**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the residents were free from physical abuse for one (Resident #1) of four residents reviewed for abuse.The facility failed to ensure Resident #1 was not slapped by LVN A on 07/23/25.An Immediate Jeopardy (IJ) situation was identified on 08/15/25. While the IJ was removed on 08/17/25, the facility remained out of compliance at a scope of isolated that with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injury, hospitalization, trauma, and psychosocial injury.Findings included:Review of Resident #1's face sheet dated 08/15/25 reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia (term for a decline in mental ability, affecting memory, thinking, and daily functioning), traumatic subdural hemorrhage (a dangerous collection of blood that forms between the brain's outer covering (dura) and the brain itself, often resulting from a severe head injury) and schizophrenia (a chronic mental disorder now understood as schizophrenia, marked by prominent, often persistent, delusions and hallucinations). Review of Resident #1's care plan dated 07/25/25 reflected a focus of Resident #1 had a behavior problem related to low frustration tolerance (an individual's difficulty in managing and accepting frustrating situations, leading to negative emotional reactions and difficulty coping with everyday challenges) with the following interventions dated 07/25/25:1. Assist the resident to develop more appropriate methods of coping and interacting2. Encourage the resident to express feelings appropriately3. Explain all procedures to the resident before starting and allow the resident time to adjust to changes4. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.5. Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention6. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.A review of Resident #1's care plan dated 07/25/25 reflected a focus of Resident #1 at risk for impaired communication with intervention dated 07/25/25 Spanish speaking.Review of Resident #1's Optional State Assessment MDS dated [DATE] reflected no BIMS score, Section A - Identification Information preferred language Spanish, Section E - Behavior Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) behavior of this type occurred 1 to 3 days.Review of Resident #1's BIMS assessment dated [DATE] reflected Incomplete - Requires Further Assessment 99.0.A review in TULIP reflected on 07/25/2025 at 12:08 am the facility reported to HHSC:Resident/Client Information Resident # 11. Pertinent Medical Diagnosis: unspecified dementia, unspecified severity, without behavioral 06/19/2025 principal diagnosis (67) admission disturbance, psychotic disturbance, mood disturbance, and anxiety, paranoid schizophrenia2. Is special supervision required? If so, please specify: No special supervision required.3. Level of cognition: BIMS SCORE 04. Is there a history of similar or prior incidents, if so please specify: No Incident Details:1. Date/Time the incident occurred: 07/24/25 nurse cannot give definitive time frame states it was around 6:30 pm or after 2. Date/Time you first learned of incident: 7/24/25 at 9:49 pm3. Brief narrative summary of the reportable incident: The Charge Nurse reported that while attempting to administer medication, the resident bit her hand, prompting a reflexive response in which she slapped the resident in the face. The nurse stated the action was unintentional. She further stated that she immediately reported the incident to the Assistant Director of Nursing (ADON). However, the ADON stated that the Charge Nurse only reported the bite incident and did not disclose that the resident had been slapped.4. Witnesses name and title: Charge Nurse states that the incident was witnessed by another CNA [CNA B]. The administrator interviewed the CNA who reports that she didn't see the incident, but that the Charge Nurse showed her the bite mark and admitted to slapping the resident. Assessment Details:1. The date and time of the assessment: 07/24/25 (no time given)2. Name and title of person who completed the assessment: [Agency Nurse]3. Results of the assessment include the extent of injuries. Provide details of any physical harm, pain, or mental anguish including serious bodily injury, or other injuries including but not limited to measurements, location, color of bruises, scratches, lacerations, fractures, changes in residents' behavior that is different from the normal baseline: The resident was assessed by the licensed nurse on duty. No visible injuries were observed upon assessment-no redness, swelling, bruising, or open skin noted on the face or surrounding areas. Alleged Perpetrator # 21. LVN A 2. Was the alleged perpetrator removed, suspended or terminated? Suspended pending further investigation.Actions and Notifications1. Who did the facility/agency notify about the incident? Ex. physician, family, ombudsman: Family and Physician, both notified of incident2. Was the incident reported to the police? If so, provide case number: N/a3. If the Texas Department of Family and Protective Services was notified, please include the DFPS call ID reference number: N/a4. Provide all steps taken immediately to ensure resident(s) are protected including but not limited to evaluating if resident feels safe, room relocation, increased supervision and other measures to prevent further abuse, neglect, exploitation and misappropriation: Staff member suspended pending investigation, resident assessed with no visible signs of injury to facial area, MD notified, Resident is Responsible Party, Referral to Psych Evaluation and treat5. Was an in-service conducted? If so, provide topic of in-service: Abuse and Neglect, Behavior Management, Resident Safe Surveys, Improving Communication with Residents Who Have Limited English Proficiency.A review of facility Provider Investigative Report 08/01/25 reflected witness name [CNA B] Denies witnessing the incident but was aware of the incident.A review of facility Provider Investigative Report 08/01/25 reflected:Assessment: Upon learning of the alleged incident, the resident was assessed from head to toe by the licensed nurse on duty. No visible injuries were observed upon assessment - no redness, swelling, bruising skin noted on the [NAME] or surrounding areas. Resident [Resident #1] exhibited no adverse reactions and remains stable Upon investigation of the allegations, it was determined that Charge Nurse [LVN A] did, in fact, slap resident [Resident #1], as confirmed by her own admission, While the act was stated to be unintentional, the incident did occur and could not be negated. The alleged witness, [CNA B] reported that she was aware of the incident only through what the Charge Nurse had told her. Based on the Charge Nurse's admission of the offense, appropriate disciplinary action was taken, and her employment was terminated. Additionally, the Assistant Director of Nursing (ADON) and CNA [CNA B] were re-educated on Abuse and Neglect policies, including the importance of immediately report all allegations of the facility's Abuse Coordinator according with regulator requirements. Resident [Resident #1] continued to exhibit no adverse reactions and remains stable at this time. A review of facility Provider Investigative Report 08/01/25 reflected MD and RP were notified. A review of facility Provider Investigative Report 08/01/25 reflected Resident Safe Survey dated 08/23/25 for 15 Residents. Resident #1 was not included in the safe survey. A review of facility Provider Investigative Report 08/01/25 included facility Abuse Policy dated 01/27/20.A review of facility Provider Investigative Report 08/01/25 included in-service dated 07/25/25:Department: nursing; AdministratorDate: 07/25/25 OngoingEmployee group(s) present: Administrator and Nursing DepartmentTopic: Abuse, Neglect, and Exploitation in the Community Contents or summary of training session: Abuse of any kind will never be tolerated. Abuse is any willful infliction of injury or neglect. The resident as the right to be free from Any type of abuse, neglect, intimidation, involuntary, seclusion/confinement and/or misappropriation of monies/funds.Conducted by: Administrator Evaluations, comments, suggestions: The Abuse Coordinator is [Administrator] followed by DON, ADON, Charge nurse. You should ALWAYS Alert the Abuse Coordinator of Abuse allegations Immediately. There is a 2 hour window for immediate reporting and a 24 hour window for report of abuse with/without injury or unknown injury. Signature of person completing report: unsigned A review of facility Provider Investigative Report 08/01/25 included signatures of staff in-service dated 07/25/25 Topic: Abuse, Neglect, and Exploitation in the Community signed by 20 staff members with no designation if staff were agency employees and some signatures did not state job title. A review of facility Provider Investigative Report 08/01/25 included a copy of the facility Behavioral Management Policy dated 04/19/05.A review of facility Provider Investigative Report 08/01/25 included in-service dated 07/25/25:Department: nursingDate: 07/25/25 OngoingEmployee group(s) present: Administrator, nursing, dietary, housekeeping Topic: Behavioral Management Contents or summary of training session: Behavior Management Behavior management included the management of anger, confusion, Hallucination and other behaviors by utilizing techniques such as group interactions, limit setting and behavior modification depending on resident needs. Establish rapport with a calm approach and supportive attitude. Place resident on frequent checks to ensure safety Conducted by: Administrator Allow wandering if it's safe and not exit seeking for those with dementia to prevent frustration and anger. Refrain from [sic] that residents take medications - stop - allow time - then revisit resident. Provide structure with routines and low to moderate stimulation to the environment. Signature of person completing report: AdministratorA review of facility Provider Investigative Report 08/01/25 included staff signatures of