unknown origin. The DON stated her, the MDS Nurse, and the ADM were auditing residents' care plans and Kardex weekly for consistency and accuracy for the next three months and reviewing monthly in QAPI for compliance and sustainability. Review of the facility's In-Services, 09/18/25-09/20/25, reflected the DON/Designee educated and demonstrated to staff on accessing and utilizing residents' EMR as a guide for residents' care needs. Review of the facility's Audit of Residents' Care Plans and EMR, 09/18/25-09/20/25, reflected residents were assessed on their transfer ability and were ensured to be accurate. There were 20 residents who required a Hoyer lift 2-person transfer. Review of the facility's Skin Assessments, 09/18/25-09/20/25, completed by the DON and other charge nurses reflected all 70 residents were assessed and did not have injuries of unknown origin. Review of the facility's Transfer Checkoffs, 09/18/25-09/20/25, utilizing Gait Belt and Hoyer lift methods completed by physical therapy personnel/designees reflected all staff successfully checked off and returned demonstration of techniques before reporting to their shift. Review of Kardex's at each nursing station reflected residents' EMR were available should the computer system go down. Review of the Audit Care Plans and Kardex reflected it was consistently and accurately reviewed weekly and monthly for compliance and sustainability by the DON, MDS Nurse, ADM and QAPI. The ADM was notified on 09/21/25 at 1:18 p.m. that the IJ had been removed. While the IJ was removed, the facility remained at a scope level of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #1) reviewed for tracheal care.1. The facility failed to have orders in place to provide care to Resident #1's tracheostomy (a hole in front of the neck and into the windpipe) since he was admitted to the facility on [DATE].2. The facility failed to provide regular tracheostomy care to Resident #1, as the nurses did not feel comfortable, leaving the resident to provide his own tracheostomy care since admission on [DATE]. Resident #1 was sent to the hospital on [DATE] and diagnosed with pneumonia. 3. The facility failed to provide trach care and suctioning to Resident #4 according to professional standards of practice. An Immediate Jeopardy (IJ) situation was identified on 08/28/2025. While the IJ was removed on 09/05/2025, the facility remained at a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.These failures could place residents at risk of infection, respiratory distress, pneumonia, and hospitalization.Findings include:1.Record review of Resident #1's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included acute respiratory failure with hypoxia (low levels of oxygen in the body's tissues), tracheostomy status, dysphagia (difficulty swallowing), and end-stage renal disease.Record review of Resident #1's quarterly MDS assessment, dated 07/10/25, reflected a BIMS score of 14, which indicated he was cognitively intact. Section O (Special Treatments, Procedures, and Programs) reflected he required tracheostomy care.Record review of Resident #1's quarterly care plan, dated 08/10/25, reflected he had a tracheostomy related to impaired breathing mechanics with an intervention of suctioning as necessary and ensuring the trach ties were secured at all times.Record review of Resident #1's physician's orders in his EMR, on 08/12/25, reflected no orders for trach care.During a telephone interview on 08/12/25 at 9:33 AM, Resident #1's RP stated the facility made him clean his own trach. She stated, the other day (unsure of date) when she visited him, he had two cannulas in a bag with water in it. She stated he had been reusing the disposable cannulas. She stated she told him he could not use the same cannula twice and was worried about his trach site getting infected.During an observation and interview on 08/12/25 at 10:20 AM, LVN B stated Resident #1 was currently at the hospital . He stated he (Resident #1) performed his own trach care because he preferred to do it himself. He stated they (nurses) just ensured he had the supplies. When asked to see trach supplies, he opened his cart and realized there were no cannulas in the cart. LVN B led the State Surveyor to the supply closet where there was a box of disposable cannulas.During an interview on 08/12/25 at 12:52 PM, Resident #1's NP stated if a resident had a trach, his expectations were there be orders in place for PRN suctioning, changing the trach on a scheduled bases, and monitoring of the stoma. He stated he was not aware Resident #1 did not have orders for trach care. He stated his expectations were that nurses provided trach care. He stated he was aware Resident #1 sometimes performed his own trach care and he told him to let the nurses do it. He stated the residents were not well-educated enough and would need training. He stated you could not reuse a disposable cannula because Disposable meant disposable. He stated there was a big risk of infection control issues or suctioning too much could also cause issues . He stated if Resident #1 could properly take care of his trach, he would be living at home. He stated he lived at the facility because he needed a higher level of care.During an interview on 08/12/25 at 2:44 PM, the RDON stated if a resident had a trach, there should be orders on suctioning, monitoring, and cleaning the site. She stated it did not meet her expectations for a resident to not have orders if they had a trach. She stated it was important to ensure they received the care they needed. She stated a negative outcome could be infection issues, death, or other safety concerns. She stated residents were not supposed to care for their own trach because that could lead to improper care and maintenance.During an observation and interview on 08/13/25 at 1:35 PM revealed Resident #1 received a dialysis treatment. He was able to communicate by the State Surveyor reading his lips. He stated he often had to tend to his stoma site and trach because the staff were not cleaning or suctioning it, and he was scared it would become infected.Observation and interview on 08/28/25 at 10:00 a.m. revealed multiple used trach inner cannulas in Resident #l's room on his bedside table. Resident #1 stated he was afraid of running out of supplies and would wash off the trach inner cannula in the sink in his bathroom. Resident #1's RP was present and stated she often had to bring supplies from home for Resident #1's trach. It was also observed, while Resident #1 was standing, he was on continuous oxygen at 4 liters, Resident #1's split gauze under his trach was scrunched up at his neck, partially covering his stoma. When Resident #1's RP tried to look at the stoma, the Resident #1 could not tolerate the process, and he began to gasp for air.During an interview on 08/29/2025 at about 10:00 a.m., Resident #1's RP stated while they were about to leave the facility on 08/28/2025 for Resident #1's GI appointment, Resident #1 stated he did not feel good. The RP stated she assessed Resident #1, and his oxygen level was in the 80s and his blood glucose was high. Resident #1's RP stated she immediately took Resident #1 to the ER where he was admitted and diagnosed with pneumonia.During an interview on 08/29/2025 at 10:12 a.m., LVN E stated nurses were responsible for performing trach care on residents. LVN E stated the RDON was responsible for training nurses on trach care. LVN E stated she felt she had the trach care training/skills to meet residents' needs, but she sometimes did not have what she needed to perform trach care . LVN E explained she felt she did not have and could not find the trach care equipment to perform trach care. LVN E stated she did not receive trach care training and proper use of trach care equipment. LVN E stated no one spoke with her about trach care when she started her shift on 08/29/2025. LVN E stated she did not receive periodic evaluations of her trach skills and knowledge from the facility. LVN E stated she felt the facility needed to reeducate nurses on trach care and said, Because nurses may forget certain steps in the procedure. If you do not work hands on, there are certain things you don't remember. Residents could be at risk of having trouble breathing, becoming confused, and becoming combative. Critical case. Has to do with the airway when it comes to the breathing and has to do with infection. Residents could acquire an infection when it comes to lack of breathing due to lack of trach care competency . During an interview on 08/29/2025 at 10:34 a.m., LVN G stated nurses were responsible for performing trach care on residents. LVN G stated she did not know who was responsible for training nurses on trach care. LVN G stated she felt she did not have the trach care training to meet residents' needs and informed the facility she did not have the trach care training upon her hire. LVN G stated she did not receive trach care training from the facility. LVN G stated no one trained her on trach care and spoke with her about trach care when she started her shift on 08/29/25. LVN G stated she needed a trach care reeducation to meet residents' needs. LVN G stated she never was asked to perform trach care. LVN G stated she had not been trained on proper use of trach care equipment. LVN G stated she also did not receive periodic evaluations of trach care. LVN G stated she knew the importance of nurses being educated and competent in trach care and said, To make sure residents are good and safe. Residents could choke or die or get an infection .During an interview on 08/29/25 at 10:55 a.m., LVN A stated he was trained on trach care 3-4 months ago. He stated he never performed trach care on a resident at the facility. He stated he felt like he would need supervision to perform trach care as he had only ever performed trach care on a mannequin. He stated he had never been asked to perform trach care at the facility and had only provided residents with trach care supplies when they asked. LVN A stated although he had been trained on proper trach care and equipment, he had not received any periodic evaluations on his trach skills and knowledge. He stated he knew it was important to have trach care education because it was life threatening and residents could be at risk of airway obstruction and infection. He stated it would not be acceptable for a resident to wash their inner cannula in the sink because the water was not sterile . He stated he did not know Resident #1 was reusing his nasal cannulas and had never observed him provide his own trach care. He stated he was not sure if Resident #1 had been trained on performing his own trach care. He stated Resident #1's trach collar was always clean and he would replace the gauze when it was dirty.During an interview on 08/29/25 at 11:27 PM, the RDON stated staff were skill-checked every six months on trach care. She sated the last check-off was early June and July of 2025. She stated the RDON was responsible for skill-checking nurses on trach care and knew it was important to educate on trach care because residents could be at risk for any complication. The RDON stated she was not aware, nor did she observe Resident #1 performing his own trach care. She stated she would have expected for floor staff to observe him perform care to ensure he was doing it appropriately. She stated if Resident #1 was refusing trach care by the nurses, she would expect them to notify the provider, RP, and family of the refusals . The RDON stated she was still looking for staff competency evaluations. During an observation and interview on 08/29/25 at 2:02 PM, Resident #1 was sitting on his hospital bed in the hospital. He stated he had been doing his own trach care at the facility because he did not believe facility staff were competent to do so. He stated the facility nurses told him they did not know how to perform trach care. He stated facility staff never supervised, monitored, nor offered to supervise his own trach care. He stated he often had to use his own trach care supplies.During an interview on 08/29/25 at 2:03 PM, HN H stated Resident #1 was admitted to the hospital for fluid overload and pneumonia. She stated Resident #1 had a trach, chronic respiratory failure, and a history of pneumonia. She stated improper trach care could potentially result in pneumonia. During a telephone interview on 08/29/25 at 4:18 PM, Resident #1's NP stated if nurses were not comfortable and untrained in trach care, residents could be at risk of not receiving proper care which could develop infections, respiratory distress, and numerous other complications. He stated he was under the impression the RT was responsible for training nurses on trach care, but he had not seen the RT for quite some time. He stated he was unaware of how often the RT visited the facility .Record review of Resident #1's hospital records, dated 08/28/2025, reflected Resident #1 was checked into the hospital on [DATE] at 10:30 a.m. and reflected the following: History of Present Illness-Patient is a [AGE] year old male w/ past medical history of End-Stage Renal Disease on hemodialysis, chronic hypoxemic respiratory failure, trach dependent who presented to the emergency department with complaints of increased shortness of breath, dyspnea for the past 2 weeks. He was saturating at 74% on arrival to the emergency department. He states he has been compliant with his dialysis and was last dialyzed yesterday. He has had increased secretions during the past week. CXR showed a moderate right pleural effusion with small loculated component and diffuse patchy opacities.Assessment/Plan--Acute on Chronic Hypoxic Respiratory Failure, right pleural effusion w/ loculated component, Diffuse patchy opacities- Concern for possible pneumonia given X-ray findings.- Will initiate treatment.4. Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old male with original admission date of 01/13/2025 and readmission date of 05/06/2025. Resident #4 had diagnoses which included tracheostomy status (a surgical procedure that creates an opening in the trachea-windpipe to allow breathing), acute and chronic Respiratory failure with hypoxia (Hypoxia is a condition in which there is an inadequate supply of oxygen to the body's tissues), Gastrostomy status (refers to the presence of a surgical opening in the stomach that allows for the insertion of a tube for feeding or other purposes), acute on chronic systolic Congestive heart failure (a condition where a sudden worsening of symptoms occurs in some who already has chronic systolic heart failure), cerebral infarction (occurs when blood flow in the brain is interrupted, leading to cell death and brain damage), and dysphagia (difficulty swallowing). Record review of Resident #4's quarterly MDS assessment, dated 08/20/2025, reflected a BIMS score of 00, which indicated severe cognitive impairment. Staff assessment reflected Resident #4 had both short-term and long-term memory problems. Section O reflected Resident #4 required Oxygen therapy, suctioning and tracheostomy care.Record review of Resident #4's care plan, initiated 01/14/2025, reflected Resident #4 had tracheostomy related to impaired breathing mechanics and was on oxygen at 4LPM, Resident #4 was NPO.Record review of Resident #4's physician orders, dated 05/08/2025, reflected: Suction as needed to maintain patency every 1 hours as needed for as needed to maintain patency of trach. Trach care daily and PRN: For disposable: remove and dispose of inner cannula. Replace with new inner cannula. one time a day for Reduce risk of infection 6-inch trachRecord review of Resident #4's physician orders, dated 06/23/2025, reflected: Monitor trach for placement every shift.Record review of Resident #4's physician orders, dated 08/29/2025, reflected: Monitor trach stoma site for issues including but not limited to: S/S of infection, irritation, redness, swelling, pain, mucosal tissue issues. Notify MD or NP for any findings which are abnormal and complete progress note. every shift for tracheostomy care Notify for abnormal findings and complete progress note. Trach care daily and PRN: For disposable: (Trach Canula size 7.5) remove and dispose of inner cannula. Replace with new inner cannula, gauze, and collar. one time a day for Reduce risk of infection Inner Canula Size [NAME] 7.5Observation on 08/29/25 at 09:03 a.m. revealed LVN E collecting supplies to perform trach care on Resident #4. LVN E was observed collecting supplies from the medication cart such as trach kit and a 10cc vial of normal saline. LVN E donned an isolation gown and a clean glove without performing hand hygiene . LVN E took clean gauze wiped Resident #4's oxygen mask removing the excess secretions, then wiped Resident #4's left neck and shoulder removing excess secretions. LVN E then reached into her pants pocket with her soiled gloved hand and pulled a glove out . LVN E then removed the glove from 1 hand, reached in her pants pocket again but did not get anything. LVN E removed gloves from the other hand and walked out to the doorway to get more gloves from her medication cart, which was parked in the doorway. LVN E grabbed more gloves from her medication cart and placed gloves in her pants pocket. LVN E applied clean gloves without hand hygiene, took the yankauer (A Yankauer is a medical suction device used to remove fluids, blood, secretions, and debris from a patient's oral airway or surgical site to prevent aspiration and maintain a clear field for healthcare providers.) and inserted it into Resident #4's trach, suctioning while going in and coming out of the trach. LVN E used water which she took from a normal saline vial (10 cc), put water in a plastic cup which was not sterile to clean the yankauer. LVN E again inserted the yankauer into Resident #4's trach, with the yankauer not being sterile, and again applied suction while going in and coming out. LVN E removed soiled gloves, no hand hygiene, reached in her pants pocket for clean gloves, the nurse applied clean gloves, applied split gauze under Resident #4's trach, did not clean Resident #4's trach stoma, did not change Resident #4's trach tide even though it was saturated with secretions. LVN E did not check Resident #4's oxygen prior to trach care or suctioning or hyper-oxygenate Resident #4 during the procedure. Resident #4 was noted kicking the wall and the window each time suction was applied . During an interview on 08/29/2025 at 10:12 a.m., LVN E stated nurses were responsible for performing trach care on residents. LVN E stated the RDON was responsible for training nurses on trach care. LVN E stated she felt she had the trach care training/skills to meet residents' needs, but she sometimes did not have what she needed to perform trach care. LVN E explained she felt she did not have and could not find the trach care equipment to perform trach care. LVN E stated she did not receive trach care training and proper use of trach care equipment. LVN E stated no one spoke with her about trach care when she started her shift on 08/29/2025. LVN E stated she did not receive periodic evaluations of her trach skills and knowledge from the facility. LVN E stated she felt the facility needed to reeducate nurses on trach care and said, Because nurses may forget certain steps in the procedure. If you did not work hands on, there were certain things you didn't remember. Residents could be at risk of having trouble breathing, becoming confused, and becoming combative. Critical case. Has to do with the airway when it comes to the breathing and has to do with infection. Residents could acquire an infection when it came to lack of breathing due to lack of trach care competency. LVN E stated she knew to suction a resident depending on when a resident choked on phlegm. LVN E stated she did not perform trach care for Resident #4 because she did not see the water to use . LVN E stated she observed Resident #4 had excessive secretions around his neck and shoulder. LVN E stated she used normal saline during Resident #4's trach care. LVN E stated she had to go to another unit to get the trach equipment to perform trach care because she did not see the equipment available on her unit. LVN E stated she was not familiar with Resident #4. LVN E stated the nurses needed inner cannula for emergency purposes, oxygen mask, sterile water, cannister when performing trach care.During an interview on 08/29/2025 at 10:34 a.m., LVN G stated nurses were responsible for performing trach care on residents. LVN G stated she did not know who was responsible for training nurses on trach care. LVN G stated she felt she did not have the trach care training to meet residents' needs and informed the facility she did not have the trach care training upon her hire. LVN G stated she did not receive trach care training from the facility. LVN G stated no one trained her on trach care and spoke with her about trach care when she started her shift on 08/29/25. LVN G stated she needed a trach care reeducation to meet residents' needs. LVN G stated she never was asked to perform trach care. LVN G stated she had not been trained on proper use of trach care equipment. LVN G stated she also did not receive periodic evaluations of trach care. LVN G stated she knew the importance of nurses being educated and competent in trach care and said, To make sure residents are good and safe. Residents could choke or die or get an infection. During an interview on 08/29/2025 at 10:55 a.m., LVN A stated he was trained on trach care 3-4 months ago. He stated he never performed trach care on a resident at the facility. He stated he felt like he would need supervision to perform trach care as he had only ever performed trach care on a mannequin. He stated he was never asked to perform trach care at the facility and had only provided residents with trach care supplies when they asked. LVN A stated although he had been trained on proper trach care and equipment, he had not received any periodic evaluations on his trach skills and knowledge. He stated he knew it was important to have trach care education because it was life threatening and residents could be at risk of airway obstruction and infection. He stated it would not be acceptable for a resident to wash their inner cannula in the sink because the water was not sterile. He stated he did not know Resident #1 was reusing his nasal cannulas and never observed him provide his own trach care. He stated he was not sure if Resident #1 had been trained on performing his own trach care. He stated Resident #1's trach collar was always clean, and he would replace the gauze when it was dirty.During an interview on 08/29/2025 at 11:27 p.m., the RDON stated staff were skill-checked every six months on trach care. The RDON stated the last check-off was early June and July of 2025. The RDON stated she was responsible for skill-checking nurses on trach care and knew it was important to educate nurses on trach care because residents could be at risk for any complication. The RDON stated she was still looking for staff competency evaluations. She expected staff to perform hand hygiene before and after any care and between glove changes. The RDON explained it was important to perform hand hygiene to protect themselves and the resident. The RDON expected staff to follow the Trach Care policy and procedure. Suction was necessary and expected to be applied at the bedside. She expected nurses to apply suction after hyperoxygenation (Breathing oxygen at higher than normal). The RDON stated she expected the nurses to hyperoxygenation the resident before applying suction. She expected the suction to be applied when pulling out the trach, not when going into the trach. The RDON stated she expected trach care equipment available at bedside for emergency services. During a telephone interview on 08/29/25 at 4:18 p.m., the NP stated if nurses were not comfortable and untrained in trach care, residents could be at risk of not receiving proper care, which they could develop infections, respiratory distress, and numerous other complications. The NP stated he was under the impression the RT was responsible for training nurses on trach care, but he had not seen the RT for quite some time. The NP stated he was unaware of how often the RT visited the facility .Interview with the Administrator and RDON on 08/28/2025 at 11:27 a.m., 08/29/2025 at 09:41 a.m., and 08/29/2025 at 1:46 p.m., staff competency skill checkoffs were requested at this time and it was not provided.Record review of facility's policy titled Suctioning the Lower Airway (Endotracheal or Tracheostomy Tube) revised October 2010 reflected: PurposeThe purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.Preparation1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for suctioning.2. Review the resident's care plan to assess for any special needs of the resident.3. Obtain baseline vital signs and oxygen saturation from the resident's medical record.4. Obtain information about the resident's medical history, including date of intubation (tracheostomy), respiratory signs and symptoms, and risk factors for increased secretions, decreased airway clearance and/or airway obstruction (i.e., Chronic Obstructive Pulmonary Disease [COPD], chest trauma, abdominal surgery, and smoking).5. Assemble the equipment and supplies as needed.6. Test equipment before use. Determine if suction equipment is generating appropriate negative pressure. Use lower negative pressure with older residents whose oral mucosa is fragile.a. Wall suction units should be set between 100-120 mm Hg.b. Portable suction devices should have negative pressure set at 10-15 mmHg.General Guidelines1. Complications of suctioning the lower airway include trauma to the airway, infection, hypoxia, hypoxemia, and cardiac dysrhythmias (resulting from hypoxemia). To minimize the risk of complications, apply the following guidelines:a. Suction only as needed, based on assessment of the resident's level of respiratory distress.b. Use sterile equipment to avoid widespread pulmonary and systemic infection (Note: Suctioning of the lower airway is a sterile procedure. All equipment that comes in contact with the lower airway must be sterile.).c. Hyperinflate the resident with a manual resuscitation (Ambu) bad (as ordered) before and after suctioning; andd. Hyperoxygenation the resident by increasing the oxygen flow (as ordered) before the procedure and between suctioning. (Note: After the procedure, oxygen should be readjusted as ordered to prevent oxygen toxicity and increased CO2 in COPD residents.)2. Monitor the resident's pulse and oxygen saturation (see procedure entitled Pulse Oximetry) during suctioning. If pulse decreases more than 20 beats per minute (8PM) or increases more than 40 8PM, or oxygen saturation drops below 90 percent (or 5 percent from baseline) discontinue suctioning and re­ventilate and re-oxygenate the resident.Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure.1. Sterile suction catheter kit.2. Sterile drape.3. Sterile cup.4. Sterile gloves.5. #10 to #16 French catheter (catheter outer diameter should not exceed one-half the internal diameter of the tube);6. Sterile gauze.7. Towel or Chux pad.8. 100 cc sterile saline or sterile water.9. Resuscitation (Ambu) bag with supplemental oxygen. 10. Wall or portable unit.11. Tubing (approximately 6 feet); and12. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed).Assessmentl . Identify the following risk factors for impaired airway clearance or aspiration:a. Impaired cough or gag reflex.b. Dysphagia; (difficulty swallowing)c. Weak respiratory muscles (from injury, abdominal surgery, etc.);d. COPD.e. Pulmonary infection.f. Presence of feeding tube.g. Smoking; and/orh. Decreased level of consciousness.2. Assess for the following signs and symptoms of respiratory distress/hypoxia/ hypoxemia:a. Diminished breath sounds.b. Tachypnea.c. Dyspnea.d. Gurgling, crackling or wheezing upon inspiration.e. Cyanosis.f. Decreased oxygen saturation (Sp02);g. Restlessness; and/orh. Drooling, secretions or vomitus in mouth.Steps in the Procedure1 . Provide for resident privacy.2. Explain the procedure to the resident.3. Perform hand antisepsis.4. Put on gloves. 5. Put on mask and protective eyewear (goggles or face shield), as indicated.6. Assist the resident to semi-Fowler's position with head turned toward you. If the resident is unconscious, place in lateral position facing you.7. Connect one end of suction tubing t 0 suction unit and place the other end near the resident.8. Turn on the suction unit and adjust to appropriate negative pressure (100-120 mmHg for wall unit or 10-15mmHg for portable unit9.Remove gloves.10. Open suction catheter kit.11. Place sterile drape across the resident's chest.12. Remove sterile cup, touching only the outside.13. Fill cup with I 00 cc sterile saline or sterile water.14. Apply sterile gloves. The dominant hand will remain sterile.15. Holding the catheter in dominant hand and the tubing in the non-dominant hand connect the catheter to the tubing.16-Suction a small amount of water from the cup to verify negative pressure. Rest catheter tip on sterile surface (e.g., sterile drape or open catheter kit).17. Remove oxygen or humidity delivery device using non-dominant hand.18. Hyperinflate and hyper oxygenate the resident using an Ambu bag connected to supplemental oxygen.19. Manually ventilate (bag) the resident 4 to 5 times, coordinating with natural breaths. Remove bag.20. instruct the resident to inhale.21. Upon inhalation, insert the catheter into airway (ET tube or tracheostomy tube) without applying suction. Advance the catheter until resistance is met and/or resident coughs (at the [NAME]). Pull back I to2 cm.22. Apply intermittent suction and slowly withdraw catheter while rotating between thumb and forefinger. Limit suction time to no more than IO seconds.23. Re-ventilate and oxygenate the resident for a minimum of one minute between suctions.24. Rinse catheter and tubing with sterile saline or sterile water until clear.25. Assess cardio-pulmonary status.26. Repeat steps 20 through 24, if necessary. Limit suction passes to a maximum of three.27. Suction the oral or nasal cavity. (Note: Oropharyngeal and nasopharyngeal suctioning contaminate the catheter. Do not re-insert catheter into ET or tracheostomy tube.)28. Replace oxygen or humidity delivery device.29. If the resident's physical or medical condition permits, assist the resident to a position that promotes deep breathing and coughing.30. Turn off suction.31. Disconnect catheter from tubing. Wrap catheter around gloved hand. Pull the glove off and over the catheter. Discard in designated receptacle.32.Remove drape and discard in designated receptacle.33. Discard water or saline in commode. Dispose of cup in designated receptacle.34. Empty and rinse collection container if necessary or as indicated by facility protocol.35. Discard personal protective equipment in designated he comfort receptacles. Wash resident, and dry if your hands thoroughly.36. Apply clean gloves and provide oral hygiene for the comfort of the resident, if indicated.37. Perform hand antisepsis.38. Reposition the bed covers. Make the resident comfortable.39. Place the call light within easy reach of the resident.40. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. Review of facility's policy titled Handwashing/Hand Hygiene revised August 2019 reflected: Policy Statement.1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventingthe transmission of healthcare-associated infections.Record review of the facility's Tracheostomy Care Policy, revised August of 2013, reflected it focused on the steps of replacing the trach and site and stoma care. It did not address physician orders or who should be providing care.This was determined to be an Immediate Jeopardy (IJ) on 08/28/2025 at 1:42 p.m. The ADM was notified. The ADM was provided with the IJ template on 08/28/2025 at 1:45 p.m . The following Plan of Removal was submitted by the facility and accepted on 09/05/25 at 1:45 p.m.:Plan of Removal (POR) - F695 POR Accepted at - 09/05/25 at 01:45 PMImmediate JeopardyOn 08/28/2025, an abbreviated survey was re-opened at the Facility. On the same date, the surveyor provided an Immediate Jeopardy (IJ) Template notification indicating that the facility failed to meet regulatory requirements under F695, placing Resident #1 at risk of serious harm due to lack of appropriate tracheostomy care.The IJ was triggered due to:- Absence of physician orders for trach care, suctioning, and stoma monitoring. - Resident #1 performing his own trach care without documented training, oversight, or competency validation. - Evidence of potential harm, including pneumonia diagnosis and unsafe supply reuse.Action 1: Safe Discharge and Removal of Tracheostomy CapabilitiesEffective immediately as of 09/04/2025, the facility will remove all tracheostomy clinical capabilities. The 2 residents with tracheo[TRUNCATE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of four residents reviewed for pain. The facility failed to: - Order Resident #1's Hydrocodone before it ran out, causing him to be excruciating pain for two days (08/10/25 - 08/12/25), resulting in him being sent to the ER.- Properly document the ordered PRN Hydrocodone administered to Resident #1 as his August 2025 MAR did not match the narc count sheet for his PRN Hydrocodone.- Assess Resident #1 for the effectiveness of his PRN Hydrocodone (as ordered) after it was administered during August 2025. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 08/12/25 at 4:49 PM. While the IJ was removed on 08/13/25 at 6:05 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of increased pain, hospitalization, and a decreased quality of life. Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with hypoxia (low levels of oxygen in the body's tissues), tracheostomy status[KA1] , dysphagia (difficulty swallowing), chronic pain, and end-stage renal disease. Review of Resident #1's quarterly MDS assessment, dated 07/10/25, reflected a BIMS score of 14, indicating he was cognitively intact. Section O (Special Treatments, Procedures, and Programs) reflected he required tracheostomy care. Section J (Health Conditions) reflected he had been hurting within the past five days and his pain occasionally affected his sleep, therapy activities, and day-to-day activities. Review of Resident #1's quarterly care plan, dated 04/16/25, reflected he required pain management D/T chronic pain r/t chronic physical back pain debility with an intervention of anticipating his need for pain relief and responding immediately to any complaint of pain. Review of Resident #1's hospital records, dated 07/09/25, reflected a discharge order for Acetaminophen-Hydrocodone (10/325 oral tablet) take by mouth every six hours as needed for pain. Review of Resident #1's physician order, dated 07/13/25, reflected Hydrocodone-Acetaminophen Oral Tablet 10-325 MG - Give 1 or 2 tablets every 4 to 6 hours as needed for pain. Review of Resident #1's August 2025 MAR, 08/01/25 - 08/12/25, reflected he was administered Hydrocodone on the following days: 08/01/25 - once08/04/25 - twice08/05/25 - three times08/06/25 - once08/07/25 - once08/09/25 - twice Review of Resident #1's August 2025 narc sheet, from 08/01/25 - 08/12/25, reflected he was administered Hydrocodone on the following days: 08/01/25 - four times08/02/25 - three times08/04/25 - twice08/05/25 - four times08/06/25 - four times08/07/25 - four times08/08/25 - four times08/09/25 - four times08/10/25 - once He received his last dose (as it ran out) on 08/10/25 at 12:00 AM. Review of Resident #1's pain assessments, on 08/12/25, reflected the following numerical pain scales: 08/10/25 at 2:00 PM - 608/12/25 at 12:15 AM - 7 Review of Resident #1's physician order, undated, reflected a pain assessment before and after PRN medications: Utilize 0-10 pain scale or PAINAD. Document pain scale results, v/s, interventions, outcomes. Review of Resident #1's August 2025 MAR, 08/01/25 - 08/12/25, reflected the above order was never utilized/documented. Review of Resident #1's progress note, dated 08/10/25 at 2:49 PM and documented by LVN B, reflected the following: [Resident #1] walked over to writer in the hallway requesting to be sent to ER, saying, Can you please call the ambulance so I can go to the hospital. [Resident #1] walked over to writer several times earlier asking for main meds, Tylenol 650MG PO given, as Norco 10/325 supply got finished at midnight. Also offered to call NP on-call to obtain Tramadol or TYL#3 order, [Resident #1] stated, Tramadol doesn't work for me and TYL3 makes me vomit. Review of Resident #1's progress note, dated 08/11/25 at 3:45 AM and documented by LVN B reflected 911 was called per his request due to complaining of chest pain. Review of Resident #1's hospital records, dated 08/11/25 at 4:35 AM reflected he was presenting from a nursing facility via EMS for chest pain onset today at 2:00 AM. He was administered Hydrocode at 5:04 AM. Review of Resident #1's progress note, dated 08/11/25 at 12:01 PM and documented by the IDON, reflected the following: [Resident #1] has returned from ER visit without new orders. Wants to go back out for pain control. Review of Resident #1's progress note, dated 08/12/25 at 7:20 AM and documented by LVN A, reflected the following: [Resident #1] complained of pain to this nurse and stated that he wanted to go to the hospital. This nurse notified the on-call practitioner. The on-call practitioner stated that the highest level of medication that he could prescribe was Tramadol, but he does not see the need to give orders for transfer to ER. [Resident #1] vocalized that he does not want Tramadol because it does not work. This nurse facilitated phone call for resident to paramedics. Review of Resident #1's physician order, dated 08/13/25, reflected Hydrocodone-Acetaminophen oral tablet 10-325 MG - Give 2 tablets orally every 6 hours as needed for pain. Review of Resident #1's August 2025 MAR, on 08/13/25, reflected at 11:49 AM he was administered the above order as his pain was rated at a 10. During a telephone interview on 08/12/25 at 9:33 AM, Resident #1's RP stated he had been out of his Hydrocodone since Saturday (08/10/25). He stated he had called her that morning crying telling her he hurt so bad and he felt like his body was going to burst. She stated she believed they were giving him Tylenol, but it obviously was not working. She stated he requested to go to the ER because he could not handle the pain. During an interview on 08/12/25 at 10:20, LVN A stated Resident #1 had requested to go to the hospital that morning because he was in excruciating pain. He stated he was out of his Hydrocodone, and it was not going to be able to be refilled until 08/20/25. He did not know what the plan was to manage his pain until then. He stated Resident #1 set an alarm to ensure he got the medication every six hours. LVN A stated if his MAR did not match the narc count sheet, it was because sometimes they (nursing staff) got busy and would forget to mark it off in the MAR. He stated he could see how it would look bad if they did not match, like the resident was possibly not getting the narcotic. During an interview on 08/12/25 at 12:52 PM, Resident #1's NP stated his expectations were that he be notified at least three days prior to a medication running out. He stated that would give ample time to ensure it was delivered on time. He stated he was not notified of Resident #1 running out of his Hydrocodone until yesterday, 08/11/25. He stated the order should not have read 1-2 tablets every 4-6 hours because the nurses should not have to determine whether they should give one or two and how often to administer them. He stated that order was made by his primary care doctor and was for more of a home setting. He stated his expectations were if they ran out of the Hydrocodone and he was in increased pain would be to try whatever they have or something in the e-kit. He stated he was not aware Resident #1 had been requesting the medication every six hours consistently. He stated if the pain was not being managed effectively, he would have tried a different medication or put another plan in place. He stated a MAR should always match the narc count sheet, especially for PRN pain medication. He stated if they were not matching, it could lead to a drug diversion. He stated his expectations were that nurses reevaluated a resident's pain after administering a PRN pain medication to ensure it was effective within 30 minutes to an hour. He stated if it was not effective, he would expect to be notified. During an interview on 08/12/25 at 2:44 PM, the RDON stated her expectations were that a MAR and a narc sheet always matched congruently. She stated they should be marked off in both places right as the medication was being administered. She stated the importance was to ensure medication errors did not occur and that pain was adequately treated and managed. She stated PRN pain medications should always be followed-up on for effectiveness within 30 minutes to an hour. She stated nurses should notify the NP when a medication is getting low within seven days. She stated the pharmacy would not dispense any more of Resident #1's Hydrocodone because they had would not dispense more than what the max was in a 30-day period. She stated it would have been different if it had been scheduled instead of PRN. She stated someone with the kind of pain Resident #1 had should have been on pain management. Review of the facility's Pain Policy, revised March 2018, reflected the following: 1. With input from the resident to the extent possible, the physician and staff will establish goals of paintreatment; for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, and sleep. Monitoring: 1. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain.a. Review should include frequency, duration and intensity of pain, ability to perform activities of daily living (ADLs), sleep pattern, mood, behavior, and participation in activities. 2. The staff will evaluate and report the resident/patients use of standing and PRN analgesics. a. Depending on the characteristics of pain, the physician may start with PRN doses or supplement standing doses with PRN doses for breakthrough pain. b. If there are more than occasional analgesic requests, the physician will consider changing to regular administration of at least one analgesic with another medication for PRN use, increasing the standing dose of an existing analgesic, switching to another analgesic, and/or adding nonpharmacological measures. Review of the facility's Medication Orders Policy, revised November 2014, reflected the following: 2. PRN Medication Orders - When recording PRN medication orders, specify the type, route, dosage, frequency, strength and the reason for administration. Review of the facility's Administering Medications Policy, revised April 2019, reflected the following: 22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.28. If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated. Review of the facility's Documentation of Medication Administration Policy, revised April 2017, reflected the following: 1. A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR).2. Administration of medication must be documented immediately after (never before) it is given. The RDON was notified on 08/12/25 at 4:49 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 08/13/25 at 3:53 PM: Action 1: Immediate Medication Access and Resident SupportStart Date: 08/12/2025Completion Date: 08/12/2025Responsible: Director of Nursing (DON) - Norco was reordered.- Resident #1 was assessed and transferred to the hospital per his request; DON gave directive to facilitate transfer of resident to ER, at his request. NP was notified of transfer but order was not given to transfer. -Resident returned to facility @1500 without any new orders. -Medication was dispensed by (pharmacy) and is onsite now. Residents pain has been assessed on an ongoing basis. Action 2: Staff Education and Documentation ProtocolsStart Date: 08/12/2025Completion Date: 08/14/2025Responsible: ADON/ DON -Regional DON (Acting DON) reviewed all policies and procedures below and started a PIP for Pain Control, Monitoring and Satisfaction aligning with POR for F697. On 8/12/25, via Teams conference, CEO reviewed Policy and Procedures, PIP and POR with Reg DON to ensure understanding of P&P, PIP and POR with satisfactory results. - All licensed staff (RN, LVN) were re-educated on pain management standards, MAR documentation, and narcotic reconciliation and were re-educated on protocols for medication ordering and inventory tracking.-Audit completed to determine all residents with PRN narcotic pain medication orders was completed and resident surveys were implemented to determine if residents are satisfied with current pain regimen or had pain control issues to report based on initial audit; no further resident concerns were identified during initial audit. Of the 28 residents identified: all other residents PRN narcotics were in stock or reordered accordingly. - Pain monitoring protocols were initiated and being monitored by DON for 28 residents receiving PRN narcotics (opioids) for pain control based on initial audit. - Competency checks were completed and filed; all licensed staff was re-educated using competency 2025 Pain Medication Competency; unavailable staff will be educated, and competency completed prior to next shift worked; all PCC access has been reset to ensure that education is completed prior to start of work for all licensed staff. -Moving forward, all new hires, Agency and PRN staff will be educated on the 2025 Pain management Competency and Policy Review prior to being issued PCC access during orientation. Action 3: Systemic Monitoring and OversightStart Date: 08/13/2025Completion Date: Ongoing (Initial 30-day daily audit, then weekly for 60 days)Responsible: Regional Director of Nursing / QAPI Committee - Daily audits of MARs and narcotic logs initiated.- Weekly resident interviews to assess pain management satisfaction.- Oversight reports submitted to QAPI for review and corrective planning for 3 months or until a plan is found to be sustainable for long term prevention of reoccurrence. The Surveyor monitored the POR on 08/13/25 as followed: Observation on 08/13/25 from 4:02 PM - 4:10 PM revealed three residents' PRN pain medication matching their narcotic count sheets from LVN B's cart. During an interview on 08/13/25 at 4:35, Resident #1 stated over the weekend (08/10/25 - 08/12/25) he was in so much pain to his back and his legs. He stated they felt like they were pulsing or stabbing. When asked to rate the pain from 1 to 10, he stated, A 20! He stated he was not currently in pain as he received his pain medication earlier that morning (08/13/25). During an interview on 08/13/25 at 4:48 PM, LVN B stated she had worked over the weekend when Resident #1 had run out of his Hydrocodone. She stated he was in pain, but his RP was who normally supplied the medication. She stated she offered him Tramadol which he refused, so she planned on having the NP assess him on his next visit to see what else could be done. During an interview on 08/13/25 at 4:55 PM, the RDON stated she and the CEO reviewed all policies on pain management and reordering medications the evening before (08/12/25). She stated the staff work 12-hour shifts and they night staff were in-serviced that morning as well as the day shift. She stated she removed all nurse's access from PCC so they would not be able to work until they were-serviced. She stated Resident #1's Hydrocodone was picked up the day before. During interviews on 08/13/25 from 4:48 PM - 6:00 PM, LVN B, RN C, LVN D, LVN E, and RN F (nurses from both shifts) all stated they were in-serviced on pain management, medication reconciliation, and re-ordering medications in timely manner. They all stated medications should be re-ordered within five days of it running out. They stated when administering a PRN narcotic, it needed to be documented the resident's MAR and the narcotic sheet. They stated PRN pain medication needed to be monitored for effectiveness within an hour of administration. They stated if pain was not being managed, they would notify the NP immediately. They all stated if a resident was not able to rate pain with the numerical pain scale, they would look for signs such as agitation, facial grimacing, or moaning. Review of the facility's Ad hoc QAPI Agenda, dated 08/12/25, reflected the RDON, the ADON, the MD, and the NP were in attendance. Review of an email, dated 08/13/25 and sent by the facility's CEO, reflected the following: I reviewed policy and procedure and re-educated with the [RDON] on: pain management standards, MAR documentation, narcotic reconciliation, med ordering and inventory tracking; a PIP was started and reviewed via Teams. Review of an in-service, dated 08/13/25 and conducted by the RDON, reflected nurses from all shifts were in-serviced on the facility policies regarding pain medication administration, medication orders and documentation, pain-clinical protocol, narcotic reconciliation, and medication ordering and inventory tracking. Review of Licensed Nurse Competency quizzes, dated 08/13/25, reflected all nurses completed the quiz on pain management and medication administration with no concerns. Review of physician orders for 28 residents (including Resident #1) with orders for PRN pain medication, dated 08/13/25, reflected an order for pain monitoring Q shift and PRN, using PAINAD or number scale. If pain unrelieved post pain medication - call provider immediately. Review of Resident #1's August 2025 MAR and his narcotic count sheet, on 08/13/25, reflected he was administered Hydrocodone that day (08/13/25) at 11:49 AM. The RDON was notified on 08/13/25 at 6:05 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern 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, interviews and record reviews the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for one of three Residents (Resident #4) reviewed for competent nursing staff.LVN E failed to provide trach care and suctioning to Resident #4 according to professional standards of practice. An Immediate Jeopardy (IJ) situation was identified on 08/28/2025. While the IJ was removed on 09/05/2025, the facility remained at a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risks for infection, respiratory distress, hospitalization and death.Findings include:Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old male with original admission date of 01/13/2025 and readmission date of 05/06/2025. Resident #4 had diagnoses which included tracheostomy status (a surgical procedure that creates an opening in the trachea-windpipe to allow breathing), acute and chronic Respiratory failure with hypoxia (Hypoxia is a condition in which there is an inadequate supply of oxygen to the body's tissues), Gastrostomy status (refers to the presence of a surgical opening in the stomach that allows for the insertion of a tube for feeding or other purposes), acute on chronic systolic Congestive heart failure (a condition where a sudden worsening of symptoms occurs in some who already has chronic systolic heart failure), cerebral infarction (occurs when blood flow in the brain is interrupted, leading to cell death and brain damage), and dysphagia (difficulty swallowing).Record review of Resident #4's quarterly MDS assessment, dated 08/20/2025, reflected a BIMS score of 00, which indicated severe cognitive impairment. Staff assessment reflected Resident #4 had both short-term and long-term memory problems. Section O reflected Resident #4 required Oxygen therapy, suctioning and tracheostomy care.Record review of Resident #4's care plan, initiated 01/14/2025, reflected Resident #4 had tracheostomy related to impaired breathing mechanics and was on oxygen at 4LPM, Resident #4 was NPO.Record review of Resident #4's physician orders, dated 05/08/2025, reflected: Suction as needed to maintain patency every 1 hours as needed for as needed to maintain patency of trach. Trach care daily and PRN: For disposable: remove and dispose of inner cannula. Replace with new inner cannula. one time a day for Reduce risk of infection 6-inch trachRecord review of Resident #4's physician orders, dated 06/23/2025, reflected: Monitor trach for placement every shift.Record review of Resident #4's physician orders, dated 08/29/2025, reflected: Monitor trach stoma site for issues including but not limited to: S/S of infection, irritation, redness, swelling, pain, mucosal tissue issues. Notify MD or NP for any findings which are abnormal and complete progress note. every shift for tracheostomy care Notify for abnormal findings and complete progress note. Trach care daily and PRN: For disposable: (Trach Canula size 7.5) remove and dispose of inner cannula. Replace with new inner cannula, gauze, and collar. one time a day for Reduce risk of infection Inner Canula Size [NAME] 7.5During an observation on 08/29/2025 at 08:46 AM, Resident #4 was observed lying in bed with the HOB elevated at about 30 degrees, Resident #4 was observed with excessive secretions from his trach, oxygen mask full of secretions, secretions dripping down Resident #4's left neck and shoulder, trach tide and split gauze under trach saturated secretions. Resident #4 was noted on continuous oxygen via mask at 4 L per hour using the oxygen concentrator. Surveyors called for help to Resident #4's room, that Resident #4 needed a nurse. LVN G stated Resident #4's nurse was somewhere down the hall. LNV G walked down the hall could not see Resident #4's nurse assigned for the day and walked to Resident #4's room. LVN G went in Resident #4's room, looked at Resident #4, turned around a little in Resident #4's room without touching him and walked out of the room. At about 8:58 a.m. Resident #4's assigned nurse, LVN E walked to Resident #4's door and stated she was going to perform trach care and suctioning on Resident #4 .Observation on 08/29/25 at 09:03 a.m. revealed LVN E collecting supplies to perform trach care on Resident #4. LVN E was observed collecting supplies from the medication cart such as trach kit and a 10cc vial of normal saline. LVN E donned an isolation gown and a clean glove without performing hand hygiene . LVN E took clean gauze wiped Resident #4's oxygen mask removing the excess secretions, then wiped Resident #4's left neck and shoulder removing excess secretions. LVN E then reached into her pants pocket with her soiled gloved hand and pulled a glove out . LVN E then removed the glove from 1 hand, reached in her pants pocket again but did not get anything. LVN E removed gloves from the other hand and walked out to the doorway to get more gloves from her medication cart, which was parked in the doorway. LVN E grabbed more gloves from her medication cart and placed gloves in her pants pocket. LVN E applied clean gloves without hand hygiene, took the yankauer (A Yankauer is a medical suction device used to remove fluids, blood, secretions, and debris from a patient's oral airway or surgical site to prevent aspiration and maintain a clear field for healthcare providers.) and inserted it into Resident #4's trach, suctioning while going in and coming out of the trach. LVN E used water which she took from a normal saline vial (10 cc), put water in a plastic cup which was not sterile to clean the yankauer. LVN E again inserted the yankauer into Resident #4's trach, with the yankauer not being sterile, and again applied suction while going in and coming out. LVN E removed soiled gloves, no hand hygiene, reached in her pants pocket for clean gloves, the nurse applied clean gloves, applied split gauze under Resident #4's trach, did not clean Resident #4's trach stoma, did not change Resident #4's trach tide even though it was saturated with secretions. LVN E did not check Resident #4's oxygen prior to trach care or suctioning or hyper-oxygenate Resident #4 during the procedure. Resident #4 was noted kicking the wall and the window each time suction was applied.During an interview on 08/29/2025 at 10:12 a.m., LVN E stated nurses were responsible for performing trach care on residents. LVN E stated the RDON was responsible for training nurses on trach care. LVN E stated she felt she had the trach care training/skills to meet residents' needs, but she sometimes did not have what she needed to perform trach care. LVN E explained she felt she did not have and could not find the trach care equipment to perform trach care. LVN E stated she did not receive trach care training and proper use of trach care equipment. LVN E stated no one spoke with her about trach care when she started her shift on 08/29/2025. LVN E stated she did not receive periodic evaluations of her trach skills and knowledge from the facility. LVN E stated she felt the facility needed to reeducate nurses on trach care and said, Because nurses may forget certain steps in the procedure. If you did not work hands on, there were certain things you didn't remember. Residents could be at risk of having trouble breathing, becoming confused, and becoming combative. Critical case. Has to do with the airway when it comes to the breathing and has to do with infection. Residents could acquire an infection when it came to lack of breathing due to lack of trach care competency. LVN E stated she knew to suction a resident depending on when a resident choked on phlegm. LVN E stated she did not perform trach care for Resident #4 because she did not see the water to use . LVN E stated she observed Resident #4 had excessive secretions around his neck and shoulder. LVN E stated she used normal saline during Resident #4's trach care. LVN E stated she had to go to another unit to get the trach equipment to perform trach care because she did not see the equipment available on her unit. LVN E stated she was not familiar with Resident #4. LVN E stated the nurses needed inner cannula for emergency purposes, oxygen mask, sterile water, cannister when performing trach care .During an interview on 08/29/2025 at 10:34 a.m., LVN G stated nurses were responsible for performing trach care on residents. LVN G stated she did not know who was responsible for training nurses on trach care. LVN G stated she felt she did not have the trach care training to meet residents' needs and informed the facility she did not have the trach care training upon her hire. LVN G stated she did not receive trach care training from the facility. LVN G stated no one trained her on trach care and spoke with her about trach care when she started her shift on 08/29/25. LVN G stated she needed a trach care reeducation to meet residents' needs. LVN G stated she never was asked to perform trach care. LVN G stated she had not been trained on proper use of trach care equipment. LVN G stated she also did not receive periodic evaluations of trach care. LVN G stated she knew the importance of nurses being educated and competent in trach care and said, To make sure residents are good and safe. Residents could choke or die or get an infection. During an interview on 08/29/2025 at 10:55 a.m., LVN A stated he was trained on trach care 3-4 months ago. He stated he never performed trach care on a resident at the facility. He stated he felt like he would need supervision to perform trach care as he had only ever performed trach care on a mannequin. He stated he was never asked to perform trach care at the facility and had only provided residents with trach care supplies when they asked. LVN A stated although he had been trained on proper trach care and equipment, he had not received any periodic evaluations on his trach skills and knowledge. He stated he knew it was important to have trach care education because it was life threatening and residents could be at risk of airway obstruction and infection. He stated it would not be acceptable for a resident to wash their inner cannula in the sink because the water was not sterile. During an interview on 08/29/2025 at 11:27 p.m., the RDON stated staff were skill-checked every six months on trach care. The RDON stated the last check-off was early June and July of 2025. The RDON stated she was responsible for skill-checking nurses on trach care and knew it was important to educate nurses on trach care because residents could be at risk for any complication. The RDON stated she was still looking for staff competency evaluations. She expected staff to perform hand hygiene before and after any care and between glove changes. The RDON explained it was important to perform hand hygiene to protect themselves and the resident. The RDON expected staff to follow the Trach Care policy and procedure. Suction was necessary and expected to be applied at the bedside. She expected nurses to apply suction after hyperoxygenation (Breathing oxygen at higher than normal). The RDON stated she expected the nurses to hyperoxygenation the resident before applying suction. She expected the suction to be applied when pulling out the trach, not when going into the trach. The RDON stated she expected trach care equipment available at bedside for emergency services. During a telephone interview on 08/29/25 at 4:18 p.m., the NP stated if nurses were not comfortable and untrained in trach care, residents could be at risk of not receiving proper care, which they could develop infections, respiratory distress, and numerous other complications. The NP stated he was under the impression the RT was responsible for training nurses on trach care, but he had not seen the RT for quite some time. The NP stated he was unaware of how often the RT visited the facility .Interview with the Administrator and RDON on 08/28/2025 at 11:27 a.m., 08/29/2025 at 09:41 a.m., and 08/29/2025 at 1:46 p.m., staff competency skill checkoffs were requested at this time and it was not provided.Record review of facility's policy titled Suctioning the Lower Airway (Endotracheal or Tracheostomy Tube) revised October 2010 reflected: PurposeThe purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.Preparation1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for suctioning.2. Review the resident's care plan to assess for any special needs of the resident.3. Obtain baseline vital signs and oxygen saturation from the resident's medical record.4. Obtain information about the resident's medical history, including date of intubation (tracheostomy), respiratory signs and symptoms, and risk factors for increased secretions, decreased airway clearance and/or airway obstruction (i.e., Chronic Obstructive Pulmonary Disease [COPD], chest trauma, abdominal surgery, and smoking).5. Assemble the equipment and supplies as needed.6. Test equipment before use. Determine if suction equipment is generating appropriate negative pressure. Use lower negative pressure with older residents whose oral mucosa is fragile.a. Wall suction units should be set between 100-120 mm Hg.b. Portable suction devices should have negative pressure set at 10-15 mmHg.General Guidelines1. Complications of suctioning the lower airway include trauma to the airway, infection, hypoxia, hypoxemia, and cardiac dysrhythmias (resulting from hypoxemia). To minimize the risk of complications, apply the following guidelines:a. Suction only as needed, based on assessment of the resident's level of respiratory distress.b. Use sterile equipment to avoid widespread pulmonary and systemic infection (Note: Suctioning of the lower airway is a sterile procedure. All equipment that comes in contact with the lower airway must be sterile.).c. Hyperinflate the resident with a manual resuscitation (Ambu) bad (as ordered) before and after suctioning; andd. Hyperoxygenation the resident by increasing the oxygen flow (as ordered) before the procedure and between suctioning. (Note: After the procedure, oxygen should be readjusted as ordered to prevent oxygen toxicity and increased CO2 in COPD residents.)2. Monitor the resident's pulse and oxygen saturation (see procedure entitled Pulse Oximetry) during suctioning. If pulse decreases more than 20 beats per minute (8PM) or increases more than 40 8PM, or oxygen saturation drops below 90 percent (or 5 percent from baseline) discontinue suctioning and re ventilate and re-oxygenate the resident.Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure.1. Sterile suction catheter kit.2. Sterile drape.3. Sterile cup.4. Sterile gloves.5. #10 to #16 French catheter (catheter outer diameter should not exceed one-half the internal diameter of the tube);6. Sterile gauze.7. Towel or Chux pad.8. 100 cc sterile saline or sterile water.9. Resuscitation (Ambu) bag with supplemental oxygen. 10. Wall or portable unit.11. Tubing (approximately 6 feet); and12. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed).Assessmentl . Identify the following risk factors for impaired airway clearance or aspiration:a. Impaired cough or gag reflex.b. Dysphagia; (difficulty swallowing)c. Weak respiratory muscles (from injury, abdominal surgery, etc.);d. COPD.e. Pulmonary infection.f. Presence of feeding tube.g. Smoking; and/orh. Decreased level of consciousness.2. Assess for the following signs and symptoms of respiratory distress/hypoxia/ hypoxemia:a. Diminished breath sounds.b. Tachypnea.c. Dyspnea.d. Gurgling, crackling or wheezing upon inspiration.e. Cyanosis.f. Decreased oxygen saturation (Sp02);g. Restlessness; and/orh. Drooling, secretions or vomitus in mouth.Steps in the Procedure1 . Provide for resident privacy.2. Explain the procedure to the resident.3. Perform hand antisepsis.4. Put on gloves. 5. Put on mask and protective eyewear (goggles or face shield), as indicated.6. Assist the resident to semi-Fowler's position with head turned toward you. If the resident is unconscious, place in lateral position facing you.7. Connect one end of suction tubing t 0 suction unit and place the other end near the resident.8. Turn on the suction unit and adjust to appropriate negative pressure (100-120 mmHg for wall unit or 10-15mmHg for portable unit9.Remove gloves.10. Open suction catheter kit.11. Place sterile drape across the resident's chest.12. Remove sterile cup, touching only the outside.13. Fill cup with I 00 cc sterile saline or sterile water.14. Apply sterile gloves. The dominant hand will remain sterile.15. Holding the catheter in dominant hand and the tubing in the non-dominant hand connect the catheter to the tubing.16-Suction a small amount of water from the cup to verify negative pressure. Rest catheter tip on sterile surface (e.g., sterile drape or open catheter kit).17. Remove oxygen or humidity delivery device using non-dominant hand.18. Hyperinflate and hyper oxygenate the resident using an Ambu bag connected to supplemental oxygen.19. Manually ventilate (bag) the resident 4 to 5 times, coordinating with natural breaths. Remove bag.20. instruct the resident to inhale.21. Upon inhalation, insert the catheter into airway (ET tube or tracheostomy tube) without applying suction. Advance the catheter until resistance is met and/or resident coughs (at the [NAME]). Pull back I to2 cm.22. Apply intermittent suction and slowly withdraw catheter while rotating between thumb and forefinger. Limit suction time to no more than IO seconds.23. Re-ventilate and oxygenate the resident for a minimum of one minute between suctions.24. Rinse catheter and tubing with sterile saline or sterile water until clear.25. Assess cardio-pulmonary status.26. Repeat steps 20 through 24, if necessary. Limit suction passes to a maximum of three.27. Suction the oral or nasal cavity. (Note: Oropharyngeal and nasopharyngeal suctioning contaminate the catheter. Do not re-insert catheter into ET or tracheostomy tube.)28. Replace oxygen or humidity delivery device.29. If the resident's physical or medical condition permits, assist the resident to a position that promotes deep breathing and coughing.30. Turn off suction.31. Disconnect catheter from tubing. Wrap catheter around gloved hand. Pull the glove off and over the catheter. Discard in designated receptacle.32.Remove drape and discard in designated receptacle.33. Discard water or saline in commode. Dispose of cup in designated receptacle.34. Empty and rinse collection container if necessary or as indicated by facility protocol.35. Discard personal protective equipment in designated he comfort receptacles. Wash resident, and dry if your hands thoroughly.36. Apply clean gloves and provide oral hygiene for the comfort of the resident, if indicated.37. Perform hand antisepsis.38. Reposition the bed covers. Make the resident comfortable.39. Place the call light within easy reach of the resident.40. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room. Review of facility's policy titled Handwashing/Hand Hygiene revised August 2019 reflected: Policy Statement.1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventingthe transmission of healthcare-associated infections. This was determined to be an Immediate Jeopardy (IJ) on 08/28/2025 at 1:42 p.m. The ADM was notified. The ADM was provided with the IJ template on 08/28/2025 at 1:45 p.m . The following Plan of Removal submitted by the facility was accepted on 09/05/25 at 1:45 p.m.:Plan of Removal - F726 POR Accepted on: 09/05/25 at 01:45 PM Immediate JeopardyOn 08/29/2025, an abbreviated survey was initiated at the Facility. On the same date, the surveyor provided an Immediate Jeopardy (IJ) notification indicating that the facility failed to meet regulatory requirements under F726, placing Resident #2 and potentially others at risk due to lack of competent tracheostomy care.The IJ was triggered due to:- Nurses performing trach care without proper training or competency validation.- Observed unsafe practices including lack of hand hygiene, improper suctioning technique, and absence of oxygenation.- No documented trach care competencies or evaluations for nursing staff.Action 1: Safe Discharge and Removal of Tracheostomy CapabilitiesEffective immediately as of 09/04/2025, the facility will remove all tracheostomy clinical capabilities. All residents with tracheostomies will be safely discharged in coordination with their responsible parties, and no residents requiring tracheostomy care remain in the facility.Residents #2 and #3 were identified as potentially affected and will be discharged accordingly. They have been assessed by Consultant RN and found to be safe, unaffected by deficiencies and in no distress. They will be discharged immediately upon formulation of discharge plan. Resident #2 will be discharged to SNF and Resident #3 will be discharged to hospital pending SNF placement due to need for dialysis. Start Date: 08/30/2025Completion Date: 09/04/2025Responsible: Consultant RN Action 2: Staff Notification of Tracheostomy Capability Removal Regarding refusals of care and non-compliance with ordered nursing treatments and resident education if preference of resident is to complete clinical tasks, this education will extend to all nursing related tasks which any resident has taken upon themselves for self-provided care- A Special Bulletin inservice with sign-in sheet. This was initially completed with DON on 8/30/2025; RN consultant to review. The Facility does not maintain a policy for residents to provide their own treatments outside of self-administration of medication; if a resident refuses or is non-compliant with ordered nursing procedures or treatments it will be documented in progress notes, physician notified, and care plan will be updated. All clinical staff and admissions team members have been notified by mass message that we will no longer accept residents or referrals for tracheostomy dependent residents. Start Date: 08/30/2025Completion Date: 09/04/2025Responsible: Consultant RN/DON/DesigneeAction 3: Final Resident Discharge and DocumentationEffective immediately as of 09/04/2025, the facility will remove all tracheostomy clinical capabilities. All residents with tracheostomies have been safely discharged in coordination with their responsible parties, and no residents requiring tracheostomy care remain in the facility.Start Date: 08/30/2025Completion Date: 9/4/2025Responsible: Consultant RNAction 4: Follow up and MonitoringAction: IJ and POR reviewed during adhoc QAPI with medical director, administrator, outside consultant and DON; POR and POC will be reviewed during monthly QAPI X3 months and revised as needed, to sustain improvement. A second adhoc QAPI was conducted via teleconference to update education plan and review of revisions. A third adhoc QAPI was conducted including RT to discuss further areas of revision to POR and engagement of RT, duties and oversight responsibilities. A fourth QAPI will be held to notify and discuss plan and new clinical capabilities with medical director. Start Date: 08/28/2025Completion Date: 09/4/2025Responsible: AdministratorMonitoring of the POR included the following: An observation on 09/05/25 at 10:15 AM confirmed Resident #2 and Resident #3 were no longer in the building, and no other tracheostomy residents resided in the facility. In an interview on 09/05/25 at 01:27 PM with SW he stated he was contacted by the ADM advising that they had to discharge Resident #2 and Resident #3; the discharge was occurring due to nursing staff lacking the competencies to care for their tracheostomy and facility clinical capabilities changing. SW confirmed Resident #2 was discharged to [SNF B] on 09/04/25 and that Resident #3 was discharged to the hospital on [DATE] and would be discharged to [SNF B] after discharging from the hospital and not returning to the facility. In an interview on 09/05/25 at 05:19 PM with the ADM, she confirmed that both Resident #2 and Resident #3 were discharged from the facility on 09/04/25. She stated Resident #2 was discharged to [SNF B] and that Resident #3 would not be returning from the hospital and would be sent to [SNF B] upon her discharge from the hospital. She stated this was due to the facility changing their clinical capabilities as of 09/05/25 due to not having staff capable of caring for residents with tracheostomies and therefore the facility would not be admitting them. The ADM stated that the message advising staff of the changes in clinical capabilities was sent by the DON to the leadership team that facilitates in new referrals and admissions and makes the decisions of those being admitted ; she stated this included the BOM and SW and provided evidence for review which included the message sent. In an interview on 09/05/25 at 06:34 with DON she confirmed the clinical capabilities changing and notice provided to those that handle admissions such as ADM and SW and notification made to medical director with QAPI meeting, with confirmation of Resident #2 and #3 not returning resulting in no more trach residents in the facility to constitute immediacy. Record review of Resident #2's progress notes reflected a nursing note dated 09/04/25, Resident discharged to [SNF B] via wheelchair with the assistance of transporter and nurse. Personal belongings and medications transfer with resident upon discharge.Record Review of Resident #3's progress notes reflected Resident #3 was discharged to the hospital on [DATE] due to abnormal chest x-ray. A separate progress note entered 09/05/25 by the ADM reflected arrangements made for Resident #3 to go to [SNF B] after discharge from the hospital. Review of text message sent to staff on 09/05/25 in mass message system reflected message that came from DON to staff Please let it be known from this moment forward that our clinical capabilities have changed, and we will no longer be accepting residents who are tracheostomy dependent. The text reflected was sent to department heads. Review of AdHOC QAPI for IJ F695 and F726 dated 09/04/25 reflected: Action: IJ and POR reviewed with medical director, administrator, RN consultant and DON. POR and POC will be reviewed during monthly QAPI X3 months and revised as needed, to sustain improvement. The facility clinical capabilities were discussed, as well as recent decision to transfer all current tracheostomy patients to other facilities/safe medical facility. It was agreed upon that facility will no longer accept new tracheostomy patients for admission.The ADM was informed the Immediate Jeopardy was removed on 08/28/2025 at 4:41 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications);- for one (Resident #1) of four residents reviewed for quality of care. The facility failed notify Resident #1's NP or RP when he was experiencing a change in condition/decline for an unknown length of time when he stopped getting out of bed, was unable to feed himself, and complained of leg pain during personal care. He was admitted to the hospital on [DATE] and was diagnosed with possible aspiration pneumonia (a lung infection that occurs when food or liquid is inhaled into the lungs, leading to inflammation and infection), a UTI, and a left femur fracture. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/25 at 4:27 PM. While the IJ was removed on 05/21/25 4:30 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary medical care, pain, injury, infection, hospitalization, and death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including stroke, unspecified dementia, age-related physical debility, nicotine dependence, and chronic pain syndrome. Review of Resident #1's admission MDS assessment, dated 03/31/25, reflected a BIMS score of 11, indicating a moderate cognitive impairment. Review of Resident #1's admission care plan, reflected there was no focus, goal, or interventions regarding his need for ADL assistance. A focused revision on 05/15/25 reflected Care Plan Meeting with a goal of choosing which activities to attend and that he was an active smoker. Review of Resident #1's Safe Smoking Evaluation, dated 03/28/25, reflected he smoked 3-5 cigarettes a day. Review of Resident #1's incident report, dated 05/07/25 and documented by RN E, reflected she was called by the AD that Resident #1 was on the floor. A head-to-toe assessment was completed, ROM to all extremities, and no apparent injuries were observed. Review of Resident #1's ST treatment note, dated 05/14/25, reflected redirection/cues and encouragement were needed to remain engaged in meal. Increased lethargy was noted with decreased awareness of deficits and impact on PO intake. Review of Resident #1's Care Plan Conference, dated 05/15/25, reflected there were no concerns/issues/changes from the last care plan. Review of Resident #1's progress note, dated 05/15/25 at 2:40 PM and documented by RN A, reflected the following: [Resident #1] been in bed today. And notified NP notified of temp 102.4 [degrees] . (pain medication) given. 6:33 PM [Resident #1] arousable and eating dinner will continue to monitor vital signs. Review of Resident #1's progress note, dated 05/15/25 at 10:14 PM and documented by LVN B, reflected the following: This nurse went to assess [Resident #1] and obtain glucose 235 and administered (insulin). During assessment febrile (showing signs of fever) 102F went to provide (pain medication) but unable to arouse [Resident #1] discarded medication. [Resident #1] was hypertensive 185/105. Noticed resident breathing with accessory muscles. Notified on call received order to transfer to hospital. Review of Resident #1's progress notes, from 05/01/25 - 05/19/25, reflected no other documentation regarding following up post-fall (05/07/25), pain to his left leg, his lethargy, him staying in bed, or being unable to feed himself. Review of Resident #1's EMS records, dated 05/15/25 at 10:19 PM, reflected the following: Dispatched for [Resident #1] at a nursing home who was altered. Staff stated that he may have aspirated (choked) earlier in the day, but he has been altered for two days. Review of Resident #1's hospital records, dated 05/15/25, reflected the following: [Resident #1] presents with altered mental status started this morning. Also noted to have a fever at the skilled nursing facility. [Resident #1] is currently nonverbal, altered, and unable to provide further history . Palliative care assessment and plan: Dyspnea (shortness of breath) 2nd to acute hypoxic (low levels of oxygen in your body tissues) respiratory failure, possible aspiration pneumonia . CTA chest with secretions within left main bronchus, left lower lobe bronchi, patchy left lower lobe opacity. Weakness secondary to above, history of chronic debility. CT revealed subacute fracture of left intertrochanteric femur . Denies pain. Up until recently he was wheelchair-bound and able to transfer, has had multiple falls at facility. Acute urinary tract infection present on admission . He was receiving antibiotics and was still admitted at the hospital as of 05/19/25. During a telephone interview on 05/19/25 at 9:15 AM, Resident #1's RP stated in his care plan meeting on 05/15/25, there was no mention of any kind of change in condition. She stated after the meeting, she went to his room (around 12:15 PM) and he was in bed and out of it. She stated it was difficult to arouse him and when she did, he would not answer any questions. She stated she was surprised he was in his room because he was always out roaming around the facility in his wheelchair. She stated she had not seen him in 2-3 weeks, but when she last saw him, he was at his baseline - wheeling himself around in his wheelchair and in the dining room eating lunch. She stated staff told her he had not smoked that day and historically he smoked every chance he got. She stated she was most concerned with the fact that he had a femur fracture upon admission to the ER as she had not been notified of any recent falls. She stated she could not believe she was not notified of any of his changes in condition as she would have sought out immediate medical care sooner. During an interview on 05/19/25 at 10:27 AM, MA C stated she worked with Resident #1 the week prior (including 05/15/25), and she stated he did not get out of bed when he was usually up in his wheelchair. She stated she could not remember how many days he was like that, but it had been a few. She stated he did take his medications, but appeared more lethargic than normal. During an interview on 05/19/25 at 10:36 AM, RN A stated she was PRN but knew Resident #1 well. She stated when she started her shift on 05/15/25, she immediately knew he was not himself. She stated he did not get out of bed, had to be fed when he normally ate everything by himself in the dining room for meals, and he did not smoke at all that day. She stated he normally was always looking to smoke. She was told by the previous nurse (at shift change) that he had not been out of bed the previous day either. She stated Resident #1's RP visited him and requested that he be put in his wheelchair. She stated they attempted to, but he was not looking good, looked sick, and was very drowsy. She stated she contacted the NP and got orders for labs . She stated in the afternoon he had a fever that would not subside, and he was later (after her shift) sent to the ER. During a telephone interview on 05/19/25 at 10:55 AM, CNA D stated she worked with Resident #1 on 05/12/25 and 05/13/25. She stated on both of those days he was not himself. She stated he stayed in bed the whole day and she had to feed him. She stated when she changed his brief, he would complain of pain to his left leg. She stated she could not remember who the nurse was, but believed she knew about the pain and that he was not at his baseline. She stated she did not remember specifically notifying her nurse. During a telephone interview 05/19/25 at 11:26 AM, CNA I stated he worked with Resident #1 one day before he went to the hospital (on 05/15/25). He stated he was not assigned to him specifically but was helping on the hall. He stated he remembered seeing him asleep in his room at lunch time which was extremely unusual for him. He stated he was normally in his wheelchair in the dining room for meals. He stated he did not remember if he notified his nurse. During a telephone interview on 05/19/25 at 11:36 AM, RN E stated she had worked with Resident #1 on 05/14/25. She stated he was in bed and asked CNA D to get him up, but she told him he refused. She stated she went into his room and his breakfast tray was sitting there. She stated she had to help him eat breakfast. She stated that was not normal for him as he normally fed himself while in his wheelchair. She stated she asked him if he wanted to get out of bed and he yelled, No! No! Leave me alone! I do not want to get up! She stated it was not normal for him but thought maybe he was tired . She stated she had been off for a few days prior to 05/14/25 so she was not sure how long it had been going on. She stated if she had known it had been more than that day, she would have notified the NP immediately because that was a big change in condition for him. She stated CNA D never notified her that he had complained of pain. During a telephone interview on 05/19/25 at 11:06 AM, CNA F stated he last worked with Resident #1 on 05/13/25. He stated for several days prior to 05/13/25 (up to two weeks), he had been declining. He stated he was hardly talking, was not active, was staying in bed, was not going outside to smoke, and would complain of leg pain when he changed his brief. He stated he believed the nurses were aware, but could not remember if he specifically told his nurse. During a telephone interview on 05/19/25 at 11:49 AM, NP G stated she was covering for NP H while he was on vacation and was not Resident #1's regular NP. She stated she had not been notified of any change in condition for Resident #1 until the day he went to the hospital on [DATE]. She stated she would have expected to have been notified sooner if there had been a change in condition. During an interview on 05/19/25 at 2:02 PM, the ADM stated Resident #1 was sent out on 05/15/25 due to a change in condition such as a fever and lethargy. She stated his baseline was he was always in his wheelchair and was very interactive with people. She stated he was not completely cognitive but could express how he was or what he needed. She stated she was not informed of any changes before that day. She stated he was a smoker but rarely smoked. She stated if there had been a change in condition such as not being able to feed himself, she would expect for the nurses to notify the DON and NP and seek recommendations such as labs, a UA, and to find out what was occurring. She stated she remembered seeing him up and about in his wheelchair until 05/15/25. She stated she was not aware he had acquired a fracture but did not believe it was due to the fall on 05/07/25. She stated, per the nursing staff, he did not sustain any injuries from the fall. During a telephone interview on 05/20/25 at 9:03 AM, NP H stated he had been on vacation and NP G had been covering for him. He stated he did remember being notified of a fall for Resident #1 on 05/07/25 and was informed there were no injuries. He stated he had not been notified of any changes after the fall incident. He stated if Resident #1 had been in bed for days, not feeding himself, and was in pain, that would be extremely concerning because that would be a huge change in condition for him. He stated NP G should have been notified immediately because she could have ordered labs and a UA, been assessed, or could have been sent to the ER sooner. Review of the facility's Change in a Resident's Condition or Status Policy, Revised December of 2010, reflected the following: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and or/status. 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been a significant change in the resident's physical/emotional/mental condition. 2. A significant change of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff by implementing standard disease-related clinical interventions. The ADM was notified on 05/19/25 at 4:27 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 05/21/25 at 7:38 AM: Immediate action: 05/19/2025 Resident #1 was affected by this deficiency (F580) and was sent out to the hospital on [DATE] and admitted to the hospital for treatment. The Director of nursing and/or nursing supervisor initiated a comprehensive assessment- Daily Skill Note of all residents on 5/19/2025 and is ongoing to be completed on 05/21/2025, to identify any unreported changes of condition. An investigation was initiated on 05/19/2025 by the Administrator on the course of change of condition for the resident #1, investigation is ongoing. Training of staff on change in resident's condition or status was initiated by the Administrator on 05/19/2025, training is estimated to be completed by 05/22/2025. An audit of the 24- hour report on residents was initiated by the Administrator and DON on 05/19/2025 for identification of any change of condition, task was completed on 05/20/2025. The CEO educated the Administrator and DON on the facility promptly notify the resident, his or her physician and representative of changes in the resident's medical/ mental condition and/ or status and comprehension verified at the same time, this was completed on 05/19/2025, prior to In servicing staff. The facility is verifying comprehension on staff training by following up after education based on a random selection. A testing form will be provided electronically to test knowledge. The Administrator will verify results from testing. Verbal contact with personnel began on 05/19/2025 on in-servicing of change in a resident's condition by department heads. Staff will not be allowed to work their shifts until this Inservice, and training has been completed, this includes PRN and new staff. The Administrator will be responsible for the direct Inservice of her staff, completed on 05/20/2025. Identification of others: All residents who have a change of condition have the potential to be impacted by this deficient practice. The Administrator reviewed all residents with changes of condition (completed 05/19/25) to identify changes/needs. All changes of conditions were reported to physician/ NP, if any by the charge nurse. As of 5/19/2025 there were no new findings. Action: Review of residents on the 24-hour report to identify any change of conditions. After review of report findings of the change of conditions, we identified five residents with a change of condition or behavior ensured that documentation of notification to physician/NP was completed. Start Date: 5/19/25 Completion Date: 5/20/25 Responsible: DON, ADON Action: Creation of spreadsheet of an audit for identifying change of condition of the current residents in the facility. Any other residents identified with a change of condition; physician/NP will be notified. Any treatments/ care received will be provided to the residents. Start Date: 5/19/25 Completion Date: 5/20/25 Responsible: DON, Administrator A review is of the change in a resident's condition or status policy was reviewed on 05/19/2025 to ensure communication on the protocol, defining a change of condition, and notification/ documentation of changes in condition or status was done by the Ad-Hoc QAPI team and revisions will be submitted to the facility for approval. No revisions were noted to be made as of 5/19/2025. The Administrator has created an audit tool to monitor compliance the facility's communication procedure for contacting Physicians and confirming changes of condition have been documented for three times a week for two weeks, weekly for two weeks and monthly for two months. Audits will be conducted by the DON daily for two weeks, weekly for 2 weeks and monthly for two months, a spreadsheet was created for the audit to be conducted and documented. Any negative findings will be reported to the administrator for immediate correction. The Medical Director was notified of the deficiency (F580) on 05/19/2025 and an Ad-Hoc QAPI meeting was held on 05/19/2025 to discuss the findings. In-service: An Inservice was conducted by the Administrator with the department heads on changes of condition. Following an Inservice was initiated by department heads with all staff (this includes PRN and new staff) on changes of condition with staff on ensuring education on notification to charge nurse, documentation of change of condition in electronic health record, and physician/ NP notification done by the nurse supervisor/ charge nurse. Verbal notification of all staff was initiated on 05/19/2025 and will obtain signatures upon arrival to the facility, this includes PRN and new staff. The Administrator will oversee the in-service. Expected compliance date is 05/19/2025. The Surveyor monitored the POR on 05/21/25 as followed: During interviews on 05/21/25 from 11:38 AM - 4:02 PM, one HSK, the MS, one MA, three CNAs, three LVNS, and two RNs from all shifts stated they were in-serviced on reporting changes of condition before starting their shifts. They all stated they would notify their charge nurse and the DON should the notice a change of condition in a resident. The nurses stated they would immediately notify the NP and document the changes in the resident's HER. They all gave examples of changes in condition, such as lethargy, staying in bed more often, or eating less than normal. During an interview on 05/21/25 at 2:56 PM, the DON stated she initiated the comprehensive assessments on all residents from 05/19/25 through 05/21/25. She identified 5 residents on 05/19/25, 2 residents on 05/20/25, and 2 residents on 05/21/25 as having change in condition. She notified the physician and family, transferred residents to hospital as indicated, and conducted additional orders as indicated. She and the ADM initiated and audit of the 24-hour reports on all residents to identify any change in condition and had the same results as found during the comprehensive assessments on all residents. She was in-serviced by the CEO on 05/19/25 on change in condition policy and procedure. She learned types of changes in condition, notifying change in condition to MD, RP, physician, and family as indicated, and document in change in condition, UDA, or progress notes. She prepared an audit spreadsheet that was to be reviewed and documented on for 2 weeks, weekly for 2 weeks, and monthly for 2 months on 05/19/25. There were some change in conditions (negative findings) identified, ADM was notified, and the notifications to the NP/Physician and family/RP were sent out on 05/19/25. She attended QAPI on 05/19/25. ADM notified the MD on 05/19/25. She also attended the department heads in-service on 05/19/25 and learned the same material as what was presented by the CEO. ADM was in-serviced by staff by phone, electronic, and in-person before they started their shifts. During an interview on 05/21/25 at 3:11 PM, the ADM stated she investigated Resident #1's change in condition. She in-serviced staff on change in condition. She found it was inconclusive if there was a change in condition based on interviews with staff informing her that Resident #1 was able to respond, feed himself, and wanted to stay in bed. Her and the DON were educated by CEO on 05/19/25 on change in condition policy, what to do when there was a change in condition, who notified physician and family, and ensuring there was documentation. She learned the types of change in condition, reporting change in condition to charge nurse, immediately notifying the physician and NP, and documenting in residents' EHR, SBAR, progress note, and residents' assessment. Her and the DON were also given comprehension tests verifying they were educated on change in condition on 05/19/25. She in-serviced the department heads on 05/19/25. Department heads in-serviced the staff in their departments started on 05/19/25. Staff who were in-serviced in person were able to sign acknowledging receiving the in-service. Staff not available in person were in-serviced by phone by the department heads on 05/19/25. She also had presented random selection comprehension tests to staff in-serviced on change in condition on 05/20/25. Her and the DON audited the 24-hour reports to identify any other residents with change in condition on 05/19/25 and completed on 05/20/25. There were no residents identified on 05/19/25. There were residents identified on 05/20/25 as having a change in condition. The residents' charts were reviewed and the DON ensured the NP/Physician was notified of the change in condition by reviewing the EHR and contacting NP. She performed a review of all residents with change in condition on 05/19/25. There were no residents noted with a change in condition on 05/19/25 during her review of the 24 hours reports. She prepared an audit tool to monitor compliance for communicating/contacting physician for three times a week for two weeks, weekly for two weeks, and monthly for two months on 05/19/25. She started to monitor the audit on 05/20/25 after the 5 residents were identified as having a change in condition. Ad-Hoc QAPI reviewed the change in condition policy on 05/19/25 and there were no revisions to the policy that needed to be completed. QAPI also met on 05/19/25 to discuss the PORs and action to remove the IJs. She notified the MD by phone on 05/19/25. Review of the facility's Ad-Hoc QAPI meeting agenda, dated 05/19/25, reflected the ADM, the DON, the SW, the DOR, the BOM, the SC, the HSKS, and the MD were in attendance. Review of the ADM's and DON's in-service comprehension verification by the CEO, dated 05/19/25, reflected they were tested on the reporting change in condition training. Review of the Facility's Change in a Resident's Condition or Status Policy, revised December 2010, reflected the facility reviewed the policy and procedure on 05/19/25, ensured significant change was defined and physician notification and documentation procedures were present. There were no updates needed at the time of the review. Review of the ADM's and DON's Audit Tool, on 05/21/25, reflected a spreadsheet in which they would monitor compliance for communicating and contacting the physician three time a week for two weeks, weekly for two weeks, and monthly for two months. The ADM and DON would review and document the date, resident, change in condition (if any), and documentation of contact. Review of the ADM's and DON's Audit Spreadsheet, on 05/21/25, reflected they would identify any residents with a change in condition by reviewing and documenting the date, resident, change in condition, date the PCP/NP was notified, and any treatment or care given to the resident. Review of the ADM's and DON's audit of all residents 24-hour reports, from 05/18/25 through 05/20/25, reflected there were five residents identified with a change in condition or behavior. NP/Physician and RP/Family were notified of the changes in condition. Review of the Department Heads In-Service, dated 05/19/25, reflected they were educated on reporting resident's change in condition. Review of the Staff's In-Service, dated 05/19/25, reflected they were educated on reporting resident's change in condition by the DON. Review of the Staff In-Service Verbal Notification, from 05/19/25 - 05/20/25, reflected staff who were not present for the in-person in-service were verbally notified and in-serviced. Review of the ADM's audit template, undated, reflected a spreadsheet that will be used to monitor resident's 24-hour reports to identify any changes in condition. The ADM was notified on 05/21/25 at 4:30 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern 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 interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. The facility failed to ensure staff did not address (and/or document) a change in condition for an unknown length of time when Resident #1 stopped getting out of bed, was unable to feed himself, and complained of leg pain during personal care. He was admitted to the hospital on [DATE] and was diagnosed with possible aspiration pneumonia (a lung infection that occurs when food or liquid is inhaled into the lungs, leading to inflammation and infection), a UTI, and a left femur fracture. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/25 at 4:27 PM. While the IJ was removed on 05/21/25 4:30 PM, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary medical care, pain, injury, infection, hospitalization, and death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including stroke, unspecified dementia, age-related physical debility, nicotine dependence, and chronic pain syndrome. Review of Resident #1's admission MDS assessment, dated 03/31/25, reflected a BIMS score of 11, indicating a moderate cognitive impairment. Review of Resident #1's admission care plan, reflected there was no focus, goal, or interventions regarding his need for ADL assistance. A focused revision on 05/15/25 reflected Care Plan Meeting with a goal of choosing which activities to attend and that he was an active smoker. Review of Resident #1's Safe Smoking Evaluation, dated 03/28/25, reflected he smoked 3-5 cigarettes a day. Review of Resident #1's incident report, dated 05/07/25 and documented by RN E, reflected she was called by the AD that Resident #1 was on the floor. A head-to-toe assessment was completed, ROM to all extremities, and no apparent injuries were observed. Review of Resident #1's ST treatment note, dated 05/14/25, reflected redirection/cues and encouragement were needed to remain engaged in meal. Increased lethargy was noted with decreased awareness of deficits and impact on PO intake. Review of Resident #1's Care Plan Conference, dated 05/15/25, reflected there were no concerns/issues/changes from the last care plan. Review of Resident #1's progress note, dated 05/15/25 at 2:40 PM and documented by RN A, reflected the following: [Resident #1] been in bed today. And notified NP notified of temp 102.4 [degrees] . (pain medication) given. 6:33 PM [Resident #1] arousable and eating dinner will continue to monitor vital signs. Review of Resident #1's progress note, dated 05/15/25 at 10:14 PM and documented by LVN B, reflected the following: This nurse went to assess [Resident #1] and obtain glucose 235 and administered (insulin). During assessment febrile (showing signs of fever) 102F went to provide (pain medication) but unable to arouse [Resident #1] discarded medication. [Resident #1] was hypertensive 185/105. Noticed resident breathing with accessory muscles. Notified on call received order to transfer to hospital. Review of Resident #1's progress notes, from 05/01/25 - 05/19/25, reflected no other documentation regarding following up post-fall (05/07/25), pain to his left leg, his lethargy, him staying in bed, or being unable to feed himself. Review of Resident #1's EMS records, dated 05/15/25 at 10:19 PM, reflected the following: Dispatched for [Resident #1] at a nursing home who was altered. Staff stated that he may have aspirated (choked) earlier in the day, but he has been altered for two days. Review of Resident #1's hospital records, dated 05/15/25, reflected the following: [Resident #1] presents with altered mental status started this morning. Also noted to have a fever at the skilled nursing facility. [Resident #1] is currently nonverbal, altered, and unable to provide further history . Palliative care assessment and plan: Dyspnea (shortness of breath) 2nd to acute hypoxic (low levels of oxygen in your body tissues) respiratory failure, possible aspiration pneumonia . CTA chest with secretions within left main bronchus, left lower lobe bronchi, patchy left lower lobe opacity. Weakness secondary to above, history of chronic debility. CT revealed subacute fracture of left intertrochanteric femur . Denies pain. Up until recently he was wheelchair-bound and able to transfer, has had multiple falls at facility. Acute urinary tract infection present on admission. He was receiving antibiotics and was still admitted at the hospital as of 05/19/25. During a telephone interview on 05/19/25 at 9:15 AM, Resident #1's RP stated in his care plan meeting on 05/15/25, there was no mention of any kind of change in condition. She stated after the meeting, she went to his room (around 12:15 PM) and he was in bed and out of it. She stated it was difficult to arouse him and when she did, he would not answer any questions. She stated she was surprised he was in his room because he was always out roaming around the facility in his wheelchair. She stated she had not seen him in 2-3 weeks, but when she last saw him, he was at his baseline - wheeling himself around in his wheelchair and in the dining room eating lunch. She stated staff told her he had not smoked that day and historically he smoked every chance he got. She stated she was most concerned with the fact that he had a femur fracture upon admission to the ER as she had not been notified of any recent falls. During an interview on 05/19/25 at 10:27 AM, MA C stated she worked with Resident #1 the week prior (including 05/15/25), and she stated he did not get out of bed when he was usually up in his wheelchair. She stated she could not remember how many days he was like that, but it had been a few. She stated he did take his medications, but appeared more lethargic than normal. During an interview on 05/19/25 at 10:36 AM, RN A stated she was PRN but knew Resident #1 well. She stated when she started her shift on 05/15/25, she immediately knew he was not himself. She stated he did not get out of bed, had to be fed when he normally ate everything by himself in the dining room for meals, and he did not smoke at all that day. She stated he normally was always looking to smoke. She was told by the previous nurse (at shift change) that he had not been out of bed the previous day either. She stated Resident #1's RP visited him and requested that he be put in his wheelchair. She stated they attempted to, but he was not looking good, looked sick, and was very drowsy. She stated she contacted the NP and got orders for labs . She stated in the afternoon he had a fever that would not subside, and he was later (after her shift) sent to the ER. During a telephone interview on 05/19/25 at 10:55 AM, CNA D stated she worked with Resident #1 on 05/12/25 and 05/13/25. She stated on both of those days he was not himself. She stated he stayed in bed the whole day and she had to feed him. She stated when she changed his brief, he would complain of pain to his left leg. She stated she could not remember who the nurse was, but believed she knew about the pain and that he was not at his baseline. She stated she did not remember specifically notifying her nurse. During a telephone interview 05/19/25 at 11:26 AM, CNA I stated he worked with Resident #1 one day before he went to the hospital (on 05/15/25). He stated he was not assigned to him specifically but was helping on the hall. He stated he remembered seeing him asleep in his room at lunch time which was extremely unusual for him. He stated he was normally in his wheelchair in the dining room for meals. He stated he did not remember if he notified his nurse. During a telephone interview on 05/19/25 at 11:36 AM, RN E stated she had worked with Resident #1 on 05/14/25. She stated he was in bed and asked CNA D to get him up, but she told him he refused. She stated she went into his room and his breakfast tray was sitting there. She stated she had to help him eat breakfast. She stated that was not normal for him as he normally fed himself while in his wheelchair. She stated she asked him if he wanted to get out of bed and he yelled, No! No! Leave me alone! I do not want to get up! She stated it was not normal for him but thought maybe he was tired. She stated she had been off for a few days prior to 05/14/25 so she was not sure how long it had been going on. She stated if she had known it had been more than that day, she would have notified the NP immediately because that was a big change in condition for him. She stated CNA D never notified her that he had complained of pain. During a telephone interview on 05/19/25 at 11:06 AM, CNA F stated he last worked with Resident #1 on 05/13/25. He stated for several days prior to 05/13/25 (up to two weeks), he had been declining. He stated he was hardly talking, was not active, was staying in bed, was not going outside to smoke, and would complain of leg pain when he changed his brief. He stated he believed the nurses were aware, but could not remember if he specifically told his nurse. During a telephone interview on 05/19/25 at 11:49 AM, NP G stated she was covering for NP H while he was on vacation and was not Resident #1's regular NP. She stated she had not been notified of any change in condition for Resident #1 until the day he went to the hospital on [DATE]. She stated she would have expected to have been notified sooner if there had been a change in condition. During an interview on 05/19/25 at 2:02 PM, the ADM stated Resident #1 was sent out on 05/15/25 due to a change in condition such as a fever and lethargy. She stated his baseline was he was always in his wheelchair and was very interactive with people. She stated he was not completely cognitive but could express how he was or what he needed. She stated she was not informed of any changes before that day. She stated he was a smoker but rarely smoked. She stated if there had been a change in condition such as not being able to feed himself, she would expect for the nurses to notify the DON and NP and seek recommendations such as labs, a UA, and to find out what was occurring. She stated she remembered seeing him up and about in his wheelchair until 05/15/25. She stated she was not aware he had acquired a fracture but did not believe it was due to the fall on 05/07/25. She stated, per the nursing staff, he did not sustain any injuries from the fall. During a telephone interview on 05/20/25 at 9:03 AM, NP H stated he had been on vacation and NP G had been covering for him. He stated he did remember being notified of a fall for Resident #1 on 05/07/25 and was informed there were no injuries. He stated he had not been notified of any changes after the fall incident. He stated if Resident #1 had been in bed for days, not feeding himself, and was in pain, that would be extremely concerning because that would be a huge change in condition for him. He stated NP G should have been notified immediately because she could have ordered labs and a UA, been assessed, or could have been sent to the ER sooner. Review of the facility's Change in a Resident's Condition or Status Policy, Revised December of 2010, reflected the following: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and or/status. 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been a significant change in the resident's physical/emotional/mental condition. 2. A significant change of condition is a decline or improvement in the resident's status that will not normally resolve itself without intervention by staff by implementing standard disease-related clinical interventions. The ADM was notified on 05/19/25 at 4:27 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 05/21/25 at 7:38 AM: Immediate action: 05/19/2025 Resident #1 was affected by this deficiency (F684) and was sent out to the hospital on [DATE] and admitted to the hospital for treatment. The Director of nursing and/or nursing supervisor initiated a comprehensive assessment- Daily Skill Note, of all residents on 5/19/2025 and is ongoing to be completed on 05/21/2025 to identify any unreported changes of condition. An investigation was initiated on 05/19/2025 by the Administrator on the course of change of condition for the Resident #1, investigation is ongoing. Training of staff on change in resident's condition or status was initiated by the Administrator on 5/19/2025, training is estimated to be completed by 05/22/2025. An audit of the 24- hour report on residents was initiated by the Administrator and DON on 05/19/2025 for identification of any change of condition, task was completed on 05/20/2025. The CEO educated the Administrator and DON on the facility promptly notifying the resident, his or her physician and representative of changes in the resident's medical/ mental condition and/ or status and comprehension verified at the same time, this was completed on 05/19/2025, prior to in-servicing staff. The facility is verifying comprehension on staff training by following up after education based on a random selection. A testing form will be provided electronically to test knowledge. The Administrator will verify results from testing. Verbal contact with personnel began on 05/19/2025 on in-servicing of change in a resident's condition by department heads. Staff will not be allowed to work their shifts until this in-service, and training has been completed, this includes PRN and new staff. The Administrator will be responsible for the direct Inservice of her staff, completed on 05/20/2025. Identification of others: All residents who have a change of condition have the potential to be impacted by this deficient practice. The Administrator reviewed all residents with changes of condition (completed 05/19/25) to identify changes/needs. All changes of conditions were reported to the physician/ NP, if any by the charge nurse. As of 5/19/2025 there were no new findings. Action: Review of residents on the 24-hour report to identify any change of conditions. After review of report findings of the change of conditions, we identified five residents with a change of condition or behavior ensured that documentation of notification to physician/NP was completed. Start Date: 5/19/25 Completion Date: 5/20/25 Responsible: DON, ADON Action: Creation of spreadsheet of an audit identifying change of condition of the current residents in the facility. Any other residents identified with a change of condition; physician/NP will be notified. Any treatments/ care received will be provided to the residents. Start Date: 5/19/25 Completion Date: 5/20/25 Responsible: DON, Administrator A review is of the change in a resident's condition or status policy was reviewed and completed on 5/19/2025 to ensure communication on the protocol, defining a change of condition, and notification/ documentation of changes in condition or status was done by the Ad-Hoc QAPI team and revisions will be submitted to the facility for approval. No revisions were noted to be made as of 5/19/2025. The Administrator has created an audit tool to monitor compliance the facility's communication procedure for contacting Physicians and confirming changes of condition have been documented for three times a week for two weeks, weekly for two weeks and monthly for two months. Audits will be conducted by the DON daily for two weeks, weekly for 2 weeks and monthly for two months, a spreadsheet was created for the audit to be conducted and documented. Any negative findings will be reported to the administrator for immediate correction. The Medical Director was notified of the deficiency (F684) on 05/19/2025 and an Ad-Hoc QAPI meeting was held on 05/19/2025 to discuss the findings. In-service: An Inservice was conducted by the Administrator with the department heads on changes of condition. Following an Inservice was initiated by department heads with all staff (this includes PRN and new staff) on changes of condition with staff on ensuring education on notification to charge nurse, documentation of change of condition in electronic health record, and physician/ NP notification done by the nurse supervisor/ charge nurse. Verbal notification of all staff was initiated on 05/19/2025 and will obtain signature upon their arrival to the facility, this includes PRN and new staff. The Administrator will oversee the in-service. Expected compliance date is 05/19/2025. The Surveyor monitored the POR on 05/21/25 as followed: Review of the ADM's and DON's in-service comprehension verification by the CEO, dated 05/19/25, reflected they were tested on the reporting change in condition training. Review of the Department Heads In-Service, dated 05/19/25, reflected they were educated on reporting resident's change in condition. Review of the Staff's In-Service, dated 05/19/25, reflected all staff were educated on reporting resident's change in condition by the DON. Review of the Staff In-Service Verbal Notification, from 05/19/25 - 05/20/25, reflected staff who were not present for the in-person in-service were verbally notified and in-serviced. During interviews on 05/21/25 from 11:38 AM - 4:02 PM, one HSK, the MS, one MA, three CNAs, three LVNS, and two RNs from all shifts stated they were in-serviced on reporting changes of condition before starting their shifts. They all stated they would notify their charge nurse and the DON should they notice a change of condition in a resident. The nurses stated they would immediately notify the NP and document the changes in the resident's EHR. They all gave examples of changes in condition, such as lethargy, staying in bed more often, or eating less than normal. During an interview on 05/21/25 at 2:56 PM, the DON stated she initiated the comprehensive assessments on all residents from 05/19/25 through 05/21/25. She identified 5 residents on 05/19/25, 2 residents on 05/20/25, and 2 residents on 05/21/25 as having change in condition. She notified the physician and families, transferred the residents to hospital as indicated, and conducted additional orders as indicated. She and the ADM initiated an audit of the 24-hour reports on all residents to identify any change in condition and had the same results as found during the comprehensive assessments on all residents. She was in-serviced by the CEO on 05/19/25 on the change in condition policy and procedure. She learned the types of changes in condition, notifying change in condition to the MD, RP, physician, and family as indicated, and documenting the change in condition, UDA, or progress notes. She prepared an audit spreadsheet that was to be reviewed and documented on for 2 weeks, weekly for 2 weeks, and monthly for 2 months on 05/19/25. There were some changes in conditions (negative findings) identified, the ADM was notified, and the notifications to the NP/Physician and family/RP were sent out on 05/19/25. She attended the QAPI on 05/19/25. The ADM notified the MD on 05/19/25. She also attended the department heads in-service on 05/19/25 and learned the same material as what was presented by the CEO. The ADM was in-serviced by staff by phone, electronic, and in-person before they started their shifts. During an interview on 05/21/25 at 3:11 PM, the ADM stated she investigated Resident #1's change in condition. She in-serviced staff on change in condition. She found it was inconclusive if there was a change in condition based on interviews with staff informing her that Resident #1 was able to respond, feed himself, and wanted to stay in bed. She and the DON were educated by the CEO on 05/19/25 on change in condition policy, what to do when there was a change in condition, who notified physician and family, and ensuring there was documentation. She learned the types of change in condition, reporting change in condition to the charge nurse, immediately notifying the physician and NP, and documenting in the residents' EHRs, SBAR, progress notes, and residents' assessments. She and the DON were also given comprehension tests verifying they were educated on change in condition on 05/19/25. She in-serviced the department heads on 05/19/25. The department heads in-serviced the staff in their departments starting on 05/19/25. Staff who were in-serviced in person were able to sign acknowledging receiving the in-service. Staff not available in person were in-serviced by phone by the department heads on 05/19/25. She also had presented a random selection comprehension tests to staff in-serviced on change in condition on 05/20/25. She and the DON audited the 24-hour reports to identify any other residents with change in condition on 05/19/25 and completed on 05/20/25. There were no residents identified on 05/19/25. There were residents identified on 05/20/25 as having a change in condition. The residents' charts were reviewed and the DON ensured the NP/Physician was notified of the change in condition by reviewing the EHR and contacting the NP. She performed a review of all residents with change in condition on 05/19/25. There were no residents noted with a change in condition on 05/19/25 during her review of the 24 hours reports. She prepared an audit tool to monitor compliance for communicating/contacting physician for three times a week for two weeks, weekly for two weeks, and monthly for two months on 05/19/25. She started to monitor the audit on 05/20/25 after the 5 residents were identified as having a change in condition. The Ad-Hoc QAPI reviewed the change in condition policy on 05/19/25 and there were no revisions to the policy that needed to be completed. The QAPI also met on 05/19/25 to discuss the PORs and action to remove the IJs. She notified the MD by phone on 05/19/25. Review of the facility's Ad-Hoc QAPI meeting agenda, dated 05/19/25, reflected the ADM, the DON, the SW, the DOR, the BOM, the SC, the HSKS, and the MD were in attendance. Review of the facility's Change in a Resident's Condition or Status Policy, revised December 2010, reflected the facility reviewed the policy and procedure on 05/19/25, ensured significant change was defined and physician notification and documentation procedures were present. There were no updates needed at the time of the review. Review of the ADM's and DON's Audit Tool, on 05/21/25, reflected a spreadsheet in which they would monitor compliance for communicating and contacting the physician three time a week for two weeks, weekly for two weeks, and monthly for two months. The ADM and DON would review and document the date, resident, change in condition (if any), and documentation of contact. Review of the ADM's and DON's Audit Spreadsheet, on 05/21/25, reflected they would identify any residents with a change in condition by reviewing and documenting the date, resident, change in condition, date the PCP/NP was notified, and any treatment or care given to the resident. Review of the ADM's and DON's audit of all residents 24-hour reports, from 05/18/25 through 05/20/25, reflected there were five residents identified with a change in condition or behavior. The NP/Physician and RP/Family were notified of the changes in condition. Review of the ADM's audit template, undated, reflected a spreadsheet that will be used to monitor resident's 24-hour reports to identify any changes in condition. The ADM was notified on 05/21/25 at 4:30 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern 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 each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 5 residents (Resident #1) reviewed for prevention and treatment of mental and substance use disorders. -The facility failed to ensure behavioral health interventions were implemented for Resident#1, who was admitted with a diagnosis of bi-polar disorder and had a history of being aggressive to residents and staff, after physician orders for psychiatry evaluation and management were received on 02/24/25 and again on 03/08/25. -The facility failed to protect Resident #2 from Resident #1 when Resident #1 scratched Resident #2 with her fingernails during an outburst on 05/03/25 which caused injuries to his thigh. An IJ was identified on 05/08/25. The IJ template was provided to the facility on [DATE] at 5:26 PM. While the IJ was removed on 05/10/25, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving behavioral health services, not having their mental and psychosocial needs met, and a decline in quality of life. Findings included: A review of Resident #1's face sheet, printed on 05/08/25 reflected a [AGE] year-old female admitted to the facility on [DATE] Her diagnoses included partial traumatic amputation of right foot (loss of a body part as the result of an accident or injury), bipolar disorder (a mental illness that causes extreme mood swings), unspecified intellectual disabilities (a condition that limits intelligence and disrupts abilities necessary for living independently), major depressive disorder, and type 2 diabetes (a condition that affects the way the body processes blood sugar). A review of Resident #1's quarterly MDS assessment, dated 04/07/25, Section C (Cognitive Patterns) reflected a BIMS score of 15 which indicated intact cognition. Section D (Mood) reflected she felt down, depressed, or hopeless two to six days in the previous two weeks. Section E (behavior) reflected no behaviors occurred during the reporting period. Section GG (Functional Abilities) reflected resident was independent with wheelchair mobility. Section O (Special Treatments, Procedures, and Programs) reflected the resident did not receive any psychological therapy. A review of Resident #1's comprehensive care plan revealed in part: Focus: (Resident #1) has a diagnosis of bipolar disorder. Date initiated 05/08/25. Goals: The resident will identify coping mechanisms (new and old) by the review date. Date initiated 05/08/25. Mood stabilization: Managing and stabilizing mood fluctuations to minimize the severity and duration of manic and depressive episodes. Date initiated 05/08/25. Interventions: Allow the resident time to answer questions and verbalize feelings, perceptions, and fears. Date initiated 05/08/25. Provide opportunities for the resident and family to participate in care. Date initiated 05/08/25. The resident needs assistance/encouragement/support to identify problems that cannot be controlled. Date initiated 05/08/25. Focus: (Resident #1) has demonstrated demanding behaviors towards others, yelling, pushing, hitting, scratching. Date initiated 05/05/25. Goals: Demonstrate less demanding behavior towards others over the next 90 days. Date initiated 05/05/25. Review possible options for adjusting to the current situation over the next 90 days. Date initiated 05/05/25. Interventions: Encourage participation in activities with other residents who have interests that are similar. Date initiated 05/05/25. Enlist assistance of family in controlling demanding behaviors as needed. Date initiated 05/05/25. Listen openly to resident's requests and offer assistance, explanations or clarifications as needed. Date initiated 05/05/25. Offer an outlet for resident to express feelings, wishes, and frustrations. Date initiated 05/05/25 . A review of Resident #1's current physician orders reflected the following: BEHAVIORS - MONITOR Other FOR THE FOLLOWING: (specify in nurses note) ITCHING, PICKING AT SKIN, RESTLESSNESS (AGITATION), HITTING, INCREASE IN COMPLAINTS, BITING, KICKING, SPITTING, CUSSING, RACIAL SLURS, ELOPEMENT, STEALING, DELUSIONS, HALLUCINATIONS, PSYCHOSIS, AGGRESSION, REFUSING CARE. Document: 'N' if monitored and none of the above observed. 