in-service dated 07/25/25 Topic: Behavioral Management signed by 20 staff members with no designation of if staff were agency employees some signatures did not state job title. The in-service signature sheet was identical to the staff in-serviced signature sheet on the Abuse, Neglect, and Exploitation in-service dated 07/25/25. A review of facility Provider Investigative Report 08/01/25 reflected memos to the ADON and CNA B from the Administrator stating, This letter serves as a reminder of the critical importance of immediately reporting any allegations or suspicions of abuse, neglect, or exploitation to the facility's Abuse Coordinator, in accordance with the state and federal regulations. Timely reporting is essential to the safety and well-being of our residents and to maintain compliance with all regulatory requirements. Failure to promptly report can place residents at risk and may result in disciplinary action. Please continue to follow facility policy by reporting all incidents immediately and accurately, ensuring that our residents remain safe and always protected signed by the Administrator, the ADON, and CNA B. A review of facility Provider Investigative Report 08/01/25 reflected in-serviced dated 07/25/25 Inservice Topic: Overcoming Language Barriers in Nursing Homes. Purpose: To Educate staff on the importance of effective communication with residents who have limited English proficiency and strategies to ensure quality care and understanding. A review of facility Provider Investigative Report 08/01/25 included staff signatures of in-service dated 07/25/25 Topic: Overcoming Language Barriers in Nursing Homes signed by 20 staff members with no designation of if staff were agency employees some signatures did not state job title. The in-service signature sheet was identical to the staff in-serviced signature sheet on the Abuse, Neglect, and Exploitation, and Behavioral Management in-services dated 07/25/25.Review of Resident #1's nurses note dated 07/23/25 by LVN A reflected handed resident his medication cup, resident would not take, kept encouraging resident to take his medication, since resident would not take his medication this writer reached to take the cup of meds and dispose of properly, resident bent forward and bit this writers thumb on my left hand, ADON, notified, p.c.p.Review of Resident #1's nurses note dated 07/25/25 by agency nurse reflected, Head to Toe Assessment Completed. Spanish speaker only, Alert and Awake. PERRLA. Skin Warm and Dry. Equal hand grips. Capillary refill less than 3 sec. No edema present. Respirations even and unlabored. No s/s of distress observed. Abdomen soft, round nontender - nondistended. Bowel sounds active x4 (This medical notation indicates that bowel sounds are present in all four quadrants of the abdomen (right upper, right lower, left upper, left lower). Pt. wheelchair bound, x1 assist. Scratch noted to right lower extremity. CNA [C] reports the scratch has been there. Bed in lowest position. Call light and personal belongings at bedside. Safety precautions in place. No safety hazards observed. No further concerns at this time. ADON Notified of scratch to RLE. Review of Resident #1's progress notes did not reflect facility contacted MD after incident, attempted to contact Resident #1's RP, or communications with Resident #1 about being slapped by LVN A. Record review of Resident #1's initial psychiatric evaluation dated 07/25/25 reflected no reference to Resident #1 being slapped by LVN A and states, particular attention will be paid to possible environmental factors contributing to agitation.Record review of MD Home Visit dated 07/24/25 reflected, [Resident #1] is seen and examined today at bedside for face redness due to an incident with Charge Nurse that occurred on 07/23. An assessment was performed, and we found no adverse s/s. Treatment 1. Contusion of other part of head, initial encounter Notes: no injuries noted. monitor at this time. Advised [Resident #1] to notify me if another incident. Interview on 08/16/25 at 10:50 am with Resident #1 with his RP as an interpreter via telephone reflected, he confirmed that a lady slapped him, but he said it did not hurt, and he is okay. He said no one at the facility talked to him about it after it happened, and he had not seen the lady who slapped him at the facility anymore. Interview on 08/15/2025 at 12:57 pm with CNA C reflected she did not know details of what happened between Resident #1 and LVN A, she only heard that Resident #1 bit LVN A and LVN A slapped him. She said she did not see or hear anything else about the incident. She said she was with the agency nurse when Resident #1 had a skin assessment. She said the agency nurse did not tell her why Resident #1 was having a skin assessment, but Resident #1 did sometimes have a lot of aggression towards the staff and the ADON asked her to go in with the agency nurse for the skin assessment. She said when they entered his room he was laying down on the bed. CNA C said the agency nurse did tell Resident #1 what they were doing but there was a communication barrier. She said they didn't understand what he was saying to them because he did not speak English. She said she did not use the communication board, and she had never seen a communication board. She said previously she gestured things to communicate with him. She said the agency nurse asked him how he was feeling and did anything hurt. The agency nurse did tell Resident #1 I heard you got hit do you want to tell me anything about that. She said the facility trained her in abuse and neglect and reporting abuse and neglect. Interview on 08/15/2025 at 1:00 pm with the ADON reflected when she learned of the incident, she asked an agency nurse to do a head-to-toe assessment.Interview on 08/15/2025 at 1:13 pm with the agency nurse revealed she did not work at the facility; she was employed by an agency, and she was asked by the ADON on 07/24/25 to do a head-to-toe assessment (a systematic, comprehensive physical examination of a patient's entire body and all major body systems, performed to identify health problems and establish a baseline of the patient's current health status) on Resident #1 but was not given any additional information. She said she had never worked at the facility before and had never worked with Resident #1. She did the head-to-toe assessment with CNA C who informed her Resident #1 did not speak English. She used an English/Spanish translation telephone application to speak with him and was able to communicate with him. She was not aware of the incident that prompted the assessment, she said she performed a generic head to toe assessment. She said she looked at his skin and asked if he was in any pain. She said it would have been very important to know if Resident #1 had been slapped because she would have conducted a different assessment than a head-to-toe assessment. She stated she would have asked if anyone harmed him or hurt him. She said her questions during the assessment would have been different. She would have asked him in more detail about what happened and asked him if he felt safe at the facility with the team of people who were at the facility and if he felt safe at that time. She said her questions during the assessment would have been targeted towards abuse and neglect. She said she did not know Resident #1 had been slapped prior to her conducting the head-to-toe assessment and she felt blindsided because she did not receive this information prior to Resident #1's assessment. She said she did not have any orientation about what happened with Resident #1, she did not feel comfortable taking over to do a head-to-toe assessment with no information communicated to her about what occurred. She said it was not fair for her and not fair for Resident #1 because he did not receive an appropriate assessment. She said she did not want to work at a facility that did not share this information with nurses who came into their facility.Interview on 08/15/2025 at 2:06 pm with the ADON reflected she was the charge nurse on 07/23/25 from 6:00 am until 6:00 pm but she stayed after 6:00 pm. LVN A was the nurse from 6:00 pm until 6:00 am and at approximately 8:00 pm LVN A approached her at the nurse's station. The ADON said LVN A looked upset. The ADON said LVN A told her that Resident #1 bit her, but LVN A did not tell her that she slapped Resident #1. The ADON said on 07/24/25 she, the Administrator, and LVN C were on a conference call and LVN C asked them if they heard that LVN A slapped a resident. The ADON said LVN C was asked who told him a resident was slapped, but LVN C did not want to tell who told him. The ADON said at that point she wanted to get off the phone with LVN C and the Administrator and call LVN A. The ADON said there was not an additional witness interview or statement taken from LVN C after this conference call. The ADON said neither she nor the Administrator were in the building. The ADON said she called LVN A who was working at the facility and asked her to walk outside of the facility to talk on the phone. During that phone call the ADON said LVN A told her she slapped Resident #1, it was witnessed by CNA B, and LVN A told CNA B that she slapped Resident #1. The ADON said on 07/23/25, that LVN A came to her and said Resident #1 bit her, but LVN A did not tell her she slapped Resident #1. After hearing that CNA B witnessed the incident the ADON called CNA B who was leaving the facility because her shift ended. The ADON spoke to CNA B who initially said she saw LVN A slap Resident #1 then later in the conversation CNA B said she did not see LVN A slap Resident #1. The ADON said she can't remember exactly what CNA B said during the conversation from first saying CNA B witnessed the incident to then saying CNA B did not witness the incident, the ADON said CNA B changed her story. She said they did not take a written statement from CNA B. She said Resident #1 was his own RP because they did not have any information for an RP when he came to the facility directly from the hospital. The