'Y' if monitored and any of the above was observed, DOCUMENT IN PROGRESS NOTES every shift for Bipolar Disorder, written 10/17/2024 . Sertraline HCl oral tablet 100mg give one tablet by mouth in the morning for depression, written 10/17/24. Refer to (name) psychiatry for evaluation and management, written 02/24/25. Refer to (name) psychiatry for evaluation and management, written 03/08/25. Depakote Sprinkles oral capsule delayed release sprinkle 125 mg, give two capsules by mouth two time a day for mood stability related to bipolar disorder, written 05/05/25. A review of Resident #1's MAR for May 2025 reflected the Sertraline was administered as ordered and the Depakote Sprinkles were administered after arrival from the pharmacy on 05/06/24. The MAR reflected the behavior monitoring was documented each shift as ordered. There were no 'Y' responses recorded. A review of Resident #1's progress note, dated 04/25/25 and written by the APRN, reflected in part, Follow up increased agitation mood changes .She was seen per nursing after she was noted with mood swings, anxious, crying earlier today .Denies urinary complaints. UA C&S if indicated, CBC, CMP ordered .Assessment and Plan: 1. Mood swings: -She was seen per nursing after she was noted with mood swings, anxious, crying earlier today . 8. Bipolar Disorder: - Mood stable - On Sertraline 100mg daily. A review of Resident #1's progress note, dated 05/03/25 and written by LVN C, reflected, AROUND 8 AM. RESIDENT STARTED YELLING, WHEN SHE GET TO THE DINNERING room, RESIDENT STATED BREAKING PLATES AND CUPS. SHE WAS REMOVED AND TAKE TO HER ROOM. [sic] A review of Resident #1's progress note, dated 05/03/25 at 8:15 PM and written by RN A, reflected, (Name) NP on call, called and notified of incident involving this resident and another in the DR just before supper. A review of Resident #1's progress note, dated 05/05/25 at 6:19 PM and written by LVN B, reflected, Resident is sitting at the door of the kitchen getting verbally aggressive with the kitchen staff. When nurse asked what was wrong she stated that these damn demons did it again and put ham on my salad instead of turkey and I'm going teach these people a lesson today since they dont understand no English!. At this time peer passed by with his leftovers to warm up in breakroom and she turned with the fork in her hand screaming Im going to kill you nigga! She rolled towards the breakroom aide attempted to intervene and she was kicking the aide in the knees and calves. Nurse was attempting to get the fork away when resident pulled back and was screaming that we weren't going to stop her from killing him when she stabbed the nurse in the right palm with the fork. SW came up to assist with redirection. Nurse was able to get fork away from resident and aide removed resident from area back to her room across building after SW spoke to her. [sic] A review of Resident #1's progress note dated 05/05/25 at 6:52 PM by LVN B, reflected, Resident came propelling herself down 100 hall yelling she was going to get him and kill him. This nurse went to see what had upset patient and saw her with a butter knife in her hand. She stated that she was going to kill him this time and nothing we said would stop her. Male aide came to assist and she was jabbing knife at him and pushing at my cart to head down hallway toward peers room. Admin was called and resident notified to give up the knife or we would have to call outside assistance. Resident refused and Admin gave approval for us to proceed with contacting outside agency. Male CNA was able to retrieve the knife when she began to wave it at the nurse and nurse went to get residents charge nurse. [sic] A review of Resident #1's progress note, dated 05/06/25 and written by the APRN, reflected in part, Chief Complaint/Reason for this Visit - Multiple behavioral outbursts, homicidal ideation, mood changes. Seen per nursing request after recurrent episodes of homicidal ideation. She threatened to stab kitchen staff, another male resident with fork. She was found propelling WC to kitchen and another resident with fork in her hand. Mental health officers were called due to safety concerns. Pending admission to an acute Psych hospital. She is currently in a fair mood, w/o anxiety, impulsive behaviors. She denies CP/SOB, fever, chills, headache or dizziness, nausea, vomiting, diarrhea, or constipation, or insomnia. Denies urinary complaints. UA 4/29 negative for UTI. She was seen by in-house Psych yesterday and was started on Depakote 125 mg BID, PRN hydroxyzine. Likely experiencing acute psych decompensation and will benefit from inpatient psych rehabilitation . A review of Resident #1's progress note, dated 05/06/25 at 2:22 PM and written by the SW, reflected, Law enforcement saw the resident regarding an incident that happened between the resident and another resident on 4/5/25 around 6 pm. Law enforcement informed the resident about the consequences of her behavior. The resident was advised to avoid any future incidents. SW will monitor resident behavior. A review of Resident #2's face sheet, printed on 05/08/25 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cerebral infarction (stroke), major depressive disorder, type 2 diabetes (a condition that affects the way the body processes blood sugar), chronic pain syndrome, and age-related physical debility. A review of Resident #2's admission MDS assessment, dated 03/31/25, Section C (Cognitive Patterns) reflected a BIMS score of 11 which indicated moderate cognitive impairment. Section D (Mood) reflected no mood symptoms were present. Section E (Behavior) reflected verbal behaviors directed at others were present one to three days. Section GG (Functional Abilities) reflected he required substantial/maximal assistance with his ADLs and supervision with wheelchair mobility. Section N (Medications) reflected he was taking antianxiety and antidepressant medications. A review of Resident #2's comprehensive care plan reflected in part: Focus: (Resident #2) has an alteration in neurological status r/t bipolar disorder. Date initiated 04/14/25. Goals: The resident will be able to communicate needs daily through the review date. Date initiated 04/14/25. The resident will be able to function at the fullest potential possible as outlined by the interdisciplinary team through the review date. Date initiated 04/14/25. Interventions: Cueing, reorientation as needed. Date initiated 04/14/25. Give medications as ordered, monitor/document for side effects and effectiveness. Date initiated 04/14/25. Focus: (Resident #2) has major depressive disorder, recurrent r/t alcohol dependence with alcohol-induced persisting dementia. Date initiated 04/14/25. Goal: The resident will exhibit indicators of depression, anxiety, or sad mood less than daily by review date. Date initiated 04/14/25. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated 04/14/25. Monitor/document/report to Nurse/MD s/sx of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Date initiated 04/14/25. A review of Resident #2's current physician orders reflected the following: Wound care for right anterior thigh abrasion: cleanse with wound cleanser, apply TAO, leave open to air, daily, written 05/06/25. A review of Resident #2's nurse progress note, dated 05/03/25 at 8:56 PM and written by RN A reflected in part, Just before supper, this resident was wheeled from the DR to the nurse's station by a staff. Staff, showing nurse resident's right thigh informing nurse that resident was fighting another resident in the DR, he got the scratch like marks from the other resident. Nurse assessed area, looks like scratch marks to his right anterior thigh with scant bleeding . Review of Resident #2's progress note, dated 05/07/25 at 2:10 PM and written by the wound care NP, reflected in part, 04/29/25: Patient was seen today for wound care. A new wound was observed on the right elbow .Treatment was initiated .The patient has a skin tear related to thin, fragile, atrophic skin. Recommend preventing further skin injury by avoiding friction/shear, careful handling during ambulation, assistance, and transfer . Review of Resident #2's progress noted, dated 05/07/25 at 3:55 PM, reflected in part, Nurse was called to the dining room that resident fell. Nurse noted resident lying on the floor . Review of Resident #1's Psychiatric Initial Assessment, dated 05/02/25 and written by the mental health NP, reflected in part, Reason for Referral: Agitation, Verbal Aggression, Physical Aggression, Sexually Inappropriate Behavior, Cognitive Testing For Medical Necessity. Chief Complaint: I'm real aggressive History of Presenting: Illness .bipolar disorder, cocaine abuse, nicotine dependence, and alcohol abuse . On exam . bright affect, very distractible and disorganized at times. Patient states I'm real aggressive and I get real angry. Patient reports poor frustration tolerance . Symptoms have been occurring for 2 weeks. Patient with a history of Bipolar d/o, labile mood, impulsive, irritable, hostile at times. Will start Depakote for mood stability . Patient with irritability, anxious, will continue Sertraline . Review of Resident #1's Psychiatric Subsequent assessment dated [DATE] and written by the mental health NP, reflected in part, Reason for Referral: Agitation, Verbal Aggression, Physical Aggression, Sexually Inappropriate Behavior, Cognitive Testing For Medical Necessity Chief Complaint: I was upset on Monday Medical Necessity for visit: Patient seen today for multiple chronic conditions requiring prescription management. Bipolar d/o, current episode mixed, labile mood, impulsive, irritable, and hostile at times. recent violent behaviors, Continue Depakote for mood stability. Will check VPA level . Mild to moderate anxiety, denies current symptoms, reports intermittent irritability and recent violent behavior. will continue Sertraline . Future Visits Revisit in I weeks. During an interview on 05/08/25 at 12:15 PM, the ADM stated Resident #1 had been having more behaviors of yelling, threatening, and throwing things, so they made a psych referral and had the resident seen . She stated it did not meet her expectations that referrals were made in February and March and the resident was not seen until May . She stated she started working at the facility in February and was not aware of the referrals at that time. During an observation and interview on 05/08/25 at 12:25 PM, Resident #2 was observed sitting up in a wheelchair in the dining room. Resident #2 had multiple small, fading bruises and healing skin tears on his arms and hands. A dressing was observed on his right elbow. Resident #2 stated he had an altercation with Resident #1 recently. He stated he may have called the other resident a name, but that was no reason for them to attack me. He stated he wanted to go back to his previous facility because he was treated better there. During an interview on 05/08/25 at 1:35 PM, the SW stated Resident #1 had been aggressive to staff and other residents. He stated Resident #1 had mood swings, she was sad, happy, or angry, and it changed day to day. He stated he had put a referral in the computer for psych services and the resident was added to the referral list. He stated he put in a referral in February for Resident #1, because of her bipolar disorder diagnosis, but there were some insurance problems, so she was not seen. He stated the company they used for psychiatric services had staff turnover and it had been difficult to get someone out to the facility. He stated everyone with a psychiatric diagnosis was referred for psych services upon admit. He stated he believed Resident #1 was admitted in February 2025 and that is when she was referred. He stated anyone with a psychiatric diagnosis was referred to psych on admission. He stated he did not know why she was not referred when she was admitted in October 2024. He stated it did not meet his expectations that it took so long for the resident to be seen. He stated Resident #1 was seen by psych services last week and medications were ordered. The SW stated Resident #1 had an incident directed towards another resident on 05/05/25. He stated they called for a mental health officer to come to the facility. He stated 3 police officers came to the facility on [DATE] and spoke briefly with Resident #1 and informed her of possible consequences of her behavior. On 05/08/25 at 2:09 PM a voice message requesting a return call was left for the psychiatric provider. A return call was not received prior to exit from the facility. On 05/08/25 at 2:11 PM a voice message requesting a return call was left for the APRN. A return call was not received prior to exit from the facility. During an interview on 05/08/25 at 2:32 PM RN A stated Resident #1 had been in her current room for about 3 weeks. She stated Resident #1 used to be on the other unit, but she was having problems with another resident, so they moved her room. She stated she had worked with Resident #1, and she had behaviors since her admission. She stated resident often cussed, yelled, slammed her door, or threw items from her room into the hallway. During an interview on 05/08/25 at 2:44 PM, CNA F stated she had worked with Resident #1 on both halls. She stated the resident had behaviors off and on since being at the facility. She stated she frequently threw things from her room into the hall. During an interview on 05/08/25 at 4:12 PM, the ADON stated residents who had a psychiatric diagnosis on admit, were usually referred for psych services. She stated she did not remember if Resident #1 had been referred upon admit, but stated the resident may have refused psych services. She stated she was not able to find any documentation that the resident had been referred or refused services on admit. She stated Resident #1 had increased behaviors, so she contacted the SW to make a psych referral. She stated the resident always had complaints about staff but did not have problems with other residents until recently. She stated the psychiatrist was in the facility on 05/02/25 and when she returned to work on 05/05/25, she saw that there were new medication orders for Resident #1. During an interview on 05/09/25 at 12:10 PM, the MHNP stated he was usually in the facility once a week but if there was an emergency, he was able to respond more frequently. He stated Resident #1 was new to him as he began seeing her last week on 05/02/25, and saw her just prior to this interview. He stated usually the provider put in a referral for psychiatric services. The facility, usually the SW, entered the referral into the (company name) portal for verification and approval. Once approved, he was sent out to see the resident. He stated to his knowledge, Resident #1 had not been seen by psych before him. He stated Resident #1 was on Sertraline before and he added a regularly scheduled mood stabilizer and a PRN medication for anxiety. He stated he would continue to follow and monitor the resident. A review of the facility Social Services Policy, revised December 2010, reflected in part, Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. 1. The Director of Social Services is a qualified social worker and is responsible for: b. Consultation to an allied professional health personnel regarding provisions for the social and emotional needs of the resident and family; 2. Medically-related social services is provided to maintain or improve each resident's ability to control everyday physical needs (e.g., appropriate adaptive equipment for eating, ambulation, etc.); and mental and psychosocial needs (e.g., sense of identity, coping abilities, and sense of meaningfulness or purpose). 3. Factors that have a potentially negative effect on psychosocial functioning include: e. Presence of a progressive, chronic disabling condition (i.e., Multiple Sclerosis, Chronic Obstructive Pulmonary Disease, Alzheimer's disease, mental illness); g. Behavioral problems (i.e., confusion, anxiety, loneliness, depressed mood, anger, fear, wandering, psychotic episodes); 4. The social services department is responsible for: f. Making referrals to social service agencies as necessary or appropriate . A review of the facility Unmanageable Residents Policy, revised August 2010, reflected in part, Each resident will be provided with a safe place of residence. A review of the facility Abuse Prevention Program Policy, revised December 2016, reflected in part, As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. The ADM, DON, and RDHR were notified on 05/08/25 at 5:26 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 05/09/25 at 3:15 PM: (Facility Name) Immediate action: 05/08/2025 Resident #1 was affected by this deficiency (F740), was assessed and noted to be stable as of 05/08/2025. An audit of this resident's current list of medications was performed by the Administrator on 05/08/2025 and revealed that all current medications for this resident were delivered and are available in the facility. The resident was last seen by Psych services on 05/02/2025 and will be seen again on 05/09/2025 for follow up and intervention (personal safety). The resident's care plan was updated 05/06/2025 with current psych diagnosis and interventions as well as specific behaviors and interventions. One on one monitoring has been placed for the resident effective today when near other residents until stable per psych NP recommendation or transfer out of the facility. Resident #2 was assessed on 05/03/2025 after the event involving Resident #1, and again today 05/08/2025 revealing no signs of distress or emotional agitation. Training of staff and audits of all residents identified as in need of behavioral health services as well as abuse and neglect were initiated by the Administrator on 05/08/2025. A spreadsheet was created with the identification of the services and if services were needed. The facility is verifying comprehension on staff training by following up after education based on a random selection. Verbal contact to personnel began on 05/08/2025. Staff will not be allowed to work their shifts until this Inservice, and training has been completed. The Administrator will be responsible for the direct Inservice of her staff. Identification of others: All residents who have diagnoses or demonstrated signs of behavioral health concerns have the potential to be impacted by this deficient practice. The Administrator is directing the review of all residents with Behavioral Health diagnoses (completed 05/08/25) to identify unmet behavioral or psychiatric needs. All open psychiatric referrals were verified and re-submitted or scheduled. Action: Review of all residents with Behavioral Health Diagnosis Start Date: 5/8/25 Completion Date: 5/8/25 Responsible: DON, ADON, Administrator Action: Creation of spreadsheet identifying unmet behavioral or psychiatric needs. Any other residents identified will be referred to psych as well. Start Date: 5/8/25 Completion Date: 5/9/25 Responsible: DON, Admin, Social Worker. Action: A review of their medications will be completed as well. The Psychiatrist will be on site 05/09/2025 to assist with any referrals or review of concerns that were identified with this audit. Start Date: 05/09/2025 Completion Date: 05/09/2025 Responsible: DON, MDS, Psychiatrist Action: Creation of spreadsheet identifying unmet behavioral or psychiatric needs. Any other residents identified will be referred to psych as well. Start Date: 5/8/25 Completion Date: 5/9/25 Responsible: DON, Admin, Social Worker. A review is scheduled 05/09/2025 for the Psychiatrist and Attending Physician on the medications as it relates to any current behaviors or events since the last Dose Reduction Review. The Regional Director of Operations has educated the Administrator, DON and ADON on behavioral care and services for the residents for the facility and comprehension will be verified at this same time (copy attached), this was completed on 05/08/2025 . The administrator has created an audit tool to monitor compliance to the facility's communication procedure for contacting Physicians and confirming orders on behavioral health matters. Audits will be conducted by the DON daily for two weeks, weekly for 2 weeks and monthly for two months. A spreadsheet was created for the audit to be conducted and documented. Any negative findings will be reported to the administrator for immediate correction. The Medical Director was notified of the deficiency (F740) on 05/08/2025 and an Ad-Hoc QAPI meeting was held on 05/08/2025 to discuss the findings. All findings will be reported to the QAPI team for QAPI. Expected compliance date is 05/08/2025. The Surveyor monitored the POR on 05/10/25 as follows: During an observation and interview on 05/10/25 at 3:39 PM, Resident #1 was observed as she sat in her wheelchair. Resident #1 was calm and had no s/sx of distress. Resident #1 stated she was fine and rolled away. CNA H stated she was assigned to Resident #1 to monitor for behaviors , for example yelling, throwing things, or being aggressive towards others. She stated there were none of those behaviors exhibited by Resident #1. During interviews on 05/10/25 from 12:44 PM - 3:07 PM, staff from all shifts including the ADON, two LVNs (LVN D and LVN E), one CNA (CNA G), one MA (MA I), one SW, and the HSK Supervisor all stated they were in-serviced on 05/08/25 or 05/09/25 on abuse and neglect. All staff knew to report any suspected abuse immediately to the ADM who was the Abuse Coordinator. All staff stated they were to report any new behaviors or increased number of behaviors such as hitting, kicking, cussing, or increased complaints, to the charge nurse. Staff stated if two residents were involved in an altercation, they would separate the residents and report the incident to the nurse. The LVNs and SW stated all diagnoses were reviewed on admit and which diagnoses required psych referrals. They stated the NP was to be notified of any new or change in behaviors. The SW stated he was to follow up on all psych referrals within 2-3 days. During an interview on 05/10/25 at 1:31 PM, the SW stated the expectation was to send psych service referrals for residents with a psychiatric diagnosis or behavior medications evaluations for residents with behaviors when admitted and as needed. He stated the expectation was to follow up on all referrals within two to three days. During an interview on 05/10/25 at 1:40 PM, the Psych NP stated he had no recommendations for staff regarding Resident #1, who he observed was stable on 05/09/25. Staff were expected to follow the facility's policy if a resident exhibited new behaviors. Staff were expected to deescalate the resident, notify appropriate parties, and provide psych services. He stated he planned to see Resident #1 weekly for a few weeks to monitor medication effectiveness. He would reevaluate then if weekly visits were still indicated or adjust the frequency as needed. During an interview on 05/10/25 at 3:07 PM, the ADON stated it was her expectation that psych and behavioral referrals were initiated and sent when a resident was admitted and if a change in behaviors occurred. She stated the SW was responsible to follow up on the referral status. During a telephone interview on 05/10/25 at 3:53 PM, the RDO stated he in-serviced the ADM, DON, and ADON on 05/08/25 regarding behavioral care and services for the residents for the facility and following up on psych referrals after sending out psych referrals. During a telephone interview on 05/10/25 at 3:55 PM, the MD stated the DON notified him about Resident #1's incident resulting in an IJ on 05/08/25 or 05/09/25. During an interview on 05/10/25 at 4:29 PM, the ADM stated she expected psych referrals be sent timely when a resident with a psychiatric diagnosis was admitted . She expected the SW to follow up with the referral to ensure the service was provided. She stated they had implemented audit tools and now monitored for compliance. She stated the audit tools were to monitor compliance to the facility's communication procedure for contacting physicians and confirming orders on behavioral health matters. Review of an in-service titled Behavioral Care and Services in Texas Nursing Homes, dated 05/08/25, reflected the RDO in-serviced the ADM, DON, and ADON on the policy and procedures. The outline from the in-service reflected in part, Objective: Equip staff with the knowledge and skills to deliver person-centered behavioral care in compliance with Texas regulations and CMS guidelines. Objectives of This In-Service: By the end of this session, participants will be able to: Recognize common behavioral and psychological symptoms in residents. Respond effectively and compassionately to behavioral issues . Understanding Behavioral Health in LTC Settings . Resident-Centered Behavioral Interventions . Role of the Interdisciplinary Team . Documentation Best Practices . Key Takeaways Behavioral care is part of holistic resident care. Staff training and communication are essential. Non-pharmacological approaches should be tried first. Documentation must be timely, factual, and complete. Interdisciplinary collaboration leads to better outcomes. Review of an in-service titled Behavioral Care and Services in Texas Nursing Homes, dated 05/08/25 and 05/09/25, reflected staff, which included 1 RN, 9 LVNs, 6 MAs, and 20 CNAs, were in-serviced, in person or over the phone, by the ADM, DON, and ADON on the policy and procedures. Review of an in-service titled Abuse/Neglect, dated 05/08/25 and 05/09/25, reflected staff , which included 1 RN, 9 LVNs, 6 MAs, 20 CNAs, 10 dietary staff, 12 housekeeping staff, 1 maintenance aide, and 7 therapy staff, were in-serviced, in person or over the phone, by the ADM, DON, and ADON on the policy and procedures. Review of an in-service titled Ensure Proper Documentation, dated 05/08/25 and 05/09/25, reflected nursing staff, which include 1 RN and 9 LVNs, were in-serviced, in person or over the phone, by the ADM, DON, and ADON on the policy and procedures. Review of an in-service titled New Admits, dated 05/08/25 and 05/09/25, reflected the SW and nursing staff, which included 1 RN, 9 LVNs, were in-serviced, in person or over the phone, by the ADM, DON, and ADON on reviewing diagnoses in a timely manner and referring to psych services. Review of the ADM's R[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse and for one (Resident #11) of twenty residents reviewed for developing and implementing abuse and neglect policies. The facility failed to implement and utilize the following two facility abuse and neglect policies; abuse investigation and reporting policy and abuse prevention and reporting policy when; 1) they did not report an allegation of rape reported to two State of Texas and the facility administrator reported by Resident #11. 2) Immediately notify police of the alleged allegations and take action to protect Resident #11 from possible physical and emotional abuse. By failing to implement these policies, the facility failed to; 3) Identify and assess all possible incidents of abuse and investigate and report all allegations of abuse within timeframes required by federal requirements. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/12/24 at 11:33 AM. While the IJ was removed on 08/13/24 at 5:30 PM, the facility remained at a level of actual no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of undetected abuse, trauma, and/or decline in feelings of safety and well-being or psychosocial harm. Findings included: Review of Resident #11's face sheet, dated 08/09/2024, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paraplegia, unspecified intracranial injury (injury to the brain caused by an external force), diffuse traumatic brain injury with loss of consciousness (a medical condition when the brain quickly moves inside the skull as a result of a traumatic injury), mild neurocognitive disorder (brain condition causing mild or sever cognitive decline), delusional disorder (a mental health condition that causes unshakable beliefs in something that's untrue), bipolar disorder (a mental health condition that causes extreme mood swings between depression and mania or hypomania), major depressive disorder (a mood disorder that causes persistent sadness and loss of interest), and unspecified psychosis (a collection of symptoms where there is a loss of contact with reality). Review of Resident #11's MDS assessment, dated 06/21/2024, reflected a BIMS of 13, indicating cognition intact. Review of Resident #11's care plan, dated 08/09/2024, an entry dated 03/13/2024 that reflected, Resident #11 has a history of making false allegations/inaccurate statements as evidenced by previously accusing/stating: They raped me. Resident #11 claimed on 03/11/2024 that people come into his room all the time and rape him. All allegations investigated and reported to administrator and was unfounded. Resident #11 was unable to explain any details or names, only repeats original statement. Interventions include, If statements are determined to be inaccurate, staff will reorient and redirect as needed with reassurance and reality orientation. Involve Ombudsman as a liaison between facility staff and Resident #11 as needed. Listen openly to allegations/inaccurate statements made by Resident #11 and offer clarification as needed. Review of Resident #11 psychiatric subsequent assessment, dated 07/12/2024 and signed by PMHNP, reflected Resident #11 stated, I'm fine. Resident seemed anxious, guarded, and suspicious of others. Nursing staff report that resident continues to have paranoid and persecutory delusions, recently was seen posturing at staff and accusing staff of raping him at night. A multidisciplinary team meeting was held on 07/12/2024 to discuss GDR of psychotropic medications, and to provide support and to manage any concerns or follow up if resident has behavioral or mood changes that arise during care. Team members present at the meeting included DON, ADON, SW, PMHNP, and (psychiatric services) Regional Account Manager. Seroquel was increased to 50 mg to target systems. Review of Resident #11 psychiatric subsequent assessment dated [DATE] signed by PMHNP, reflected Resident #11 was seen at staff request. Resident was irritable and guarded. Staff reported a history of paranoia and resident complains of being raped at night. Review of Resident #11 psychiatric subsequent assessment dated [DATE] signed by PMHNP, reflected Resident #11 was seen by staff request regarding complaints of being raped at night. Resident #11 stated, Everyone knows what they are fucking doing to me. Review of chart showed staff report a history of paranoia, and persecutory delusions of being raped at night. Resident #11 had recently, reported to the administrator that he is being raped at night. It is not the nurses, it is the aides, they will not sit me right in the bed. Resident #11 was angrily starring at provider, more irritable and anxious with frequent use of curse words. During an interview on 08/09/2024 at 12:04 pm, Resident #11 came into the conference room where two HHSC investigators were working and stated he was raped; it happened all the time and everyone knew about it. He did not give any specifics regarding perpetrators, dates, or locations. He made a statement about how he was being positioned when staff changed him, and he could not see what staff were doing to his body. When we told him we were going to investigate it, he said y'all aren't going to do anything about it. During an interview on 08/09/2024 at 12:11 pm, HHSC investigators notified the ADM of Resident #11's rape allegation. During an interview on 08/10/2024 at 12:32 pm, ADM stated to the HHSC investigators that after he learned about Resident #11's allegation of rape, he immediately went to speak with Resident #11 who said that he was not raped. The ADM stated that resident (Resident #11) told him he wants to be repositioned differently. The ADM said he then spoke with the facility PMHNP, who completed an assessment with Resident #11. The ADM stated that the facility PMHNP told him that Resident #11 said he was not raped but wanted different positioning. The ADM said he asked residents on the hallway if they felt safe and they said yes. The ADM said because he spoke with Resident #11 who stated he was not raped, and the PMHNP said that Resident #11 said that he was not raped, that he would not make a report of abuse and neglect to HHSC. At that time, ADM had not entered a report in Resident #11's progress notes about speaking with Resident #11. There ADM did not, in accordance with facility policy, provide any supporting documents relative to the alleged incident, either inform or keep the resident and his/her representative (sponsor) informed of the about Resident #11's allegations or progress of the investigation or take measures to protect the safety and privacy of the resident. The ADM did not inform the police of the alleged crime or discuss with Resident #11 or his representative the procurement of a SANE exam (Sexual Assault Nurse Examiner exam, is a medical forensic exam that collects evidence and provides healthcare services after a sexual assault). The ADM did not, in accordance with facility policy, interview the resident's attending physician, interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, interview the resident's family members, and visitors or review all events leading up to the alleged incident. During an interview on 08/10/2024 at 1:13 pm, when asked if Resident #11 was still being raped, Resident #11 said, yea, all the time and everyone knows about it. When asked if the ADM asked if he was raped, he said no, and said the ADM spoke to him about how to do things better or some shit. When asked a second time if the ADM asked him if he was being raped, Resident #11 said, they just want to mess with my mind and they don't do things the right way they just want to hurt my bottom. Resident #11 said the aides manhandle him and he stated everyone knows he was being raped. During an interview on 08/12/2024 at 8:55 am, the ADM stated that he called HHSC/CII himself on 08/10/2024 at 6:31 pm and made the self-report about the sexual assault. During an interview on 08/12/2024 at 12:53 pm, the PMHNP stated that when he asked Resident #11 if he was raped, Resident #11 did not make a statement to him stating he was not raped. The PMHNP stated that Resident #11 said repeatedly that they (the facility staff) are not treating his body right and they are not positioning him on the bed right and it was the night aides that are doing it. During an interview on 08/13/2024 at 2:27 pm, the ADM stated that, abuse and neglect should be reported immediately and not more than two hours after the alleged event. The importance of reporting abuse was so allegations can be fully investigated. If it was not reported, and allegations were not investigated, it was possible that abuse existed and may continue to exist in the facility. The facility's abuse and neglect policy were that it was every employee's responsibility to make sure that the facility was an abuse free environment for all residents they served and that reports of abuse and neglect would be reported to the administrator, supervisor, and HHSC. Review on 08/10/2024 at 4:00 pm reflected facility records in TULIP on 03/11/2024; 07/12/2024; 08/02/2024; and 08/09/2024, did not reveal a self-report for the allegation of sexual abuse of Resident #11. (TULIP was a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on assisted living facilities for the State of Texas.) Review on 08/13/2024 of the Facility records in TULIP reflected a self-report email was sent to CII on 08/10/2024 at 6:12 pm, for the allegation of sexual abuse of Resident #11 made on 08/09/2024. Review of facility policy, undated, abuse investigation and reporting revealed: Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy Interpretation and Implementation Role of the Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. 6. The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Role of the Investigator: The individual conducting the investigation will, as a minimum: 1. Review the completed documentation forms; 2. Review the resident's medical record to determine events leading up to the incident; 3. Interview the person(s) reporting the incident; 4. Interview any witnesses to the incident; 5. Interview the resident (as medically appropriate); 6. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; 7. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; 8. Interview the resident's roommate, family members, and visitors; 9. Interview other residents to whom the accused employee provides care or services; and 10. Review all events leading up to the alleged incident. The following guidelines will be used when conducting interviews: 1. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. 2. The investigator will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the review process. 3. If the ombudsman declines the invitation to participate in the investigation, that information will be noted in the investigation record. The ombudsman will be notified of the results of the investigation as well as any corrective measures taken. 4. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms Reporting All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: 1. The State licensing/certification agency responsible for surveying/licensing the facility; 2. The local/State Ombudsman; 3. The Resident's Representative (Sponsor) of Record; 5. Law enforcement officials; 6. The resident's Attending Physician; and 7. The facility Medical Director. 8. Suspected abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately. 9. Alleged abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately if the alleged events have resulted in serious bodily injury; 10. If events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within twenty-four hours. 11. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone. Notices will include, as appropriate: 1. The name of the resident; 2. The number of the room in which the resident resides; 3. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.); 4. The date and time the alleged incident occurred; 5. The name(s) of all persons involved in the alleged incident; and 6. What immediate action was taken by the facility. 7. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. Facility policy on abuse prevention program, undated, reflected: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect or mistreatment of our resident. Require staff training/orientation programs that include such topics as abuse prevention, identification, and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Investigate and report any allegations of abuse within timeframes as required by federal requirements; and Protect residents during abuse investigations. The ADM was notified on 08/12/24 at 11:33 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 08/12/24 at 4:49 PM: Plan of Removal On 08/12/2024 the surveyor provided an Immediate Jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the resident health and safety. Removal of Immediacy Plan. The notification of Immediate Jeopardy stated as follows: Resident made allegations of sexual abuse on 3/11/2024 and 8/9/2024 and the allegations were not thoroughly investigated and reported to local, state, and federal agencies. Identified here are the steps and immediate actions facility was taking to address the non-compliance. Medical Director notified of immediate jeopardy. Completed 8/12/24. 1. Resident #1 a. On 8/10/24 Director of Nursing called police called to report an allegation of rape. (Resident #11) b. On 8/10/24 at 6:12pm investigation initiated, Administrator reported to HHSC the allegation of rape. c. On 8/10/24 Director of Nursing sent Resident to hospital to receive a rape kit inspection. d. On 8/10/24 Administrator notified physician that Resident #1 has reported being raped, and the immediate response, interventions by staff personnel. Action taken: Reviewed documents confirming Administrator conducted resident safe surveys for both interviewable and non-interviewable residents and began in-servicing staff on abuse and neglect, reporting abuse without fear of retaliation, reporting abuse immediately, and actions to take if staff report abuse to the abuse and neglect coordinator and no action is taken. e. On 8/10/24 Director of Nursing called family to notify them of the allegation. Action taken - On 8/20/24, time unknonwn, telephone call with the resident's RP confirmed the facility contacted her about Resident #11's report of alleged abuse. f. On 8/10/24 Resident (#11) offered reassurance by the Director of Nursing. Psych services referral made by Director of Nursing on 8/11/24. Action Taken - On 08/21/24 reviewed Resident #11's progress notes and confirmed Resident #11 was offered reassurances by the DON and a psych services referral was made. 2. All other Residents a. To be completed by 8/13/24, all interviewable Residents interviewed by Director of Nursing and Therapy Director to ensure their safety in the facility, and to report any concerns relating to their safety. Action Taken -Confirmed interviewable residents felt safe in the facility. b. To be completed by 8/13/24, non-verbal Residents visually assessed by the Director of Nursing for signs of abuse, fear or change in behavior. Signs of abuse may include grimacing, clenching of teeth, distress, moaning, groaning, yelling, guarding, intermittent body movements, or any other cues that could point to a change of condition. Action taken - Confirmed non-verbal Residents were asked if they feel safe in the facility. 3. Administrator Training, in-servicing a. On 8/12/24 the Regional Nurse Consultant educated the Administrator on the importance of fully investigating allegations of abuse in order to ensure Resident safety as a top priority. Action taken - Confirmed, through an email from the Regional Nurse Consultant, the Administrator was re-educated on the company's abuse and neglect prevention policy and policy on reporting allegations of abuse timely and correctly, per the facility provider letter (TULIP, HOTLINE, EMAIL). On 8/12/24 the Administrator received education on facility's Chain of Command Policy reporting abuse up the chain in the facility. Action taken - On 08/21/24 confirmed, through an email from the Regional Nurse Consultant and interview with the Administrator that he passed the return demonstration test to demonstrate competency about the facility policy and proficient in his understanding of facility abuse and neglet and reporting and investigating abuse and neglect policies to proceeded to train the facility staff and staff who will assist training staff. 5. Staff Training, in-servicing a. To be completed by 8/13/24, Administrator or a trained designee is in-servicing each staff, with a return demonstration test to confirm competence. Staff are required to come to the facility to complete their training and test. Staff out of town will complete their training virtually with a trained designee. Each current staff and newly hired staff will complete training before working their next shift in the facility. The chain of command policy stated: 1. HEALTHCARE STAFF ARE MANDATED (TITLE 9) TO REPORT ABUSE, WITHOUT FEAR OF RETALIATION 2. SUSPECTED ABUSE IS REPORTED IMMEDIATELY TO YOUR SUPERVISOR AND ABUSE COORDINATOR 3. ABUSE IS TO BE REPORTED TO STATE WITHIN 2 HOURS. IF LEADERSHIP DOES NOT REPORT ABUSE, THERE IS AN HHS HOTLINE POSTED IN THE FACILITY AT ENTRANCE AND NURSE STATIONS 4. THE PERSON SUBMITTING ABUSE WILL NOTIFY a. HHSC b. POLICE c. OMBUDSMAN d. FAMILY e. PHYSICIAN 4. Follow up for effectiveness of the plan and auditing e. IDT meeting held 8/12/24 with Physician, DON, ADON and Administrator to ensure compliance with facility policy on abuse and neglect, training all staff to identify and report abuse. Action taken - Received confirmation that IDT meeting was 8/12/24 with signatures from the Physician, DON, ADON and Administrator to ensure compliance with facility policy on abuse and neglect, training all staff to identify and report abuse f. For three months, Administrator or designee to audit weekly all incidents of abuse and confirm they are reported, investigated, and completed. g. All findings are presented to the quality assurance committee for continued tracking/trending, assessment, and timely intervention as is necessary. QAPI committee will review these processes for 3 months, or as long as is deemed necessary to promote a continued safe environment for all Residents free from all abuse and neglect. The Surveyor monitored the POR on 08/13/24 as followed: During interviews on 08/13/24 from 10:01 AM - 1:09 PM, one RN, three LVNs, 5 CNAs, 2 medication aides, the Therapy Directory, Business Office Manager, Dietary Manager, Dietary Aide, staffing coordinator, receptionist, and two housekeeping staff (from different shifts) all stated they were in-serviced and took a post-test before working their shifts. All were able to state that their ADM was the Abuse and Neglect Coordinator and give examples of different types of abuse such as physical, verbal, emotional, and psychosocial. All stated that if they would report any abuse or suspected abuse the facility abuse and neglect coordinator immediately and if action were not taken by the facility, they would report the incident to HHSC. All were knowledgeable about the location of the position in the facility with the HHSC reporting hotline telephone number. All stated they were aware that it was the responsibility of all healthcare workers to report abuse and neglect and the facility cannot retaliate against them for reporting abuse and neglect and they felt safe that the facility would not retaliate against them for reporting abuse and neglect. In an interview with the Administrator on 08/21/24, time unknown, investigator confirmed he passed the return demonstration test and demonstrate competency about the facility policy and was proficient in his understanding of facility abuse and neglet and reporting and investigating abuse and neglect policies. Review of in-services, dated 08/12/24 - 08/13/24 reflected staff from all shifts were in-serviced on ANE policy and procedures, the Abuse and Neglect Coordinator, reporting, healthcare staff are mandated to report abuse without fear of retaliation, suspected abuse is reported immediately to the supervisor and abuse coordinator, and if the abuse is not reported by leadership, there is an HHSC hotline posted in the facility at the entrance and nurses' stations. Review of Abuse Post-Tests, dated 08/12/24 - 08/13/24, reflected all staff completed the test with passing scores. While the IJ was removed on 08/13/24 at 5:30 PM, the facility remained at a level of actual 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. Refer to CMS Form 2567, F dated /2023, for evidence of licensure violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for one of twenty residents (Resident #11) reviewed for abuse and neglect, in that The facility had failed to conduct an investigation when there was an allegation of rape from Resident #11. The resident had approximately 3 other allegations of rape that the facility could not provide supporting documentation that those allegations were indeed investigated. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/12/24 at 11:33 AM. While the IJ was removed on 08/13/24 at 5:30 PM, the facility remained at a level of actual no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of undetected abuse, trauma, and/or decline in feelings of safety and well-being or psychosocial harm. Findings included: Review of Resident #11's face sheet, dated 08/09/2024, reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including paraplegia, unspecified intracranial injury (injury to the brain caused by an external force), diffuse traumatic brain injury with loss of consciousness (a medical condition when the brain quickly moves inside the skull as a result of a traumatic injury), mild neurocognitive disorder (brain condition causing mild or sever cognitive decline), delusional disorder (a mental health condition that causes unshakable beliefs in something that's untrue), bipolar disorder (a mental health condition that causes extreme mood swings between depression and mania or hypomania), major depressive disorder (a mood disorder that causes persistent sadness and loss of interest), and unspecified psychosis (a collection of symptoms where there is a loss of contact with reality). Review of Resident #11's MDS assessment, dated 06/21/2024, reflected a BIMS of 13, indicating cognition intact. Review of Resident #11's care plan, dated 08/09/2024, an entry dated 03/13/2024 that reflected, Resident #11 has a history of making false allegations/inaccurate statements as evidenced by previously accusing/stating: They raped me. Resident #11 claimed on 03/11/2024 that people come into his room all the time and rape him. All allegations investigated and reported to administrator and was unfounded. Resident #11 was unable to explain any details or names, only repeats original statement. Interventions include, If statements are determined to be inaccurate, staff will reorient and redirect as needed with reassurance and reality orientation. Involve Ombudsman as a liaison between facility staff and Resident #11 as needed. Listen openly to allegations/inaccurate statements made by Resident #11 and offer clarification as needed. Review of Resident #11 psychiatric subsequent assessment, dated 07/12/2024 and signed by PMHNP, reflected Resident #11 stated, I'm fine. Resident seemed anxious, guarded, and suspicious of others. Nursing staff report that resident continues to have paranoid and persecutory delusions, recently was seen posturing at staff and accusing staff of raping him at night. A multidisciplinary team meeting was held on 07/12/2024 to discuss GDR of psychotropic medications, and to provide support and to manage any concerns or follow up if resident has behavioral or mood changes that arise during care. Team members present at the meeting included DON, ADON, SW, PMHNP, and (psychiatric services) Regional Account Manager. Seroquel was increased to 50 mg to target systems. Review of Resident #11 psychiatric subsequent assessment dated [DATE] signed by PMHNP, reflected Resident #11 was seen at staff request. Resident was irritable and guarded. Staff reported a history of paranoia and resident complains of being raped at night. Review of Resident #11 psychiatric subsequent assessment dated [DATE] signed by PMHNP, reflected Resident #11 was seen by staff request regarding complaints of being raped at night. Resident #11 stated, Everyone knows what they are fucking doing to me. Review of chart showed staff report a history of paranoia, and persecutory delusions of being raped at night. Resident #11 had recently, reported to the administrator that he is being raped at night. It is not the nurses, it is the aides, they will not sit me right in the bed. Resident #11 was angrily starring at provider, more irritable and anxious with frequent use of curse words. During an interview on 08/09/2024 at 12:04 pm, Resident #11 came into the conference room where two HHSC investigators were working and stated he was raped; it happened all the time and everyone knew about it. He did not give any specifics regarding perpetrators, dates, or locations. He made a statement about how he was being positioned when staff changed him, and he could not see what staff were doing to his body. When we told him we were going to investigate it, he said y'all aren't going to do anything about it. During an interview on 08/09/2024 at 12:11 pm, HHSC investigators notified the ADM of Resident #11's rape allegation. During an interview on 08/10/2024 at 12:32 pm, ADM stated to the HHSC investigators that after he learned about Resident #11's allegation of rape, he immediately went to speak with Resident #11 who said that he was not raped. The ADM stated that resident (Resident #11) told him he wants to be repositioned differently. The ADM said he then spoke with the facility PMHNP, who completed an assessment with Resident #11. The ADM stated that the facility PMHNP told him that Resident #11 said he was not raped but wanted different positioning. The ADM said he asked residents on the hallway if they felt safe and they said yes. The ADM said because he spoke with Resident #11 who stated he was not raped, and the PMHNP said that Resident #11 said that he was not raped, that he would not make a report of abuse and neglect to HHSC. At that time, ADM had not entered a report in Resident #11's progress notes about speaking with Resident #11. There ADM did not, in accordance with facility policy, provide any supporting documents relative to the alleged incident, either inform or keep the resident and his/her representative (sponsor) informed of the about Resident #11's allegations or progress of the investigation or take measures to protect the safety and privacy of the resident. The ADM did not inform the police of the alleged crime or discuss with Resident #11 or his representative the procurement of a SANE exam (Sexual Assault Nurse Examiner exam, is a medical forensic exam that collects evidence and provides healthcare services after a sexual assault). The ADM did not, in accordance with facility policy, interview the resident's attending physician, interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, interview the resident's family members, and visitors or review all events leading up to the alleged incident. During an interview on 08/10/2024 at 1:13 pm, when asked if Resident #11 was still being raped, Resident #11 said, yea, all the time and everyone knows about it. When asked if the ADM asked if he was raped, he said no, and said the ADM spoke to him about how to do things better or some shit. When asked a second time if the ADM asked him if he was being raped, Resident #11 said, they just want to mess with my mind and they don't do things the right way they just want to hurt my bottom. Resident #11 said the aides manhandle him and he stated everyone knows he was being raped. During an interview on 08/12/2024 at 8:55 am, the ADM stated that he called HHSC/CII himself on 08/10/2024 at 6:31 pm and made the self-report about the sexual assault. During an interview on 08/12/2024 at 12:53 pm, the PMHNP stated that when he asked Resident #11 if he was raped, Resident #11 did not make a statement to him stating he was not raped. The PMHNP stated that Resident #11 said repeatedly that they (the facility staff) are not treating his body right and they are not positioning him on the bed right and it was the night aides that are doing it. During an interview on 08/13/2024 at 2:27 pm, the ADM stated that, abuse and neglect should be reported immediately and not more than two hours after the alleged event. The importance of reporting abuse was so allegations can be fully investigated. If it was not reported, and allegations were not investigated, it was possible that abuse existed and may continue to exist in the facility. The facility's abuse and neglect policy were that it was every employee's responsibility to make sure that the facility was an abuse free environment for all residents they served and that reports of abuse and neglect would be reported to the administrator, supervisor, and HHSC. Review on 08/10/2024 at 4:00 pm reflected facility records in TULIP on 03/11/2024; 07/12/2024; 08/02/2024; and 08/09/2024, did not reveal a self-report for the allegation of sexual abuse of Resident #11. (TULIP was a database utilized by the state to maintain licensing, demographic information, complaints, and self-reported incidents on assisted living facilities for the State of Texas.) Review on 08/13/2024 of the Facility records in TULIP reflected a self-report email was sent to CII on 08/10/2024 at 6:12 pm, for the allegation of sexual abuse of Resident #11 made on 08/09/2024. Review of facility policy, undated, abuse investigation and reporting revealed: Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy Interpretation and Implementation Role of the Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual. 2. The Administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. 3. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The Administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. 6. The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Role of the Investigator: The individual conducting the investigation will, as a minimum: 1. Review the completed documentation forms; 2. Review the resident's medical record to determine events leading up to the incident; 3. Interview the person(s) reporting the incident; 4. Interview any witnesses to the incident; 5. Interview the resident (as medically appropriate); 6. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; 7. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; 8. Interview the resident's roommate, family members, and visitors; 9. Interview other residents to whom the accused employee provides care or services; and 10. Review all events leading up to the alleged incident. The following guidelines will be used when conducting interviews: 1. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. 2. The investigator will notify the ombudsman that an abuse investigation is being conducted. The ombudsman will be invited to participate in the review process. 3. If the ombudsman declines the invitation to participate in the investigation, that information will be noted in the investigation record. The ombudsman will be notified of the results of the investigation as well as any corrective measures taken. 4. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms Reporting All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: 1. The State licensing/certification agency responsible for surveying/licensing the facility; 2. The local/State Ombudsman; 3. The Resident's Representative (Sponsor) of Record; 5. Law enforcement officials; 6. The resident's Attending Physician; and 7. The facility Medical Director. 8. Suspected abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately. 9. Alleged abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately if the alleged events have resulted in serious bodily injury; 10. If events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within twenty-four hours. 11. Verbal/written notices to agencies may be submitted via special carrier, fax, e-mail, or by telephone. Notices will include, as appropriate: 1. The name of the resident; 2. The number of the room in which the resident resides; 3. The type of abuse that was committed (i.e., verbal, physical, sexual, neglect, etc.); 4. The date and time the alleged incident occurred; 5. The name(s) of all persons involved in the alleged incident; and 6. What immediate action was taken by the facility. 7. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. Facility policy on abuse prevention program, undated, reflected: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect or mistreatment of our resident. Require staff training/orientation programs that include such topics as abuse prevention, identification, and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Investigate and report any allegations of abuse within timeframes as required by federal requirements; and Protect residents during abuse investigations. The ADM was notified on 08/12/24 at 11:33 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 08/12/24 at 4:49 PM: Plan of Removal On 08/12/2024 the surveyor provided an Immediate Jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the resident health and safety. Removal of Immediacy Plan. The notification of Immediate Jeopardy stated as follows: Resident made allegations of sexual abuse on 3/11/2024 and 8/9/2024 and the allegations were not thoroughly investigated and reported to local, state, and federal agencies. Identified here are the steps and immediate actions facility was taking to address the non-compliance. Medical Director notified of immediate jeopardy. Completed 8/12/24. 1. Resident #1 a. On 8/10/24 Director of Nursing called police called to report an allegation of rape. (Resident #11) b. On 8/10/24 at 6:12pm investigation initiated, Administrator reported to HHSC the allegation of rape. c. On 8/10/24 Director of Nursing sent Resident to hospital to receive a rape kit inspection. d. On 8/10/24 Administrator notified physician that Resident #1 has reported being raped, and the immediate response, interventions by staff personnel. Action taken: Reviewed documents confirming Administrator conducted resident safe surveys for both interviewable and non-interviewable residents and began in-servicing staff on abuse and neglect, reporting abuse without fear of retaliation, reporting abuse immediately, and actions to take if staff report abuse to the abuse and neglect coordinator and no action is taken. e. On 8/10/24 Director of Nursing called family to notify them of the allegation. Action taken - On 8/20/24, time unknonwn, telephone call with the resident's RP confirmed the facility contacted her about Resident #11's report of alleged abuse. f. On 8/10/24 Resident (#11) offered reassurance by the Director of Nursing. Psych services referral made by Director of Nursing on 8/11/24. Action Taken - On 08/21/24 reviewed Resident #11's progress notes and confirmed Resident #11 was offered reassurances by the DON and a psych services referral was made. 2. All other Residents a. To be completed by 8/13/24, all interviewable Residents interviewed by Director of Nursing and Therapy Director to ensure their safety in the facility, and to report any concerns relating to their safety. Action Taken -Confirmed interviewable residents felt safe in the facility. b. To be completed by 8/13/24, non-verbal Residents visually assessed by the Director of Nursing for signs of abuse, fear or change in behavior. Signs of abuse may include grimacing, clenching of teeth, distress, moaning, groaning, yelling, guarding, intermittent body movements, or any other cues that could point to a change of condition. Action taken - Confirmed non-verbal Residents were asked if they feel safe in the facility. 3. Administrator Training, in-servicing a. On 8/12/24 the Regional Nurse Consultant educated the Administrator on the importance of fully investigating allegations of abuse in order to ensure Resident safety as a top priority. Action taken - Confirmed, through an email from the Regional Nurse Consultant, the Administrator was re-educated on the company's abuse and neglect prevention policy and policy on reporting allegations of abuse timely and correctly, per the facility provider letter (TULIP, HOTLINE, EMAIL). On 8/12/24 the Administrator received education on facility's Chain of Command Policy reporting abuse up the chain in the facility. Action taken - On 08/21/24 confirmed, through an email from the Regional Nurse Consultant and interview with the Administrator that he passed the return demonstration test to demonstrate competency about the facility policy and proficient in his understanding of facility abuse and neglet and reporting and investigating abuse and neglect policies to proceeded to train the facility staff and staff who will assist training staff. 5. Staff Training, in-servicing a. To be completed by 8/13/24, Administrator or a trained designee is in-servicing each staff, with a return demonstration test to confirm competence. Staff are required to come to the facility to complete their training and test. Staff out of town will complete their training virtually with a trained designee. Each current staff and newly hired staff will complete training before working their next shift in the facility. The chain of command policy stated: 1. HEALTHCARE STAFF ARE MANDATED (TITLE 9) TO REPORT ABUSE, WITHOUT FEAR OF RETALIATION 2. SUSPECTED ABUSE IS REPORTED IMMEDIATELY TO YOUR SUPERVISOR AND ABUSE COORDINATOR 3. ABUSE IS TO BE REPORTED TO STATE WITHIN 2 HOURS. IF LEADERSHIP DOES NOT REPORT ABUSE, THERE IS AN HHS HOTLINE POSTED IN THE FACILITY AT ENTRANCE AND NURSE STATIONS 4. THE PERSON SUBMITTING ABUSE WILL NOTIFY a. HHSC b. POLICE c. OMBUDSMAN d. FAMILY e. PHYSICIAN 4. Follow up for effectiveness of the plan and auditing e. IDT meeting held 8/12/24 with Physician, DON, ADON and Administrator to ensure compliance with facility policy on abuse and neglect, training all staff to identify and report abuse. Action taken - Received confirmation that IDT meeting was 8/12/24 with signatures from the Physician, DON, ADON and Administrator to ensure compliance with facility policy on abuse and neglect, training all staff to identify and report abuse f. For three months, Administrator or designee to audit weekly all incidents of abuse and confirm they are reported, investigated, and completed. g. All findings are presented to the quality assurance committee for continued tracking/trending, assessment, and timely intervention as is necessary. QAPI committee will review these processes for 3 months, or as long as is deemed necessary to promote a continued safe environment for all Residents free from all abuse and neglect. The Surveyor monitored the POR on 08/13/24 as followed: During interviews on 08/13/24 from 10:01 AM - 1:09 PM, one RN, three LVNs, 5 CNAs, 2 medication aides, the Therapy Directory, Business Office Manager, Dietary Manager, Dietary Aide, staffing coordinator, receptionist, and two housekeeping staff (from different shifts) all stated they were in-serviced and took a post-test before working their shifts. All were able to state that their ADM was the Abuse and Neglect Coordinator and give examples of different types of abuse such as physical, verbal, emotional, and psychosocial. All stated that if they would report any abuse or suspected abuse the facility abuse and neglect coordinator immediately and if action were not taken by the facility, they would report the incident to HHSC. All were knowledgeable about the location of the position in the facility with the HHSC reporting hotline telephone number. All stated they were aware that it was the responsibility of all healthcare workers to report abuse and neglect and the facility cannot retaliate against them for reporting abuse and neglect and they felt safe that the facility would not retaliate against them for reporting abuse and neglect. In an interview with the Administrator on 08/21/24, time unknown, investigator confirmed he passed the return demonstration test and demonstrate competency about the facility policy and was proficient in his understanding of facility abuse and neglet and reporting and investigating abuse and neglect policies. Review of in-services, dated 08/12/24 - 08/13/24 reflected staff from all shifts were in-serviced on ANE policy and procedures, the Abuse and Neglect Coordinator, reporting, healthcare staff are mandated to report abuse without fear of retaliation, suspected abuse is reported immediately to the supervisor and abuse coordinator, and if the abuse is not reported by leadership, there is an HHSC hotline posted in the facility at the entrance and nurses' stations. Review of Abuse Post-Tests, dated 08/12/24 - 08/13/24, reflected all staff completed the test with passing scores. While the IJ was removed on 08/13/24 at 5:30 PM, the facility remained at a level of actual 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. Refer to CMS Form 2567, F dated /2023, for evidence of licensure violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** POST IDR Based on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #1 and Resident #2) of five residents reviewed for quality of care, in that: The facility failed to provide wound treatments according to physician orders and to assess and obtain treatment orders for new or worsening wounds from 09/01/23 to 10/02/23. Resident #1 and Resident #2's wounds deteriorated during that timeframe. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/20/23 at 4:29 PM. While the IJ was removed on 10/24/23 at 5:20 PM, the facility remained at a level of actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of pain, infection, hospitalization, and a decreased quality of life. 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 type II diabetes, age-related physical debility, candidiasis (a localized infection of the skin or fingernails) of skin and nails, and venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart). Review of Resident #1's quarterly MDS assessment, dated 08/21/23, reflected a BIMS of 15, indicating no cognitive impairment. Section M (Skin Conditions) reflected she was at risk of developing pressure ulcers/injuries and she had six venous and arterial ulcers present. Review of Resident #1's quarterly care plan, revised 07/05/23, reflected she has wounds to her right calf, left shin, right shin, right second toe, and right great toe with an intervention of following the physician's treatment orders. Review of Resident #1's physician order, dated 07/28/23, reflected wound care to right calf: cleanse with wound cleaner, pat dry, apply triad paste twice a week and PRN until resolved: Apply compression roll to left lower extremity, then gauze roll, then self-adhere compression wrap every Tuesday and Friday. Review of Resident #1's TAR, September 2023, reflected she received wound care treatment to her right calf three of the nine opportunities for the month, on Friday 09/08, Tuesday 09/12, and Friday 09/15. Review of Resident #1's physician order, dated 06/29/23, reflected wound care to left shin: cleanse with wound cleaner, pat dry, apply triad paste twice a week and PRN until resolved: Apply compression roll to left lower extremity, then gauze roll, then self-adhere compression wrap every Monday and Thursday. Review of Resident #1's TAR, September 2023, reflected she received wound care treatment to her left shin one of the eight opportunities for the month, on Thursday 09/07. Review of Resident #1's physician order, dated 06/29/23, reflected wound care to right shin: cleanse with wound cleaner, pat dry, apply triad paste twice a week and PRN until resolved: Apply compression roll to left lower extremity, then gauze roll, then self-adhere compression wrap every Monday and Thursday. Review of Resident #1's TAR, September 2023, reflected she received wound care treatment to her right shin one of the eight opportunities for the month, on Thursday 09/07. Review of Resident #1's physician order, dated 06/16/23, reflected wound care to right 2nd toe: Clean open area with wound cleaner then hypochlorous acid. Pat dry and apply calcium alginate with silver. Cover with dry dressing daily and PRN. Review of Resident #1's TAR, September 2023, reflected she received wound care treatment to her right 2nd toe four of the 30 opportunities for the month, on Thursday 09/07, Friday 09/08, Tuesday 09/12, and Friday 09/15. Review of Resident #1's physician order, dated 06/16/23, reflected wound care to right 4th toe: Clean open area with wound cleaner then hypochlorous acid. Pat dry and apply calcium alginate with silver. Cover with dry dressing daily and PRN. Review of Resident #1's TAR, September 2023, reflected she received wound care treatment to her right 4th toe four of the 30 opportunities for the month, on Thursday 09/07, Friday 09/08, Tuesday 09/12, and Friday 09/15. Review of Resident #1's WCD assessment, dated 08/24/23, reflected the following: Venous wound of the left shin: 13 cm x 16 cm x 0.2 cm Venous wound of the right shin: 23 cm x 23 cm 0.1 cm Diabetic wound of the right 2nd toe: 0.3 cm x 0.2 cm x 0.2 cm Venous wound of the right 4th toe: Resolved Venous wound of the right, posterior calf: 22 cm x 10 cm x 0.1 cm Venous wound of the left calf: 8 cm x 3 cm x 0.1 cm Venous wound of the right 3rd toe: 2.5 cm x 1.2 cm x 0.2 cm Review of Resident #1's next WCD assessment after the one from 08/24/23, dated 09/28/23, reflected the following: Venous wound of the left shin: 23 cm x 17 cm x 0.2 cm Venous wound of the right shin: 27 cm x 22 cm x 0.2 cm Diabetic wound of the right 2nd toe: Resolved Venous wound of the right, posterior calf: 17 cm x 11 cm x 0.1 cm Venous wound of the left calf: Resolved Venous wound of the right 3rd toe: 1.7 cm x 0.7 cm x 0.2 cm Observation and interview on 10/20/23 at 1:59 PM revealed the WCN C nurse performing treatment to Resident #1's wounds on her right toes. He stated his first day at the facility was 10/02/23 and he worked Monday - Friday from 7:30 AM - 2:00 PM. During an interview on 10/20/23 at 2:17 PM, Resident #1 stated when she was initially admitted to the facility her wounds had been treated and healed at the hospital, and now we were back to having all of these wounds. She stated when the old wound care nurse was working at the facility, she would treat her wounds some days and some days she would not. She stated when she stopped showing up, she kept telling the nurses she needed wound care and they would walk out of the room and not come back. She stated during that timeframe her wounds worsened and they had drainage. She stated since WCN C started, wound care treatments had been done regularly and her wounds had gotten better. Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type II diabetes, end stage renal disease, chronic kidney disease, and acquired absence of other left toe(s). Review of Resident #2's admission MDS assessment, dated 07/14/23, reflected a BIMS of 15, indicating no cognitive impairment. Section M (Skin Conditions) reflected he was at risk of developing pressure ulcers/injuries and he had a diabetic foot ulcer. Review of Resident #2's admission care plan, dated 07/13/23, reflected he admitted with actual impairments to skin integrity related to diabetes with an intervention of following physician treatment orders. Review of Resident #2's physician order, dated 08/01/23, reflected wound care to left foot: Clean open area with Hypochlorous Acid Solution, pat dry, apply Calcium Alginate with silver, apply ABD pad and wrap with kerlix daily and PRN. Review of Resident #2's TAR, September 2023, reflected he received wound care treatment to his left foot seven of the 30 opportunities for the month, on Tuesday 09/05, Thursday 09/07, Friday 09/08, Monday 09/11, Tuesday 09/12, Wednesday 09/13, and Friday 0n 09/15. Review of Resident #2's WCD assessment, dated 08/24/23, reflected the following: Diabetic wound of the left foot: 4.4 cm x 8.7 cm x 0.3 cm Review of Resident #2's next WCD assessment after the one from 08/24/23, dated 09/28/23, reflected the following: Diabetic wound of the left foot: 2.6 cm x 9.5 cm x 0.4 cm During an interview on 10/20/23 at 3:07 PM, Resident #2 stated he went over two weeks without wound care. He stated the bandages were soggy and painful and he kept asking the aides to get a nurse to help him but the nurses never did. He stated, thank God for the new treatment nurse as he had been wonderful. Review of Resident #2's next WCD assessment after the one from 09/07/23, dated 09/28/23, reflected the following: Stage IV pressure wound to coccyx: 2.2 cm x 1.7 cm x 0.2 cm During an interview on 10/20/23 at 1:36 PM, the DON stated she started working at the facility as the interim DON at the end of July (2023). She stated when she started, they had a treatment nurse who provided wound treatments to the residents. She stated sometime in early September, the treatment nurse started calling out more often until she eventually just stopped showing up. She stated the nurses were instructed to then provide wound care to their residents and she would remind them daily in the morning meeting. She stated the WCD was not able to reach the treatment nurse so he might have missed some visits during that timeframe, leaving weekly wound care assessments going undone. She stated she was not sure if the nurses were tracking the wounds or getting measurements during wound treatments. She stated it ultimately had been her responsibility to ensure treatments and assessment had been getting done. The DON stated the wound care treatment system was broken, but they recognized the problem and it had since been fixed. She stated their new treatment nurse (WCN C) started at the beginning of October and he was providing daily wound treatments during the week and LVN F was providing the treatments on the weekends. She stated she was unaware there were gaps on resident TARs in September and was unsure if the nurses failed to sign off on the TAR or had failed to provide the treatments. She stated if there were blanks on the TAR and it was not signed off, it usually meant it was not done. During an interview on 10/20/23 at 2:02 PM, RN A stated she worked on Resident #1, #2, and #3's hall on the 6:00 AM - 2:00 PM shift. She stated she had been notified by the DON that the nurses were to provide wound treatments after the treatment nurse quit. She stated she would divide the residents that required treatments in half so that the nurse coming in after her could complete the rest of the treatments. She stated she had put her name by the resident's name she provided treatments for on the 24-hour report so the next nurse would know who she was supposed to provide treatments for. She stated she did not provide treatment for Resident #1, #2, or #3, they were the responsibility of the 2:00 PM - 10:00 PM shift nurse. During an interview on 10/20/23 at 2:09 PM, LVN B stated no one had notified her they were without a treatment nurse or that she was to be providing treatments to any of her residents. She stated it was a few weeks after the treatment nurse left before she was made aware. She stated she found when Resident #2 kept asking her when his treatment would be done and that was when she asked where the treatment nurse was. She stated she had been informed that she had been gone for a while at that point. During an interview on 10/20/23 at 3:13 PM, CNA D stated when the old treatment nurse left, she would tell the nurses that the residents needed their wound care done, especially Resident #1. He stated during that timeframe Resident #1's wounds on her shins got very bad, were draining a lot, and she would have to put towels down under her legs. She stated Resident #1 used to cry because her dressings were not being changed and she did not know how her wounds were doing. During a telephone interview on 10/20/23 at 3:34 PM, the WCD stated the old treatment nurse would often cancel rounds with him and then just stopped responding all together. He stated he was not informed by anyone at the facility that she had quit. He stated there was about a two-week period where he was unable to make rounds to conduct wound assessments and treatments due to not being able to get ahold of that treatment nurse to schedule rounds. He stated if a resident missed wound care treatments by him, he would expect for the nurses to provide the treatments. He stated he finally had his Client Relations Manager reach out to the front desk at the facility and he was informed they no longer had a treatment nurse. He stated he then started conducting rounds with LVN E. Review of the facility's Abuse and Neglect Policy, revised 05/20/22, reflected the following: Policy: Residents of (facility) will be protected from abuse, neglect, mistreatment, or misappropriation of property in accordance with State and Federal Regulations. Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or necessary services for daily living activities. Neglect occurs when facility staff fail to monitor and/or supervise the delivery of resident care and services to assure that care is provided as needed by the residents. Neglect occurs when a facility fails to provide necessary care for residents, such as situations in which residents are being left to lie in urine or feces. The ADM and DON were notified on 10/20/23 at 4:29 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 10/24/23 at 12:23 PM: F600 - The residents have the right to be free from neglect. The facility neglected to provide wound treatment as ordered by the Physician. Immediate Corrective Action for residents affected by the deficient practice: Resident #1 was immediately assessed on 10/20/2023 by the Director of Nursing, four known sites of wound/skin integrity issues were observed, and no new skin integrity issues were identified. The four known sites of wound/skin integrity issues are all progressing as expected, all TARs are signed and treatments done daily by the facility's wound care nurse, as per the MD orders. The Director of Nursing and wound care nurse were provided education on conducting audits of residents with wound/skin integrity issues on 10/20/2023. The Director of Nursing and the Wound care nurse, then conducted an audit of all residents, completed on 10/20/2023, with wound/skin integrity issues and found them all to be progressing as expected, all TARs were signed, and all treatments done daily as per MD orders. The Director of Nursing and Treatment Nurse were educated by Regional Nurse Consultant on 10/20/2023, this education included who is responsible for providing wound care, following physician orders, and documenting treatments appropriately. The Director of Nursing then provided an in-service/education for all nurses, full time and PRNs, on providing wound care. The facility utilizes no agency nurses. The Administrator was provided the above education by the Regional Nurse Consultant on 10/22/2023. The Director of Nursing provided an education on following Physician's orders, to all nurses. All nurses were instructed that they are responsible for both the Medication administration and Treatment administration of all residents on their assignment, furthermore they were responsible for ensuring that all MARs and TARs were signed after medications and treatments were administered. Nurses were instructed that in the event the treatment nurse is out or unavailable, they would be responsible for treatments and wound care, of all residents on their assignment. This education was completed on 10/22/2023. All of the above training will be added to the facility's onboarding and annual education programs. The Director of Nursing Provided an in-service/education to all CNAs, directing them to report to the nurse, any resident dressing that has come off during care, became soiled, or needed to be replaced. This training was completed on 10/22/2023 Actions taken to prevent a serious adverse outcome from recurring: The Director of Nursing has created an audit to monitor TARs of all residents with skin issues for any non-compliance. Audits will be conducted daily for 30 days and biweekly for another 30 days. Any negative findings will be reported to the administrator for immediate correction. Audits have started on 10/21/2023 and will be ongoing. All findings will be reported to the QAPI team on a weekly basis. The Director of Nursing was provided and in-service on preventing abuse and neglect on 10/22/2023, by the Regional Nurse Consultant. The DON then provided training to all staff on 10/22/2023, on preventing Abuse and Neglect, on 10/22/2023. The Medical director was notified of this deficiency on 10/22/2023, and an Ad Hoc QAPI meeting was held on 10/22/2023 to discuss the findings. The Administrator and DON will monitor for compliance. When will actions be complete: 10/22/2023 The Surveyor monitored the POR on 10/24/23 as followed: During interviews on 10/24/23 from 1:18 PM - 3:40 with WCN C, five LVN's, one RN, and two CNAs, all stated they were in-serviced before their shifts on abuse and neglect. All staff members were able to relay different types of abuse such as physical, mental, verbal, and sexual. They all stated their ADM was their Abuse and Neglect Coordinator and all suspicions of abuse or neglect should be reported to him immediately. Observations made on 10/24/23 from 3:52 PM - 4:08 PM revealed the bandages for Resident #1 and #2's wounds were dated for that day. The dressings were dry and intact. Review of an Ad Hoc QAPI Meeting Agenda Summary, dated 10/22/23, reflected the NP, WCN C, DON, ADM, and two charge nurses were in attendance. Review of an in-service entitled Abuse and Neglect, dated 10/22/23 and conducted by the DON, reflected staff were educated in person and by phone on the different types of abuse and neglect and reporting all allegations or concerns of abuse or neglect to the ADM immediately. While the IJ was removed on 10/24/23 at 5:20 PM, the facility remained at a level of actual harm at a scope of pattern 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 residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new pressure ulcers from developing for one (Resident #3) of five residents reviewed for pressure injuries, in that: The facility failed to provide wound treatments according to physician orders and to assess and obtain treatment orders for new or worsening wounds from 09/01/23 to 10/02/23. Resident #3's wounds deteriorated during that timeframe. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/20/23 at 4:29 PM. While the IJ was removed on 10/24/23 at 5:20 PM, the facility remained at a level of actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of pain, infection, deterioration of existing pressure injuries, hospitalization, and a decreased quality of life. Findings included: Review of Resident #3's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, age-related physical debility, generalized muscle weakness, and abnormal posture. Review of Resident #3's quarterly MDS, dated [DATE], reflected a BIMS of 5, indicating a severe cognitive impairment. Section M (Skin Conditions) reflected he had a stage IV pressure ulcer/injury and was at risk of developing pressure ulcer/injuries. Review of Resident #3's quarterly care plan, revised 05/28/23, reflected he had developed a stage IV pressure injury to his coccyx (facility acquired) due to immobility related to dementia and a nutritional status of dysphagia (difficulty with swallowing) and protein calorie-malnutrition with an intervention of administering wound care as ordered by the physician. Review of Resident #3's physician order, dated 08/01/23, reflected wound care to [NAME] IV pressure ulcer to coccyx: Cleans wound with wound cleanser, pat dry, apply collagen powder, apply calcium alginate with silver, apply skin prep and cover with border gauze dressing daily and PRN. Review of Resident #3's TAR, September 2023, reflected he did not receive wound care treatment to his coccyx nine of the 30 opportunities for the month, on Friday 09/01, Monday 09/04, Tuesday 09/05, Wednesday 09/06, Saturday 09/09, Saturday 09/16, Sunday 09/17, Thursday 09/28, and Saturday 09/30. Review of Resident #3's WCD assessment, dated 09/07/23, reflected the following: Stage IV pressure wound to coccyx: 2.2 cm x 1.6 cm x 0.2 cm Review of Resident #2's next WCD assessment after the one from 09/07/23, dated 09/28/23, reflected the following: Stage IV pressure wound to coccyx: 2.2 cm x 1.7 cm x 0.2 cm During an interview on 10/20/23 at 3:02 PM, Resident #3 stated in a soft voice that he was feeling okay. He stated there was a time period when he was not getting treatment to his wound but it was better now. During an interview on 10/20/23 at 1:36 PM, the DON stated she started working at the facility as the interim DON at the end of July (2023). She stated when she started, they had a treatment nurse who provided wound treatments to the residents. She stated sometime in early September, the treatment nurse started calling out more often until she eventually just stopped showing up. She stated the nurses were instructed to then provide wound care to their residents and she would remind them daily in the morning meeting. She stated the WCD was not able to reach the treatment nurse so he might have missed some visits during that timeframe, leaving weekly wound care assessments going undone. She stated she was not sure if the nurses were tracking the wounds or getting measurements during wound treatments. She stated it ultimately had been her responsibility to ensure treatments and assessment had been getting done. The DON stated the wound care treatment system was broken, but they recognized the problem and it had since been fixed. She stated their new treatment nurse (WCN C) started at the beginning of October and he was providing daily wound treatments during the week and LVN F was providing the treatments on the weekends. She stated she was unaware there were gaps on resident TARs in September and was unsure if the nurses failed to sign off on the TAR or had failed to provide the treatments. She stated if there were blanks on the TAR and it was not signed off, it usually meant it was not done. During an interview on 10/20/23 at 2:02 PM, RN A stated she worked on Resident #1, #2, and #3's hall on the 6:00 AM - 2:00 PM shift. She stated she had been notified by the DON that the nurses were to provide wound treatments after the treatment nurse quit. She stated she would divide the residents that required treatments in half so that the nurse coming in after her could complete the rest of the treatments. She stated she had put her name by the resident's name she provided treatments for on the 24-hour report so the next nurse would know who she was supposed to provide treatments for. She stated she did not provide treatment for Resident #1, #2, or #3, they were the responsibility of the 2:00 PM - 10:00 PM shift nurse. During an interview on 10/20/23 at 2:09 PM, LVN B stated no one had notified her they were without a treatment nurse or that she was to be providing treatments to any of her residents. She stated it was a few weeks after the treatment nurse left before she was made aware. She stated she found when Resident #2 kept asking her when his treatment would be done and that was when she asked where the treatment nurse was. She stated she had been informed that she had been gone for a while at that point. During an interview on 10/20/23 at 3:13 PM, CNA D stated when the old treatment nurse left, she would tell the nurses that the residents needed their wound care done, especially Resident #1. He stated during that timeframe Resident #1's wounds on her shins got very bad, were draining a lot, and she would have to put towels down under her legs. She stated Resident #1 used to cry because her dressings were not being changed and she did not know how her wounds were doing. During a telephone interview on 10/20/23 at 3:34 PM, the WCD stated the old treatment nurse would often cancel rounds with him and then just stopped responding all together. He stated he was not informed by anyone at the facility that she had quit. He stated there was about a two-week period where he was unable to make rounds to conduct wound assessments and treatments due to not being able to get ahold of that treatment nurse to schedule rounds. He stated if a resident missed wound care treatments by him, he would expect for the nurses to provide the treatments. He stated he finally had his Client Relations Manager reach out to the front desk at the facility and he was informed they no longer had a treatment nurse. He stated he then started conducting rounds with LVN E. Review of the facility's Skin and Wound Management Policy, revised 01/17/23, reflected the importance of the Braden Scale Pressure Ulcer Risk Assessment. It did not reflect weekly wound/skin assessments are completing treatments as ordered by the physician. Review of the facility's Physician's Orders Policy, revised 05/20/23, reflected the following: Purpose: To ensure that the plan of care is followed in accordance with the orders established by the physician and/or nurse practitioner. . Treatment orders: All treatments should include the treatment to be used and location of where the treatment should be placed, frequency and if appropriate, how the area should be cleaned and how it should be covered. Reason for the treatment is required (diagnosis). This will be reflected on the Treatment Administration Record (TAR). The ADM and DON were notified on 10/20/23 at 4:29 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 10/24/23 at 12:23 PM: F686 - The facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Immediate Corrective Action for residents affected by this deficient practice: Resident #1 was immediately assessed on 10/20/2023 by the Director of Nursing, four known sites of wound/skin integrity issues were observed, and no new skin integrity issues were identified. The four known sites of wound/skin integrity issues are all progressing as expected, all TARs are signed and treatments done daily, as per MD orders, by the facility's wound care nurse. This deficient practice, of failing to provide the necessary treatments and services to promote wound healing, had the potential to affect 17 residents receiving wound care services. The Director of Nursing and wound care nurse were provided education on how to conduct audits for this deficiency on 10/20/2023. The Director of nursing and Wound care nurse, then conducted an audit of all residents, completed on 10/20/2023, with wound/skin integrity issues and found them all to be progressing as expected, all TARs were signed, and all treatments done daily as per MD orders. Education was provided by Regional Nurse Consultant on 10/20/2023, the Director of Nursing and new Treatment Nurse were educated. This education included following physician orders, and documenting treatments appropriately. The Director of Nursing then provided an in-service/education for all nurses, including full time and PRN employees. The facility employed no agency nurses. The Administrator was also provided the above education on 10/22/2023.The treatment nurse will perform wound care as ordered Monday through Friday, and treatments on the weekend will be conducted by the two scheduled charge nurses. The facility utilizes three charge nurses Monday through Friday, and Two on the weekend, all charge nurses have been educated by the Director