ADON confirmed the facility telephone number was the correct telephone number to call the facility. After Resident #1's RP was added, they did not contact the RP and tell the RP that Resident #1 was slapped because the addition of the RP happened after the incident.Interview on 08/15/2025 at 3:55 pm with the Administrator reflected on 07/24/25 she and the ADON were on a conference call with LVN C. LVN C asked them if they heard LVN A slapped Resident #1. The Administrator said she called LVN A and asked LVN A if she slapped Resident #1 and LVN A said yes. The Administrator told LVN A by phone her employment was terminated. The Administrator asked if someone saw LVN A slap Resident #1 and LVN A said CNA B saw her slap Resident #1. The Administrator said she called CNA B who said she confirmed that she saw LVN A slap Resident #1 but she did not report it because LVN A said she told the ADON. CNA B's employment was not terminated. The Administrator said she told CNA B that it was her job to follow up and make sure that abuse and neglect was reported, and the Administrator did an in-service with CNA B on reporting abuse and neglect. She said Resident #1 did not have an RP at the time of the incident, he was like a loner but there was now something in the system for whom to contact. She wanted to say the nursing department did call the RP and tell the RP what happened but if they did not, she does not know why.Interview on 08/15/2025 at 4:08 pm via telephone with LVN A reflected on 07/23/25 she was in the hallway with Resident #1, and she handed him his medications in a cup. Resident #1 did not want to take his medications, and she reached to take the cup with the medications away from Resident #1 and Resident #1 bit her and she slapped him on the chin. LVN A said the slap was a reaction to being bitten and she knew it was wrong and felt terrible about it. CNA B was in the hallway with her, and she said to CNA B, did you see that, I slapped that man, I am going to lose my job. LVN A said she immediately walked down the hall and told the ADON that Resident #1 bit her and she slapped Resident #1. LVN A said the ADON told her, I did not hear a thing. LVN A said she did not know what the ADON meant when she told her I did not hear a thing. LVN A said she worked the remainder of her shift until 6:00 am and the following day and on 07/24/24, she returned to the facility a 6:00 pm to begin her shift. She received a phone call from the ADON but did not remember the time. She told the ADON on the phone that she slapped Resident #1 when he bit her, and she knew CNA B saw her slap Resident #1 and she told CNA B she slapped Resident #1. LVN A said her job was terminated by telephone that evening.Interview on 08/15/2025 at 4:23 pm with the CNA B reflected she did not see anything but was told by LVN A Resident #1 bit her and she had hit him. She said LVN A said she told the ADON that she slapped Resident #1. CNA B she did not hear LVN A report it to the ADON. CNA B did see her go to the nurse's station. She said she did not witness anything and supposedly LVN A told on herself. She said Resident #1 only speaks Spanish and they communicated with him through gestures or translation with the laundry ladies. She said she was trained in abuse and neglect and reporting through facility in-services and was trained to report abuse and neglect when it happened. She said the only reason she did not report it to the Administrator was because the LVN A told her she was going to tell the ADON. She said after LVN A went to the nurse's station and spoke with the ADON, LVN A continued working her shift that evening. Interview on 08/15/2025 at 4:41 pm with the facility MD reflected was he was notified about the nurse slapping the resident but forgot the name of the person who called to tell him about the incident. Record review of policy Accidents and Incidents - Investigating and Reporting dated February 2014 reflected all accidents or incidents involving residents, employees, visitors, vendors, occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and/or the department director shall promptly initiate and document investigation of the accident or incident.Interview on 08/15/2025 at 4:48 pm with the LVN C reflected he was on a phone conference with the Administrator and the ADON and he said an aide told him that LVN A hit Resident #1. He said the facility did not ask him any additional information or to make a statement after the telephone call. He said he was trained in abuse and neglect and reporting abuse and neglect when he began to work for the facility. He said the Administrator was the abuse and neglect coordinator and abuse should be reported immediately. He said he did not witness the incident and did not have any additional information about the incident. Interview on 08/15/2025 at 5:15 pm with Resident #1's RP, she said on 07/30/25 she received an email from the facility requesting her permission and signature on documents for approval for Resident #1 to receive psychiatric medication. The RP stated Resident #1 had never been able to make his own decisions. She said she had a disability and lived far from the facility, but a family member was in the area, and she asked the family member to go to the facility to check on Resident #1. She said the family member told a nurse (name unknown) that the RP had tried calling multiple times using the number that was confirmed at the facility as their telephone number, and no one answered the phone. The RP said the facility did not call her and tell her that Resident #1 was slapped. The RP said Resident #1 called her a little while back and told her a lady slapped him really hard, but she thought he was making it up because of his history of behavioral issues.Interview on 08/17/25 at 11:10 am with the DON reflected she had worked at the facility since 08/06/25 and had been a DON for approximately 2.5 years. She said there was literally no consistency at the facility because staff were agency and prn apart from herself and the ADON. It contributed to the issues that involved the abuse and neglect with LVN A and Resident #1. She said there should have been written statements taken from LVN A, CNA B and CNA C and all of the staff who worked that evening. She said statements needed to be taken before the staff left the facility and when the information was fresh on peoples' minds. She said if you took statements later the stories could change a million times. She said it was part of the facility abuse and neglect policies and procedures to take statements. She said CNA B should have reported to the Administrator about the resident being slapped. CNA B should have received disciplinary action for not reporting. She was told by LVN A that she slapped Resident #1 and CNA B was told by LVN A that LVN A was going to report the incident. She said they should have assessed all the residents for pain and trauma. She said if staff don't talk to the other residents, you don't know if other residents could have been abused. She said the incident was not handled well and it left the residents open to possible concerns of abuse. She said someone should have spoken to the resident immediately when they learned of the incident and he should have had a trauma assessment, pain assessment, skin assessment and his statement about what happened should have been taken, and the police should have been notified. She said a head-to-toe assessment was not enough. She said there was no mention of a slap to the Resident #1 when he was assessed by the agency nurse, and that was crucial information. She said the abuse should have been assessed and addressed with Resident #1. She said if the agency nurse had the information about Resident #1 being slapped by a nurse she would have known what to ask him and how to approach the situation. She said it was a problem that the agency nurse did not know that Resident #1 did not speak English because she was not informed about communication challenges. She said this investigation was not handled in a way where the residents were not exposed or free from abuse. She said it was not possible for a person who had a BIMS of 99 to advocate for themselves, make their own decisions, and be their own RP. She said as soon as the facility obtained information for a RP for Resident #1, the RP should have been called and informed that Resident #1 was slapped by a nurse. She said all steps in the facility policies for investigating abuse and neglect should have been followed and documented.Interview on 08/17/25 at 12:48 pm ADON reflected she was responsible for the investigation, and she looked at the facility abuse and neglect policy concerning what to do when there was abuse and neglect. The ADON said there were no written statements from any staff, but the facility policy said to take written statements. She said the day after she learned of the incident, she was not at the facility and the Administrator was there and the Administrator did everything. She was not aware of anyone speaking to Resident #1 about the incident except he had a head-to-toe assessment. She said a head-to-toe assessment was different than a trauma assessment. She said Resident #1 being slapped was trauma. The ADON gave instructions by telephone to the AN to give Resident #1 the head-to-toe assessment. A head-to-toe assessment was different than a trauma assessment. In a trauma assessment, when the resident was slapped, the number one question you would ask was if the resident felt safe. She did not know if the nurse asked him that question. In a trauma assessment you would want to ask if the resident was okay. The ADON said maybe Resident #1 should have had a head to toe and trauma assessment, but she just told the AN to do a head-to-toe assessment. She said the negative effect of not doing a trauma assessment would be you do not know if he felt safe or had information about previous abuse that might have affected his behavior. There was no documentation that shows that someone asked him if he felt safe in the facility, a trauma informed assessment should have been done. She said because it was not documented did not mean that he was not asked if he felt safe but stated that nursing policy was that if it was not documented, it did not happen. The ADON said Resident #1 was not a fluent English speaker and if he was going to understand someone it needed to be spoken to him in Spanish. The primary way of communicating with him was using the communication binder and when the AN administered his head-to-toe assessment, she should have had the communication binder. The ADON said that LVN A said she slapped Resident #1, and that was assault and maybe the police should have been called. She said more things should have been done and she did not know if everything was done to make sure that there was no additional abuse in the facility. She said the possible negative effect of not following the procedures in the facility abuse and neglect investigation was that they were not making sure Resident #1 was okay and they were not making sure there was not any additional abuse. The ADON said when she obtained information to contact Resident #1's RP, she should have contacted her and let her know that he was slapped by a nurse.Interview on 08/17/25 at 1:55 pm with the facility former SW reflected she was unaware of the incident involving LVN A and Resident #1 and the Resident Safe Survey she conducted on 07/23/25 for 15 Residents were safe surveys she conducted periodically, every 1 to 2 weeks, and not associated with any specific facility incident.Interview on 08/17/2025 at 5:42 pm with the Administ[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure alleged violations were thoroughly investigated for one (Resident #1) of four residents reviewed for abuse.The facility failed to ensure the facility conducted a thorough investigation when Resident #1 was slapped by a facility nurse on 7/23/25. The facility did not notify law enforcement, did not take statements from witnesses and other staff working at the same time as the incident, did not interview Resident #1 in his native language, did not complete a trauma-based assessment, and did not notify Resident #1's responsible party.An Immediate Jeopardy (IJ) situation was identified on 08/15/25. While the IJ was removed on 08/19/25, the facility remained out of compliance at a scope of isolated that with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems.This failure could place residents at risk of additional exposure for abuse and neglect.Findings included:Review of Resident #1's face sheet dated 08/15/25 reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including dementia (term for a decline in mental ability, affecting memory, thinking, and daily functioning), traumatic subdural hemorrhage (a dangerous collection of blood that forms between the brain's outer covering (dura) and the brain itself, often resulting from a severe head injury) and paranoid schizophrenia (a chronic mental disorder now understood as schizophrenia, marked by prominent, often persistent, delusions and hallucinations). Review of Resident #1's care plan dated 07/25/25 reflected a focus of Resident #1 had a behavior problem related to low frustration tolerance (an individual's difficulty in managing and accepting frustrating situations, leading to negative emotional reactions and difficulty coping with everyday challenges) with the following interventions dated 07/25/25:1. Assist the resident to develop more appropriate methods of coping and interacting2. Encourage the resident to express feelings appropriately3. Explain all procedures to the resident before starting and allow the resident time to adjust to changes4. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed.5. Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention6. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.A review of Resident #1's care plan dated 07/25/25 reflected a focus of Resident #1 risk for impaired communication with intervention dated 07/25/25 Spanish speaking.Review of Resident #1's Optional State Assessment MDS dated [DATE] reflected no BIMS score, Section A - Identification Information preferred language Spanish, Section E - Behavior Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) behavior of this type occurred 1 to 3 days.Review of Resident #1's BIMS assessment dated [DATE] reflected Incomplete - Requires Further Assessment 99.0.A review in TULIP reflected on 07/25/2025 at 12:08 am the facility reported to HHSC:Resident/Client Information Resident # 11. Pertinent Medical Diagnosis: unspecified dementia, unspecified severity, without behavioral 06/19/2025 principal diagnosis (67) admission disturbance, psychotic disturbance, mood disturbance, and anxiety, paranoid schizophrenia2. Is special supervision required? If so, please specify: No special supervision required.3. Level of cognition: BIMS SCORE 04. Is there a history of similar or prior incidents, if so please specify: No Incident Details:1. Date/Time the incident occurred: 07/24/25 nurse can not give definitive time frame states it was around 6:30 pm or after 2. Date/Time you first learned of incident: 7/24/25 at 9:49 pm3. Brief narrative summary of the reportable incident: The Charge Nurse reported that while attempting to administer medication, the resident bit her hand, prompting a reflexive response in which she slapped the resident in the face. The nurse stated the action was unintentional. She further stated that she immediately reported the incident to the Assistant Director of Nursing (ADON). However, the ADON stated that the Charge Nurse only reported the bite incident and did not disclose that the resident had been slapped.4. Witnesses name and title: Charge Nurse states that the incident was witnessed by another CNA [CNA B]. The administrator interviewed the CNA who reports that she didn't see the incident, but that the Charge nurse showed her the bite mark and admitted to slapping the resident. Assessment Details:1. The date and time of the assessment: 07/24/25 (no time given)2. Name and title of person who completed the assessment: [Agency Nurse]3. Results of the assessment include the extent of injuries. Provide details of any physical harm, pain, or mental anguish including serious bodily injury, or other injuries including but not limited to measurements, location, color of bruises, scratches, lacerations, fractures, changes in residents' behavior that is different from the normal baseline: The resident was assessed by the licensed nurse on duty. No visible injuries were observed upon assessment-no redness, swelling, bruising, or open skin noted on the face or surrounding areas. Alleged Perpetrator # 21. LVN A 2. Was the alleged perpetrator removed, suspended or terminated? Suspended pending further investigation.Actions and Notifications1. Who did the facility/agency notify about the incident? Ex. physician, family, ombudsman: Family and Physician, both notified of incident2. Was the incident reported to the police? If so, provide case number: N/a3. If the Texas Department of Family and Protective Services was notified, please include the DFPS call ID reference number: N/a4. Provide all steps taken immediately to ensure resident(s) are protected including but not limited to evaluating if resident feels safe, room relocation, increased supervision and other measures to prevent further abuse, neglect, exploitation and misappropriation: Staff member suspended pending investigation, resident assessed with no visible signs of injury to facial area, MD notified, Resident is Responsible Party, Referral to Psych Evaluation and treat5. Was an in-service conducted? If so, provide topic of in-service: Abuse and Neglect, Behavior Management, Resident Safe Surveys, Improving Communication with Residents Who Have Limited English Proficiency.A review of facility Provider Investigative Report 08/01/25 reflected witness name [CNA B] Denies witnessing the incident but was aware of the incident.A review of facility Provider Investigative Report 08/01/25 reflected:Assessment: Upon learning of the alleged incident, the resident was assessed from head to toe by the licensed nurse on duty. No visible injuries were observed upon assessment - no redness, swelling, bruising skin noted on the [NAME] or surrounding areas. Resident [Resident #1] exhibited no adverse reactions and remains stable Upon investigation of the allegations, it was determined that Charge Nurse [LVN A] did, in fact, slap resident [Resident #1], as confirmed by her own admission, While the act was stated to be unintentional, the incident id occur and could not be negated. The alleged witness, [CNA B] reported that she was aware of the incident only through what the Charge Nurse had told her. Based on the Charge Nurse's admission of the offense, appropriate disciplinary action was taken, and her employment was terminated. Additionally, the Assistant Director of Nursing (ADON) and CNA [CNA B] were re-educated on Abuse and Neglect policies, including the importance of immediately report all allegations of the facility's Abuse Coordinator according with regulator requirements. Resident [Resident #1] continued to exhibit no adverse reactions and remains stable at this time. A review of facility Provider Investigative Report 08/01/25 reflected MD and RP were notified. A review of facility Provider Investigative Report 08/01/25 reflected Resident Safe Survey dated 08/23/25 for 15 Residents. Resident #1 was not included in the safe survey. A review of facility Provider Investigative Report 08/01/25 included facility Abuse Policy dated 01/27/20.A review of facility Provider Investigative Report 08/01/25 included in-service dated 07/25/25:Department: nursing; AdministratorDate: 07/25/25 OngoingEmployee group(s) present: Administrator and Nursing DepartmentTopic: Abuse, Neglect, and Exploitation in the Community Contents or summary of training session: Abuse of any kind will never be tolerated. Abuse is any willful infliction of injury or neglect. The resident as the right to be free from Any type of abuse, neglect, intimidation, involuntary, seclusion/confinement