of Nursing on 10/22/2023. Should the treatment nurse be off, all charge nurses (3 charge nurses Monday -Friday and 2 charge nurses on the weekend) will be responsible for completing wound care and treatments for all resident on their respective assignments. The Director of Nursing was provided an education by the Regional Nurse Consultant on 10/20/2023, on following Physician's orders. The Director of nursing then provided education on following Physician's orders, to all nurses. The Director of Nursing has created an audit to ensure treatments are completed and documented as scheduled on a daily basis. Audits will be conducted daily for 30 days and biweekly for another 30 days All nurses were instructed that they are responsible for the Medication administration, and that they will be responsible for Treatment administration of all residents on their assignment in the event the Treatment Nurse is not in the facility. furthermore, they will be responsible for ensuring that all MARs and TARs were signed after medications and treatments were administered. The Director of Nursing Provided education by the Regional Nurse Consultant on 10/20/2023. The DON then provided in-service/education to all CNAs, directing them to report to the nurse, any resident dressing that has come off during care, became soiled, or needed to be replaced. Once reported the Director of Nursing or designee will direct the treatment or charge nurse to assess the resident, ensure no ill effects have been suffered, call the doctor to discuss the issue and ensure proper treatment is rendered. This in-service is ongoing and expected to be completed by end of day 10/22/2023. All education and in-services will be added to the facility's onboarding and annual education program. Actions taken to prevent a serious adverse outcome from recurring: The Director of Nursing has created and audit to monitor TARs of all residents with skin issues for any non-compliance. Audits will be conducted daily for 30 days and biweekly for another 30 days, any signs of non-compliance will be corrected immediately and reported to the administrator. The Director of Nursing and designee will conduct the audit and share the results with the Treatment Nurse and Administrator daily. All findings will be taken to the QAPI team for review on a weekly basis. Audits have started on 10/21/2023 and will continue for thirty days, then biweekly for another 30 days. The Medical director was notified of this deficiency on 10/22/2023, and an Ad Hoc QAPI meeting was held on 10/22/2023 to discuss the findings. The Administrator and DON will monitor for compliance. When will actions be complete: 10/22/2023 The Surveyor monitored the POR on 10/24/23 as followed: During interviews on 10/24/23 from 1:18 PM - 3:40 with WCN C, five LVN's, one RN, and two CNAs, all stated they were in-serviced before their shifts wound care, signing off on the TAR when treatments were completed, and the nurses being responsible for wound care when the treatment nurse was unavailable. The CNAs both stated that if they noticed any bandages that had fallen off or appeared dirty, they were to notify the charge nurses immediately. The CNAs also stated that if they noticed a new skin integrity issue on a resident, they were to notify the charge nurses immediately. During an interview on 10/24/23 at 2:46 PM, the ADM stated the wound care team did a skin sweep for all the residents, chart audits/reviews, and in-services were conducted for all staff. He stated the main thing was for the nurses to know they were responsible for wound care if the wound care nurse was not available. Observations made on 10/24/23 from 3:52 PM - 4:08 PM revealed the bandages for Resident #1, #2, and #3's wounds were dated for that day. The dressings were dry and intact. Review of a statement signed by WCN C, dated 10/20/23, reflected the following: I, [WCN C], the Wound Care Nurse was provided and educated on 10/20/23 by the Regional Nurse Consultant on how to conduct audits on residents with wound/skin integrity issues, monitoring TARs for completeness and ensuring that treatments are provided as per MD orders. Review of a statement signed by the DON, dated 10/20/23, reflected the following: I, [DON], the Director of Nursing, was provided and educated on 10/20/23 by the Regional Nurse Consultant, on following Physician's orders and documenting treatments appropriately. This education also highlighted the importance of the scheduled charge nurses being responsible for all treatment administration and wound dressing changes on the weekend and whenever the wound care nurse is unavailable. Review of an in-service entitled Wound Care/TAR, dated 10/20/23 and given by the DON, reflected all nurses were educated on the following: It is the responsibility of the nurse to make sure all MARs and TARs are cleared by the end of their shift. The wound care nurse is to communicate any missed treatments with the charge nurse on the days he is here to perform wound care. The wound care nurse is not here 7 days a week. The nurses are responsible for making sure the wound care is performed and the TARs are completed prior to the end of their shift. All dressings are to be dated and initialed when a dressing change is performed and the TAR is to be signed off. Review of an in-service entitled Wound Care, dated 10/22/23 and given by the DON, reflected all CNAs were educated on the following: CNAs are to report any dressings coming off on wounds and/or any soiled dressings to the charge nurse. Charge nurses or the wound care nurse are to perform the treatment, reapply the dressing, and notify the physician as indicated. Review of an Ad Hoc QAPI Meeting Agenda Summary, dated 10/22/23, reflected the NP, WCN C, DON, ADM, and two charge nurses were in attendance. While the IJ was removed on 10/24/23 at 5:20 PM, the facility remained at a level of actual harm at a scope of pattern 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 was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 (Resident #15, Resident #51, and Resident #71) of 3 residents reviewed for accidents and supervision. Resident #71 offered illegal substances to Residents #15 and #51 to smoke in the facility. The facility failed to ensure the resident was assessed upon admission to the facility to determine if she was safe to smoke independently. The resident was found smoking in the building on two separate occasions, smoking outside the building unsupervised on one occasion and after a search of her room, smoking and drug paraphernalia were found. The facility failed to conduct any smoking assessments or provide effective interventions to keep residents safe. An IJ was identified on 06/27/2023. The IJ template was provided to the facility on 6-27-23 at 5:17 PM. While the IJ was removed on 06/29/2023, the facility remained out of compliance at a scope of isolated with no actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk of smoke inhalation, burns, loss of property, hospitalization, and death. The findings were: Review of Resident #15's face sheet dated 06/29/2023 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia (happens when you don't have enough oxygen in your blood), drug induced subacture dyskensia (involuntary movement disorder), cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) and chronic post-traumatic stress disorder. Review of Resident #15's quarterly MDS assessment, dated 05/13/2023, reflected the BIMS of 15 indicating intact cognition. Review of Resident #51's face sheet 06/29/2023 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease (the kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), Type 2 diabetes, fluid overload, and edema (swelling caused by fluid in your body's tissues). Review of Resident #51's quarterly MDS assessment, dated 05/11/2023, reflected the BIMS of 14 indicating intact cognition. Review of Resident #71's face sheet dated 06/28/2023 reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including other pancytopenia (a problem with the blood-forming stem cells in the bone marrow), adult failure to thrive, human immunodeficiency virus disease, and patient's noncompliance with other medical treatment and regimen for unknown reason. Review of Resident #71's quarterly MDS assessment, dated 05/09/2023, reflected the BIMS of 15, reflecting intact cognition. Review of Resident #71's quarterly care plan revised on 06/07/2023 reflected Resident #71 was a smoker/used tobacco product and was non-compliant with facility smoking policy. On 5/25/23 Resident #71 was found smoking inside the facility in the breezeway and on 06/07/2023 the resident was smoking by the dumpster (a non-designated smoking area). A goal was initiated on 05/05/2023 for Resident #71 to not have any complications from smoking through the next review date. Interventions on 05/05/2023 listed the resident was counseled by the ADM for non-compliance with the facility smoking policy; the resident was educated about the facility smoking policies and facility smoking area; the resident signed a smoking contract per facility policy and was encouraged, offered education for smoking cessation. There were no interventions related to the supervision or monitoring of resident for smoking. Review of Resident #71's quarterly care plan initiated on 06/06/2023 reflected Resident #71 had a history of substance abuse: cocaine, methamphetamine. A goal was initiated on 05/06/2023 that Resident #1 would not have access to illicit drugs or exhibit signs of their use. Record review of the Smoking Agreement dated 05/05/2023 and signed by Resident #71, the Social Worker, the ADM and a fourth person (signature illegible) reflected Policy Statement: The facility will establish and maintain safe smoking practices, upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non- smoking preferences, no smoking signs shall be displayed throughout the facility where smoking is prohibited, smoking restrictions shall be strictly enforced in all non-smoking areas, any smoking related privileges, restrictions, and concerns shall be noted in the care plan, the facility may impose smoking restrictions on residents at ANY TIME if it is determined that the resident cannot smoke safely with the available levels of support /supervision, residents with independent smoking privileges may NOT have or keep any types of smoking articles, to include cigarettes, lighters, tobacco, or vaping devices on them or in their room, the facility may check periodically to determine if residents have any smoking articles in violation of our smoking policies, the first offense is a verbal warning, the second offense is a 30 day discharge notice to the facility of their choice. Record review of Resident 71#'s social services progress note dated 05/25/2023 entered by the ADM revealed the resident was found to be smoking in a restricted area of the facility. The resident put out a cigarette. The resident refused to give the lighter or smoking materials to the ADM, rolled her eyes and laughed at the request to not smoke. The resident was educated it was a violation of the smoking agreement and was notified a further occurrence would lead to a discharge notice. The resident was also educated on the safety concerns of starting a fire and a potential for other residents with oxygen to the enter area. Facility would continue to monitor. Record review of Resident #71's nurses progress note dated 06/21/2023 revealed the writer was informed by the ADON that the resident was found smoking in her room. In response to this report, the writer accompanied the ADON and the hospice nurse to the resident's room to address the situation. The resident acknowledged that she had been smoking in the room and assured us that she would not do it again. The resident stated that she was not supplying any smoking materials to other residents within the facility. The writer took the opportunity to explain to the resident the hazards associated with smoking in enclosed spaces, emphasizing the increased risk of fire, health issues, and discomfort it could cause for other residents. The writer made it clear that any future instances of smoking in the room would result in an immediate discharge from the facility. The resident appeared receptive to the explanation and expressed remorse for her actions. We will continue to monitor the resident closely to ensure compliance with facility policies regarding smoking. Record review of Resident #71's social services progress note dated 06/22/2023, late entry entered by the ADM, revealed the resident was found in her room with multiple used cigarette butts, liquor bottles, and illegal drug paraphernalia. A 30-day discharge notice was delivered to the resident on 6/22/2023. The resident signed the notice and stated she may leave sooner than that. The IDT requested the resident to communicate her discharge plans and explained the facility would work with the resident to transition to a safe place. Record review of Resident #71's social services progress note dated 06/22/2023 entered by the ADM revealed resident allegedly gave another resident paraphernalia including a powdery white substance in a cigarette box, a long clear glass cylindrical pipe, and a blow torch lighter. Resident #71 then allowed staff to search her room. In the room multiple items were found, including: 4 half smoked cigarette butts, a beer bottle, a half full bottle of brandy, a nearly empty bottle of vodka, OTC laxatives, a blue glass smoking pipe, 4 lighters, and varying other paraphernalia. The resident was informed those substances were not acceptable in the facility. The police were notified and removed the items. The police responded with case #231730407. After multiple violations of the facility smoking policy, and repeated attempts to educate resident of rules, the facility would move forward with a 30-day discharge notice. Record review of Resident #71's care plan reflected no smoking safety assessment completed for Resident #71 upon admission. Observation on 06/28/2023 at 3:30 PM of an unlocked closed closet revealed a red label of oxygen that was approximately 10 feet from Resident #71's room. The closet contained approximately two and a half dozen full tanks of O2. Observation on 06/27/2023 at 11:30 AM of Resident #71's room revealed she did not have a roommate. Interview of 06/27/2023 at 11:30 AM with Resident #71revealed she had smoked cigarettes in her room and had smoked cigarettes in the building. She revealed she brought some illegal drugs, including a drug pipe, into the facility and offered it to other residents to smoke. Resident #71 did not reveal the names of the other residents during the interview. She revealed that one resident did smoke illegal drugs with her but thought that other resident felt guilty about smoking and reported her to the facility. She said the facility conducted an illegal search of her room and found cigarettes and drug pipes. Interview on 06/28/2023 at 3:15 PM with MAA revealed that on 06/22/2023 she was outside of Resident #71's room and she smelled cigarettes and when she entered Resident #71's room the whole room was filled with smoke. She stated Resident #71 tried to hide the cigarette but Resident #71 was clearly smoking. MA A said she left Resident #71's room and went to get the charge nurse. Interview on 06/28/2023 at 12:32 PM with LVN A, charge nurse, revealed on 06/22/2023 she was told by MA A that Resident #71 was smoking in her room. LVN A asked LVN HN to come with her to Resident #71's room. In Resident #71's room LVN A witnessed Resident #71 with a lit cigarette. LVN A said Resident #71 took a couple of puffs. LVN A said she asked Resident #71 for the cigarettes and lighter. LVN A said Resident #71 gave the cigarettes but Resident #71 declined to give her the lighter saying it was an expensive lighter and she did not want to lose it. LVN A revealed she was concerned about the safety of the residents because Resident #71's smoked in the room. The possible outcome of residents smoking in their room were that people with respiratory conditions might have had an asthma attack and there are O2 tanks in the building that were flammable. Interview on 06/28/2023 at 4:00 PM with LVN HN revealed that on 06/21/2023 she witnessed Resident #71 smoking in her room. She walked into the room along with LVN PF and saw that Resident #71 was holding a lit cigarette. LVN HN revealed that smoking in the facility was a safety concern because several people at the facility used O2. Interview on 06/28/2023 at 11:11 AM with Resident #15revealed that Resident #71 offered her meth on 06/20/2023. She revealed she told Resident #71 she did not want anything to do with it and felt bad and unsafe that someone offered her meth. Resident #15 revealed she was concerned that if residents brought in meth, how could they say they wouldn't bring in a gun? Interview on 06/28/2023 at 10:57 AM with Resident #51 revealed she was friends with Resident #71 who gave her a pipe with crystal meth and Resident #71 wanted Resident #51 to smoke it. Resident #51 revealed Resident #71 gave her the pipe and the white crystal meth powder wrapped in a paper towel. Resident #51 said she gave the items to the DON and said the facility had done nothing about it because Resident #71 was still at the facility. Resident #51 said that if it was another resident, they would have been gone the same day and felt like that could happen again with Resident #71. Interview on 06/28/2023 at 3:11 PM with the DON revealed that Resident #51 gave her a black winter cap that contained a packet of cigarettes and a transparent small bag with white a substance at approximately 6:00 AM. The DON revealed she gave it to the ADM who called the police. A police officer removed the substance. Interview on 06/27/2023 at 4:01 PM with the ADM revealed there were three incidents of Resident #71 violating the facility's smoking policies. One incident occurred on 05/21/2023 when a staff member (the ADM could not remember the name of the staff member) notified her that Resident #71 was smoking in the breezeway inside the building. The ADM stated the second incident occurred on 06/07/2023 when Resident #71 was smoking outside by the dumpster in a non-designated smoking area; and the third incident occurred on 06/21/2023 when Resident #71 was found smoking in her room. The ADM revealed that after Resident #71 was found smoking in her room the ADM spoke with her and explained the dangers to Resident #71 and the ADM said she believed Resident #71 was remorseful and believed she would not smoke inside the facility again. The ADM revealed that no in-services were conducted after these events, no additional training was conducted, and Resident #71's care plan was not amended to include increased supervision and no requirement was made of staff to increase supervision for Resident #71. The ADM revealed there was concern for resident safety when a resident smoked in the facility because of O2 and fire hazard. She revealed there was nothing else she could do concerning Resident # 71 because she was non-compliant. The ADM revealed that Resident #71 did not receive a smoking assessment when she was admitted to the facility, and she should have received the assessment. The ADM revealed that after Resident #51 gave the DON the packet of cigarettes and a small transparent bag with white a substance, the police were called and Resident #71's room was searched by her. She stated four smoked cigarette butts, a beer bottle, a half full bottle of brandy, a nearly empty bottle of vodka, OTC laxatives, a blue glass smoking pipe, four lighters, including torch lighters, and varying other paraphernalia were discovered. Record review of the facility Nursing Policy and Procedure Subject: Smoking dated 05/2017 revealed it is the policy of the home that: all residents who smoke will be supervised, smoking will be permitted in designated safe area(s) only, oxygen equipment is not permitted in the smoking area(s), the minimum safe distance for oxygen equipment from the smoking area is 50 feet, residents not complying with the home's smoking policy may be discharged from the home, a Smoking Safety Evaluation will be completed for all residents who smoke on admission, change of condition and quarterly, the results of the Smoking Safety Evaluation will be entered into the resident's Care Plan and reviewed and updated with change of condition and quarterly. All residents that wish to smoke will be given the opportunity to smoke with supervision at the designated smoking times; residents must keep all smoking materials (lighters, matches, cigarettes, pipes, cigars, smoking tobacco, electronic cigarettes, etc.) at the nursing station; at no time are the residents permitted to keep smoking materials in their room; smoking materials will not be distributed to the resident until they are in the designated smoking area; and smoking materials will be distributed to accommodate a single smoke at a time. Refusal to follow the smoking policy could be cause for a resident to be involuntarily discharged from the Home. Record review Record review of facility Smoking Policy - Residents, dated 08/2022, revealed prior to, and upon admission, residents are informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or-non-smoking preferences. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Smoking is not allowed inside the facility under any circumstances. Oxygen use is prohibited in smoking areas. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of tobacco consumption. b. method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.); c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). The staff consults with the attending physician and the DON to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation, a resident's ability to smoke safely is re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff, any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues, the facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision, any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking, only disposable safety lighters are permitted, all other forms of lighters, including matches, are prohibited, residents are not permitted to give smoking items to other residents, residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision, staff members and volunteer workers are not permitted to purchase and/or provide any smoking items for residents, this facility maintains the right to confiscate smoking items found in violation of our smoldng policies, if the facility policy changes to one that prohibits smoking, residents who are currently allowed to smoke will be provided an area to smoke which maintains the quality of life and safety for smoking residents, while considering the health and well-being of non-smoking residents. This was determined to be an Immediate Jeopardy (IJ) on 06/27/2023 at 5:17 PM and the ADM was notified and provided the IJ Template. The following Plan of Removal was submitted by the facility and was accepted on 06/29/2023 at 8:28 AM: On 06/27/2023 an abbreviated survey was initiated at the facility. On 06/27/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that Regulatory Services determined that the condition at the facility constituted an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F689 - The facility failed to have adequate supervision to prevent potential accidents. Action 1: R1 was placed on 1:1 monitoring. All items previously removed from resident room and new sweep occurred on 6/27/23 with no concerns. Until the resident can be safely discharged , R1 is on 1:1 monitoring. Start Date: 6/27/2023 Completion Date: Ongoing until discharge Responsible: Leadership team (ADM, DON, ADON, LMSW, & designee) and Nursing Team (staff CNAs and nurses assigned to complete 1:1. Action 2: The facility was swept for contraband items including but not limited to cigarettes, lighters, illegal substances, and alcohol on 6/27/23. All smoking items found were removed from resident rooms and given to the charge nurse to be secured behind locked doors. All residents are aware that smoking paraphernalia and/or lighters kept in rooms are prohibited and residents agreed to this when signing the smoking agreement. Plan in place: Additional sweeps of the facility will occur daily x 2 weeks, then weekly for 2 weeks, and monthly thereafter. This will be kept on a daily monitoring sheet that will be completed by Administrator or designee. This sheet will be reviewed weekly and as necessary, any new items found will be confiscated, appropriate interventions will be put in place (such as notification to responsible parties, care plan updates, more routine monitoring such as 15- or 30-minute checks as determined by the IDT and dependent upon the situation, resident counseling, and potential for behavior contracts). Further instances of inappropriate behavior will be cause for the issuance of a 30- day discharge notice and the beginning of the discharge process. Start Date: 6/27/2023 Completion Date: 6/27/2023, daily room checks completed through 7/4/2023. Responsible: Leadership Team (ADON, DON, ADM, LMSW, MDS, DOH) Action 3: An Ad Hoc QAPI Meeting was held on 06/27/2023 to discuss the incident, make staff members aware of the policy on smoking at the facility, as well as potential danger to the facility and other residents. Start Date: 6/27/2023 Completion Date: 6/27/2023 Responsible: Management Team, ADM (attendees included: Medical Director via conference call, DON, ADON, Wound Nurse, Social Worker, Activities Director, DOR, MDS, HR, BOM, Dietary Manager, Housekeeping Supervisor, Staffing Coordinator, COO of company, incoming ADM). Action 4: All staff in-serviced and educated regarding the smoking policy and intervention with residents who are not abiding by the smoking policy. New team members will be in-serviced during orientation, upon hire. The Leadership team was in-serviced by the Administrator and Director of Nursing prior to assisting in education and training of in-servicing for team. The Administrator and Director of Nursing were in-serviced by the Regional Nurse Consultant. Start Date: 6/27/2023 Completion Date: Majority of all staff educated on or by 6/28/2023, in-servicing ongoing until all staff are educated with a completion by date of 6/29/23. Each staff member that has not been in-serviced yet will be in-serviced prior to or immediately upon their next shift. Responsible: Leadership team (Adm, DON, ADON, LMSW) Action 5: All staff and residents in-serviced and educated by the DON/ADM/ADON/HR or LMSW regarding the dangers and risks of fire and burns with oxygen present. Each staff member that has not been in-serviced yet will be in-serviced prior to or immediately upon their next shift. New team members will be in-serviced during orientation, upon hire. The Leadership team was in-serviced by the Administrator and Director of Nursing prior to assisting in education and training of in-servicing for team. The Administrator and Director of Nursing were in-serviced by the Regional Nurse Consultant. Start Date: 6/27/2023 Completion Date: Majority of all staff educated on or by 6/28/2023, in-servicing ongoing until all staff are educated with a completion by date of 6/29/23. Each staff member that has not been in-serviced yet will be in-serviced prior to or immediately upon their next shift. Responsible: Leadership team (Adm, DON, ADON, LMSW) Action 6: All staff in-serviced and educated by the DON/ADM/ADON/HR or LMSW regarding protocols for intervening and reporting resident behaviors that put others at risk. New team members will be in-serviced during orientation, upon hire. The Leadership team was in-serviced by the Administrator and Director of Nursing prior to assisting in education and training of in-servicing for team. The Administrator and Director of Nursing were in-serviced by the Regional Nurse Consultant. Start Date: 6/27/2023 Completion Date: Majority of all staff educated on or by 6/28/2023, in-servicing ongoing until all staff are educated with a completion by date of 6/29/23. Each staff member that has not been inserviced yet will be inserviced prior to or immediately upon their next shift. Responsible: Leadership team (Adm, DON, ADON, LMSW) Action 7: Smoking assessment and smoking policy reviewed for all smoking residents, including R1, to review need for smoking restrictions. There were no changes made from prior after review the smoking assessments. R1 has a BIMs score of 15/15. R1 is currently on 1:1 and if R1 chooses to participate in the facility supervised smoke breaks, R1's sitter will join and facility will assist resident. R1 is on hospice with a terminal illness and while R1 is compliant with current interventions, facility wishes to promote their resident's rights and dignity in final days, as long as it is safe for resident and all other residents. The restrictions (1:1 supervision) for R1 has been placed in the care plan and [NAME], and staff have been educated regarding restrictions. Start Date: 6/27/2023 Completion Date: Ongoing while R1 remains in the facility Responsible: Leadership team (Adm, DON, ADON, LMSW Monitoring of the Plan of Removal from 06/27/2023 - 06/29/2023 included the following: Interview on 06/27/2023 at 8:00 PM with the ADM and COO revealed that on 06/28/2023 beginning at 9:05 PM one staff person was assigned to monitor Resident #71 with her door open and their eyes on the resident. Observation on 06/28/2023 at 10:05 AM revealed a staff member standing outside of Resident #71's room with the door open. Review of one-on-one monitoring timeline for Resident #71 revealed staff utilized the facility 15 Minute Checks sheet to provide routine updates of resident activity during their monitoring from 06/27/2023 through 06/28/2023. Interview on 06/28/2023 at 10:30 AM with CNA E revealed she arrived at the facility a 10:00 PM and took over the assignment from CNA F to stay outside of Resident #71's room at all times and every 15-minutes to visually look at Resident #71. CNA E revealed she was to follow Resident #71 if Resident #71 left her room to walked around. CNA E revealed Resident #71 took a smoke break in the designated smoking area at the designated 9:00 AM smoking time. Review of the signed chart titled, Dailey Sweep Rounds revealed Resident #71's room was swept for contraband items including but not limited to cigarettes, lighters, illegal substances, and alcohol on 06/27/2023 - 06/29/2023. Review of the following signed in-services give to staff and residents revealed: In-service to staff regarding the smoking policy and intervention with residents who were not abiding by the smoking policy; In-service to staff and residents regarding the dangers and risks of fire and burns with oxygen present; In-service to staff for the protocols for intervening and reporting resident behaviors that put others at risk; and In-service to residents on smoking assessment and facility smoking policy and the need for smoking restrictions. Interviews on 06/29/2023 at 1:21 PM with two CNAs, one housekeeper, and one LVN who stated they participated, understood, and felt comfortable with the information given in the recent smoking policy and restrictions and were able to describe what actions should be taken during the event of a resident not following proper facility smoking policy. The ADM and DON were informed the Immediate Jeopardy was removed on 06/29/2023 at 4:00 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy identified and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.