and/or misappropriation of monies/funds.Conducted by: Administrator Evaluations, comments, suggestions: The Abuse Coordinator is [Administrator] followed by DON, ADON, Charge nurse. You should ALWAYS Alert the Abuse Coordinator of Abuse allegations Immediately. There is a 2 hour window for immediate reporting and a 24 hours window for report of abuse with/without injury or unknown injury. Signature of person completing report: unsigned A review of facility Provider Investigative Report 08/01/25 included signatures of staff in-service dated 07/25/25 Topic: Abuse, Neglect, and Exploitation in the Community signed by 20 staff members with no designation of if staff were agency employees and some signatures did not state job title. A review of facility Provider Investigative Report 08/01/25 included a copy of the facility Behavioral Management Policy dated 04/19/05.A review of facility Provider Investigative Report 08/01/25 included in-service dated 07/25/25:Department: nursingDate: 07/25/25 OngoingEmployee group(s) present: Administrator, nursing, dietary, housekeeping Topic: Behavioral Management Contents or summary of training session: Behavior Management Behavior management included the management of anger, confusion, Hallucination and other behaviors by utilizing techniques such as group interactions, limit setting and behavior modification depending on resident needs. Establish rapport with a calm approach and supportive attitude. Place resident on frequent checks to ensure safety Conducted by: Administrator Allow wondering if its safe and and not exit seeking for those with dementia to prevent frustration and anger. Refrain from [sic] that residents take medications - stop - allow time - then revisit resident. Provide structure with routines and low to moderate stimulation to the environment. Signature of person completing report: AdministratorA review of facility Provider Investigative Report 08/01/25 included staff signatures of in-service dated 07/25/25 Topic: Behavioral Management signed by 20 staff members with no designation of if staff were agency employees some signatures did not state job title. The in-service signature sheet was identical to the staff in-serviced signature sheet on the Abuse, Neglect, and Exploitation in-service dated 07/25/25. A review of facility Provider Investigative Report 08/01/25 reflected memos to the ADON and CNA B from the Administrator stating, This letter serves as a reminder of the critical importance of immediately reporting any allegations or suspicions of abuse, neglect, or exploitation to the facility's Abuse Coordinator, in accordance with the state and federal regulations. Timely reporting is essential to the safety and well-being of our residents and to maintain compliance with all regulatory requirements. Failure to promptly report can place residents at risk and may result in disciplinary action. Please continue to follow facility policy by reporting all incidents immediately and accurately, ensuring that our residents remain safe and always protected signed by the Administrator, the ADON, and CNA B. A review of facility Provider Investigative Report 08/01/25 reflected in-serviced dated 07/25/25 Inservice Topic: Overcoming Language Barriers in Nursing Homes. Purpose: To Educate staff on the importance of effective communication with residents who have limited English proficiency and strategies to ensure quality care and understanding. A review of facility Provider Investigative Report 08/01/25 included staff signatures of in-service dated 07/25/25 Topic: Overcoming Language Barriers in Nursing Homes signed by 20 staff members with no designation of if staff were agency employees some signatures did not state job title. The in-service signature sheet was identical to the staff in-serviced signature sheet on the Abuse, Neglect, and Exploitation, and Behavioral Management in-services dated 07/25/25.Review of Resident #1's nurses note dated 07/23/25 by LVN A reflected handed resident his medication cup, resident would not take, kept encouraging resident to take his medication, since resident would not take his medication this writer reached to take the cup of meds and dispose of properly, resident bent forward and bit this writers thumb on my left hand, ADON, notified, p.c.p.Review of Resident #1's nurses note dated 07/25/25 by agency nurse reflected, Head to Toe Assessment Completed. Spanish speaker only, Alert and Awake. PERRLA. Skin Warm and Dry. Equal hand grips. Capillary refill less than 3 sec. No edema present. Respirations even and unlabored. No s/s of distress observed. Abdomen soft, round nontender - nondistended. Bowel sounds active x4 (This medical notation indicates that bowel sounds are present in all four quadrants of the abdomen (right upper, right lower, left upper, left lower). Pt. wheelchair bound, x1 assist. Scratch noted to right lower extremity. CNA [C] reports the scratch has been there. Bed in lowest position. Call light and personal belongings at bedside. Safety precautions in place. No safety hazards observed. No further concerns at this time. ADON Notified of scratch to RLE. Review of Resident #1's progress notes did not reflect facility contacted MD after incident, attempted to contact Resident #1's RP, or communications with Resident #1 about being slapped by LVN A. Record review of Resident #1's initial psychiatric evaluation dated 07/25/25 reflected no reference to Resident #1 being slapped by LVN A and states, particular attention will be paid to possible environmental factors contributing to agitation.Record review of MD Home Visit dated 07/24/25 reflected, [Resident #1] is seen and examined today at bedside for face redness due to an incident with Charge nurse that occurred on 07/23. An assessment was performed and we found no adverse s/s. Treatment 1. Contusion of other part of head, initial encounter Notes: no injuries noted. monitor at this time. Advised [Resident #1] to notify me if another incident. Interview on 08/16/25 at 10:50 am with Resident #1 with his RP as an interpreter via telephone reflected, he confirmed that a lady slapped him, but he said it did not hurt, and he is okay. He said no one at the facility talked to him about it after it happened, and he had not seen the lady who slapped him at the facility anymore. Interview on 08/15/2025 at 12:57 pm with CNA C reflected she did not know details of what happened between Resident #1 and LVN A, she only heard that Resident #1 bit LVN A and LVN A slapped him. She said she did not see or hear anything else about the incident. She said she was with the agency nurse when Resident #1 had a skin assessment. She said the agency nurse did not tell her why Resident #1 was having a skin assessment, but Resident #1 did sometimes have a lot of aggression towards the staff and the ADON asked her to go in with the agency nurse for the skin assessment. She said when they entered his room he was laying down on the bed. CNA C said the agency nurse did tell Resident #1 what they were doing but there was a communication barrier. She said they didn't understand what he was saying to them because he did not speak English. She said she did not use the communication board, and she had never seen a communication board. She said previously she gestured things to communicate with him. She said the agency nurse asked him how he was feeling and did anything hurt but she did tell him I heard you got hit do you want to tell me anything about that. She said the facility trained her in abuse and neglect and reporting abuse and neglect. Interview on 08/15/2025 at 1:00 pm with the ADON reflected when she learned of the incident, she asked an agency nurse to do a head-to-toe assessment.Interview on 08/15/2025 at 1:13 pm with the agency nurse revealed she did not work at the facility; she was employed by an agency, and she was asked by the ADON on 07/24/25 to do a head-to-toe assessment (a systematic, comprehensive physical examination of a patient's entire body and all major body systems, performed to identify health problems and establish a baseline of the patient's current health status) on Resident #1 but was not given any additional information. She said she had never worked at the facility before and had never worked with Resident #1. She did the head-to-toe assessment with CNA C who informed her Resident #1 did not speak English. She used an English/Spanish translation telephone application to speak with him and was able to communicate with him. She was not aware of the incident that prompted the assessment, she said she performed a generic head to toe assessment. She said she looked at his skin and asked if he was in any pain. She said it would have been very important to know if Resident #1 had been slapped because she would have conducted a different assessment than a head-to-toe assessment. She stated she would have asked if anyone harmed him or hurt him. She said her questions during the assessment would have been different. She would have asked him in more detail about what happened and asked him if he felt safe at the facility with the team of people who were at the facility and if he felt safe at that time. She said her questions during the assessment would have been targeted towards abuse and neglect. She said she did not know Resident #1 had been slapped prior to her conducting the head-to-toe assessment and she felt blindsided because she did not receive this information prior to Resident #1's assessment. She said she did not have any orientation about what happened with Resident #1, she did not feel comfortable taking over to do a head-to-toe assessment with no information communicated to her about what occurred. She said it was not fair for her and not fair for Resident #1 because he did not receive an appropriate assessment. She said she did not want to work at a facility that did not share this information with nurses who came into their facility.Interview on 08/15/2025 at 2:06 pm with the ADON reflected she was the charge nurse on 07/23/25 from 6:00 am until 6:00 pm but she stayed after 6:00 pm. LVN A was the nurse from 6:00 pm until 6:00 am and at approximately 8:00 pm LVN A approached her at the nurse's station. The ADON said LVN A looked upset. The ADON said LVN A told her that Resident #1 bit her, but LVN A did not tell her that she slapped Resident #1. The ADON said on 07/24/25 she, the Administrator, and LVN C were on a conference call and LVN C asked them if they heard that LVN A slapped a resident. The ADON said LVN C was asked who told him a resident was slapped, but LVN C did not want to tell who told him. The ADON said at that point she wanted to get off the phone with LVN C and the Administrator and call LVN A. The ADON said there was not an additional witness interview or statement taken from LVN C after this conference call. The ADON said neither she nor the Administrator were in the building. The ADON said she called LVN A who was working at the facility and asked her to walk outside of the facility to talk on the phone. During that phone call the ADON said LVN A told her she slapped Resident #1, it was witnessed by CNA B, and LVN A told CNA B that she slapped Resident #1. The ADON said on 07/23/25, that LVN A came to her and said Resident #1 bit her, but LVN A did not tell her she slapped Resident #1. After hearing that CNA B witnessed the incident the ADON called CNA B who was leaving the facility because her shift ended. The ADON spoke to CNA B who initially said she saw LVN A slap Resident #1 then later in the conversation CNA B said she did not see LVN A slap Resident #1. The ADON said she can't remember exactly what CNA B said during the conversation from first saying CNA B witnessed the incident to then saying CNA B did not witness the incident, the ADON said CNA B changed her story. She said they did not take a written statement from CNA B. She said Resident #1 was his own RP because they did not have any information for an RP when he came to the facility directly from the hospital. The ADON confirmed the facility telephone number was the correct telephone number to call the facility. After Resident #1's RP was added, they did not contact the RP and tell the RP that Resident #1 was slapped because the addition of the RP happened after the incident.Interview on 08/15/2025 at 3:55 pm with the Administrator reflected on 07/24/25 she and the ADON were on a conference call with LVN C. LVN C asked them if they heard LVN A slapped Resident #1. The Administrator said she called LVN A and asked LVN A if she slapped Resident #1 and LVN A said yes. The Administrator told LVN A by phone her employment was terminated. The Administrator asked if someone saw LVN A slap Resident #1 and LVN A said CNA B saw her slap Resident #1. The Administrator said she called CNA B who said she confirmed that she saw LVN A slap Resident #1 but she did not report it because LVN A said she told the ADON. CNA B's employment was not terminated. The Administrator said she told CNA B that it was her job to follow up and make sure that abuse and neglect was reported, and the Administrator did an in-service with CNA B on reporting abuse and neglect. She said Resident #1 did not have an RP at the time of the incident, he was like a loner but there was now something in the system for whom to contact. She wanted to say the nursing department did call the RP and tell the RP what happened but if they did not, she does not know why.Interview on 08/15/2025 at 4:08 pm via telephone with LVN A reflected on 07/23/25 she was in the hallway with Resident #1, and she handed him his medications in a cup. Resident #1 did not want to take his medications, and she reached to take the cup with the medications away from Resident #1 and Resident #1 bit her and she slapped him on the chin. LVN A said the slap was a reaction to being bitten and she knew it was wrong and felt terrible about it. CNA B was in the hallway with her, and she said to CNA B, did you see that, I slapped that man, I am going to lose my job. LVN A said she immediately walked down the hall and told the ADON that Resident #1 bit her and she slapped Resident #1. LVN A said the ADON told her, I did not hear a thing. LVN A said she did not know what the ADON meant when she told her I did not hear a thing. LVN A said she worked the remainder of her shift until 6:00 am and the following day and on 07/24/24, she returned to the facility a 6:00 pm to begin her shift. She received a phone call from the ADON but did not remember the time. She told the ADON on the phone that she slapped Resident #1 when he bit her, and she knew CNA B saw her slap Resident #1 and she told CNA B she slapped Resident #1. LVN A said her job was terminated by telephone that evening.Interview on 08/15/2025 at 4:23 pm with the CNA B reflected she did not see anything but was told by LVN A Resident #1 bit her and she had hit him. She said LVN A said she told the ADON that she slapped the resident. CNA B she did not hear LVN A report it to the ADON. CNA B did see her go to the nurse's station. She said she did not witness anything and supposedly LVN A told on herself. She said Resident #1 only speaks only Spanish and they communicated with him through gestures or translation with the laundry ladies. She said she was trained in abuse and neglect and reporting through facility in-services and was trained to report abuse and neglect when it happened. She said the only reason she did not report it to the Administrator was because the LVN A told her she was going to tell the ADON. She said after LVN A went to the nurse's station and spoke with the ADON, LVN A continued working her shift that evening. Interview on 08/15/2025 at 4:41 pm with the facility MD reflected was he was notified about the nurse slapping the resident but forgot the name of the person who called to tell him about the incident. Record review of facility policy Accidents and Incidents - Investigating and Reporting dated February 2014 reflected all accidents or incidents involving residents, employees, visitors, vendors, occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and/or the department director shall promptly initiate and document investigation of the accident or incident.Interview on 08/15/2025 at 4:48 pm with the LVN C reflected he was on a phone conference with the Administrator and the ADON and he said an aide told him that LVN A hit Resident #1. He said the facility did not ask him any additional information or to make a statement after the telephone call. He said he was trained in abuse and neglect and reporting abuse and neglect when he began to work for the facility. He said the Administrator was the abuse and neglect coordinator and abuse should be reported immediately. He said he did not witness the incident and did not have any additional information about the incident. Interview on 08/15/2025 at 5:15 pm with Resident #1's RP, she said on 07/30/25 she received an email from the facility requesting her permission and signature on documents for approval for Resident #1 to receive psychiatric medication. The RP stated Resident #1 had never been able to make his own decisions. She said she had a disability and lived far from the facility, but a family member was in the area, and she asked the family member to go to the facility to check on Resident #1. She said the family member told a nurse (name unknown) that the RP had tried calling multiple times using the number that was confirmed at the facility as their telephone number, and no one answered the phone. The RP said the facility did not call her and tell her that Resident #1 was slapped. The RP said Resident #1 called her a little while back and told her a lady slapped him really hard, but she thought he was making it up because of his history of behavioral issues.Interview on 08/17/25 at 11:10 am with the DON reflected she had worked at the facility since 08/06/25 and had been a DON for approximately 2.5 years. She said there was literally no consistency at the facility because staff were agency and prn apart from herself and the ADON and it contributed to the issues that involved the abuse and neglect with LVN A and Resident #1. She said there should have been written statements taken from LVN A, CNA B and CNA C and all of the staff who worked that evening. She said statements needed to be taken before the staff left the facility and when the information was fresh on peoples' minds. She said if you took statements later the stories could change a million times. She said it was part of the facility abuse and neglect policies and procedures to take statements. She said CNA B should have reported to the Administrator about the resident being slapped. CNA B should have received disciplinary action for not reporting she was told by LVN A that she slapped Resident #1 even though CNA B was told by LVN A that said she was going to report the incident. She said they should have assessed all the residents for pain and trauma. She said if you don't talk to the other residents, you don't know if other residents could have been abused. She said the incident was not handled well and it left the residents open to possible concerns of abuse. She said someone should have spoken to the resident immediately when they learned of the incident and he should have had a trauma assessment, pain assessment, skin assessment and his statement about what happened should have been taken, and the police should have been notified. She said a head-to-toe assessment was not enough. She said there was no mention of a slap to the Resident #1 when he was assessed by the agency nurse, and that was crucial information. She said the abuse should have been assessed and addressed with Resident #1. She said if the agency nurse had the information about Resident #1 being slapped by a nurse she would have known what to ask him and how to approach the situation. She said it was problem that the agency nurse did not know that he did not speak English because she was not informed about communication challenges. She said this investigation was not handled in a way where the residents were not exposed or free from abuse. She said it was not possible for a person who had a BIMS of 99 to advocate for themselves, make their own decisions, and be their own RP. She said as soon as the facility obtained information for a RP for Resident #1, the RP should have been called and informed that Resident #1 was slapped by a nurse. She said all steps in the facility policies for investigating abuse and neglect should have been followed and documented.Interview on 08/17/25 at 12:48 pm ADON reflected she was responsible for the investigation, and she looked at the facility abuse and neglect policy concerning what to do when there was abuse and neglect. The ADON said there were no written statements from any staff, but the facility policy said to take written statements. She said the day after she learned of the incident, she was not at the facility and the Administrator was there and the Administrator did everything. She was not aware of anyone speaking to Resident #1 about the incident except he had a head-to-toe assessment. She said a head-to-toe assessment was different than a trauma assessment. She said Resident #1 being slapped was trauma. The ADON gave instructions by telephone to the AN to give Resident #1 the head-to-toe assessment. A head-to-toe assessment was different than a trauma assessment. In a trauma assessment, when the resident was slapped, the number one question you would ask was if the resident felt safe. She did not know if the nurse asked him that question. In a trauma assessment you would want to ask if the resident was okay. The ADON said maybe Resident #1 should have had a head to toe and trauma assessment, but she just told the AN to do a head-to-toe assessment. She said the negative effect of not doing a trauma assessment would be you do not know if he felt safe or had information about previous abuse that might have affected his behavior. There was no documentation that shows that someone asked him if he felt safe in the facility, a trauma informed assessment should have been done. She said because it was not documented did not mean that he was not asked if he felt safe but stated that nursing policy was that if it was not documented, it did not happen. The ADON said Resident #1 was not a fluent English speaker and if he was going to understand someone it needed to be spoken to him in Spanish. The primary way of communicating with him was using the communication binder and when the AN administered his head-to-toe assessment, she should have had the communication binder. The ADON said that LVN A said she slapped Resident #1, and that was assault and maybe the police should have been called. She said more things should have been done and she did not know if everything was done to make sure that there was no additional abuse in the facility. She said the possible negative effect of not following the procedures in the facility abuse and neglect investigation was that they were not making sure Resident #1 was okay and they were not making sure there was not any additional abuse. The ADON said when obtained information to contact Resident #1's RP, she should have contacted her and let her know that he was slapped by a nurse.Interview on 08/17/25 at 1:55 pm with the [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. The facility failed to obtain daily weights and report weight gain for Resident #1 who had a diagnosis of CHF to ensure there was no fluid overload in accordance with medical provider's order dated [DATE]. The facility failed to timely and accurately obtain Resident #1's labs in accordance with medical providers orders dated [DATE]. While at the facility on [DATE] Resident #1 suffered shortness of breath and altered mental status. Resident #1 was taken by EMS to the hospital on [DATE] and was diagnosed with sepsis. Resident #1 died at the hospital on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:42 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of no actual harm because of the facility's need to evaluate the effectiveness of the corrective system. This failure could place residents at risk of not receiving care and services identified to meet their needs. Findings include: Review of Resident #1's face sheet dated [DATE] reflected an [AGE] year-old male who was originally admitted to the facility on [DATE] with diagnoses that included combined systolic and diastolic heart failure (systolic failure is a problem with the heart's pumping action, while diastolic failure is a problem with the heart's filling phase) and chronic respiratory failure with hypoxia (the body isn't getting enough oxygen due to impaired lung function). Review of Resident #1's care plan focus, goal, and interventions dated [DATE] revealed: Focus reflected regular diet, no added salt, 2000 ml fluid restriction. Goal reflected Resident #1 will have adequate nutrition and fluid intake throughout the review date. Interventions reflected weight every month and PRN - report 5% loss/gain to MD and responsible party. Review of Resident #1's MDS dated [DATE] reflected a BIMS score of 10, indicating moderate cognitive impairment, he used a wheelchair, and had an active diagnoses of congestive heart failure and respiratory failure. American Heart Associate on managing heart failure symptoms reflected, Your body and your heart can often respond to effects of heart failure so that you never notice any symptoms. Your heart compensates for added strain by working harder. However, as heart failure worsens, your heart can gradually become less able to keep pumping blood to the body. Additionally, when a situation worsens by small degrees over time, you might not even notice the trend. Your sense for what ' s normal can become altered. Review of social services progress note dated [DATE] reflected Resident #1 was a full code (a medical directive indicating that a patient wishes to receive all possible life-saving measures in the event of a medical emergency, such as cardiac or respiratory arrest). Review of Resident #1's orders beginning [DATE] DC [DATE] revealed, Daily weights: Notify PA/MD for weight gain > 3lbs in one day or 5lbs in one-week every day shift monitoring Review of Resident #1's nurses note by LVN A dated [DATE] revealed resident was with a therapist and became short of breath. Vital signs reflected O2 saturation (a measure of oxygen in the blood) levels between 88-90%, suggesting decreased oxygenation and intervention needed. Resident assessment revealed altered mental status and difficulty keeping eyes open. EMS arrived and transported resident to the ER at 11:52 am. Review of Resident #1's MD order dated [DATE] reflected weigh daily and record. Review of Resident #1's weights from his admission on [DATE] until discharge [DATE]: [DATE] 10:40 am 167.5 lbs. standing [DATE] 4:15 pm 167.0 lbs. standing [DATE] 10:12 am 167.1 lbs. wheelchair [DATE] 12:45 pm 167.5 lbs. wheelchair [DATE] 10:43 am 167.3 lbs. wheelchair [DATE] 6:52 am 167.3 lbs. wheelchair [DATE] 11:12 am 167.0 lbs. sitting [DATE] 1:22 pm 167.2 lbs. wheelchair [DATE] 1:08 pm 167.0 lbs. wheelchair [DATE] 1:50 pm 167.3 lbs. wheelchair [DATE] 7:39 pm 167.4 lbs. wheelchair [DATE] 12:14 pm 175.5 lbs. sitting Review of PA progress notes, located in the miscellaneous tab in of Resident#1's electronic medical records, PA encounter date [DATE] revealed, Patient seen today in person at [nursing facility] for evaluation and coordination of care. Staff reported noncompliance with 02 and is high risk for falls. Orders for labs, meds., etc., were faxed earlier this week were apparently not received so I provided a copy to the DON today. Review of copy of Resident #1's orders dated [DATE] included in PA progress notes encounter dated [DATE] reflected a stamp reading orders faxed on [DATE] to the facility. Order dated [DATE] reflected lab order to check: CBC (a common blood test that provides information about the different types of cells in the blood) CMP (a routine blood test that measures various substances in the body to assess overall metabolism and organ function) TSH (assess the function of the thyroid gland, which produces hormones that regulate metabolism) Digoxin (measure the amount of digoxin (a medication used to treat congestive heart failure)) Thiamine (measure the amount of thiamine (vitamin B1)) Folic Acid (measure the amount of folic acid (a B vitamin)) Review of Resident #1's hospital history of present illness from [DATE] reflected Resident #1 had a diagnosis of dementia and chronic mixed heart failure and came from his nursing facility with altered mental status and shortness of breath. He was seen at the facility by gerontology (the study of aging people and people who are aging) and had increased in water weight. EMS was called, vitals were notable for hypotension (a condition where the blood pressure is significantly lower than normal), hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues), and hypothermia (a life-threatening condition that occurs when the body loses heat faster than it can produce it, resulting in a dangerously low body temperature). He was transferred to another hospital due to altered mental status and concern for ability to protect airway and was intubated. CT scan (Computerized tomography a noninvasive medical examination or procedure that uses specialized X-ray equipment to produce cross-sectional images of the body) demonstrated bilateral pleural effusion (a condition where excess fluid accumulates in the pleural spaces on both sides of the lungs), volume overload (a condition where there is an excessive amount of fluid in the body, particularly in the bloodstream), and cystitis (a bladder infection) and was on minimal vent settings. Review of Resident #1's hospital records from [DATE] reflected principal problem: septic shock (a life-threatening condition that occurs when an infection spreads throughout the body and causes a dangerously low blood pressure). Review of Nursing Home Documentation Form dated [DATE] by PA reflected Resident #1 seen today in person at [facility name] for evaluation and coordination of care. Documentation reflected history of present illness - Resident #1 seen for follow up. There was a delay in getting lab results that the MD ordered on [DATE]. The CMP (comprehensive Metabolic Panel, a routine blood test that measures various substances in the blood to assess overall metabolism and organ function) was not done and the DON was aware it needed to be added. The facility had not done a daily weight in X7 days. The weight was 4 lbs. higher than last week so ordered additional dose of Lasix (medication for the treatment of edema associated with congestive heart failure). A review of Resident #1's lab results dated [DATE] reflected collection date [DATE] and test results for CBC, Digoxin, TSH, Thiamine, Folic Acid, and Free T4. The lab results do not reflect results for CMP. The CBC reflected that out of 22 panels (a lab analysis of a blood sample that measures the levels of various substances in the blood) checked in the CBC, 13 panels had an outcome outside of normal range, either low or high. RBC (red blood cell count) - Low 3.98, normal range 4.63 - 6.08 Hemoglobin (a protein found in red blood cells that is responsible for transporting oxygen from the lungs to the body's tissues and carbon dioxide from the tissues back to the lungs) - Low 12, normal range 13.7 - 17.5 Hematocrit (a medical test that measures the percentage of red blood cells in the blood) - Low 36.6, normal range 40.1 - 51.0% Platelet (small colorless call fragments in the blood that play a crucial role in blood clotting) - Low 80, normal range 163-337 RDW (Red Cell Distribution Width - measures the variation in size of red blood cells) - High 15.7%, normal range 11.6 - 14.4% Neutrophil % (a type of white blood cell (leukocyte) that play a crucial role in the immune system) - High 82.2%, normal range 34.0 - 67.9% Lymphocyte# (a white blood cell that helps the body fight infection and disease) Low 0.49, normal range 1.32 - 3.57 Monocyte# (white blood cells that play a crucial role in the immune system) Low .23, normal range 0.30 - 0.82 Basophil% (a type of white blood cell (leukocyte) that play a crucial role in the immune system) Low 0.0%, normal range 0.2 - 1.2% Basophil# (a type of white blood cell (leukocyte) that play a crucial role in the immune system) Low 0.00, normal range 0.01 - 0.08 A review of Resident #1's electronic medical record from [DATE] through [DATE] reflected no notation of any communications to Resident #1's MD, PA, or family about of Resident #1's labs, collected 20 days after MD lab order. Interview on [DATE] with the PA at 12:48 pm revealed orders were written for labs for Resident #1 on, she thought, [DATE] and when Resident #1 was admitted to the hospital, they only had partial lab results. She said every week when she was at the facility, she verbally told the DON and the ADM that she needed the lab work for Resident #1. The facility did not have the results for the CMP blood test ordered on [DATE] that referred to Resident #1's level of calcium (an essential mineral that plays a vital role in maintaining strong bones, teeth, and other bodily function). The PA revealed that had they known the results of Resident #1's calcium level in a timely manner, they might have been able to reverse Resident #1's medical condition. The PA revealed Resident #1 was diagnosed at the hospital with sepsis (a lift-threatening condition that occurs when the body's immune system overacts to an infection) and his calcium level could have contribute to sepsis in addition to the fluid overload that was not discovered or reported to the PA or MD because the facility was not weighing Resident #1 in accordance with the MD orders. Interview on [DATE] with RN D at 10:37 am revealed it was important to weigh someone with congestive heart failure to make sure you could accurately keep a record of their fluid accumulation. If a resident accumulated too much fluid it could cause respiratory and circulatory issues and their medication might not be therapeutic. It was important to weight residents in accordance with the MD orders. If the order stated to do weights regularly you weighted residents regularly according to the MD order. If the resident had an increase or a loss in weight the MD needed to be informed to see if the resident needed a change in medication. When Resident #1 first admitted to the facility his weight should have been taken and documented for a baseline. Someone from the nursing staff, the CNA or a licensed nurse should have weighted and recorded the weight in accordance with the MD order to make sure it was accurate and consistent. A negative outcome of not weighing a resident who had congestive heart failure would be not knowing if there was fluid overload. Residents should be weighted the same time every day in accordance with the MD orders and they should be weighted the same way, either consistently standing, mechanical, or using a wheelchair, using the same scale. If they have congestive heart failure, you really wanted to encourage them to be weighted the same way. If a MD orders labs, you want to get it processed when it was received. The negative outcome of not getting labs processed would be not providing medication that was therapeutic. There is potential for harm if labs are not ordered and reported to the MD. Residents could be hospitalized or die if lab work is not handled properly. Interview on [DATE] with the Resident #1's MD on 12:28 pm revealed he did not know if Resident #1's complete labs were received. He stated it is hard to monitor chronic conditions without lab work and felt that not having the lab work could have contributed to Resident #1's death. The MD stated that Resident #1 suffered from dementia and could not let people know when things were really wrong. He said Resident #1 had heart failure and he wrote an order to do daily weights for Resident #1. The weights were necessary because they were needed to have some objective way to monitor and follow Resident #1's congestive heart failure and not doing the weights could have possibly contributed to heart failure. Interview on [DATE] with the ADM at 4:32 revealed the former DON and the former ADON were responsible for the lab tracking and there was no documentation in the daily lab tracking form. She said she could not locate the notebook that was supposed to contain the lab tracking. She said not tracking labs was a problem because it could cause harm to a resident. She stated when labs were not tracked, someone could drop the ball, and something could be missed. The ADM felt the ADON was not trained properly by the DON, and everything was falling by the wayside. She said she wanted to terminate the DON, but she had to make sure she had someone else to take her spot. She said as a nurse you have to follow up and follow through and this was not happening for either weights or labs. Interview on [DATE] with the PA at 1:34 pm revealed the facility not weighing Resident #1 daily contributed to his decline and hospitalization. Facility policy Lab management dated [DATE] reflected it is the policy of this community to provide or obtain laboratory services to meet the needs of its residents. The community is responsible for the timeliness of the services. The community must notify the attending physician of the lab results. Procedure All labs require a physician order. 1. The Designated Clinical Officer will be responsible to monitor lab orders to ensure that all ordered labs have been drawn as ordered by the physician. 2. Lab tracking is to be documented daily on the lab tracking form. 3. Ensure that all labs ordered have been collected with results communicated to MD/family in a timely manner. Proof of notification to be included on lab report sheet and slash or in the nurse's notes. 4. Lab personnel will be responsible to report to the charge nurse all labs that have been drawn or not drawn that day. Lab draws that cannot be drawn that day will be communicated to the physician and reordered if necessary. 5. The designated clinical officer will be responsible to notify the lab when a lab result is not received in a timely manner. 6. If issues are identified with the lab provider process. The designated clinical officer is to contact lab company immediately for corrective action. Quality assurance plan to be developed by lab provider to prevent recurrence of identified issue issue(s). 7. If issue with community process is identified, provide immediate staff in service and re-education regarding the importance of labs and their impact on residents. 8. Lab tracking process is to be monitored during scheduled QAPI meeting. The CDO must periodically check lab tracking book on a random basis to ensure the director of clinical office slash designee is compliant with the process. 9. Ensure lab provider conducts a lab audit per contract and provides community with access to routine labs and frequency. 10. The attending physician will be notified promptly of lab results. 11. Lab results will be maintained in the resident's clinical record. Facility policy Nutrition Management dated [DATE] reflected the purpose of this policy is to establish facility guidelines on how and when the facility obtains and documents residents weights. The policy is also to ensure that residents with significant weight loss or weight gain are rapidly identified to ensure that the resident maintains the highest quality of life and wellness in the facility. Procedure Resident weights Based on resident's comprehensive assessment, the facility must ensure that a resident: 1. Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. Obtaining Resident weights When obtaining resident weights: It is best practice to use the same scale each time to weight the residents. Ensure that the resident is weighed, if possible, during the same time of the day Ensure that the resident has the approximate amount of clothing each time they are weighed New Admissions - The resident's height and weight should be obtained upon admission. The ADM was notified on [DATE] at 5:42 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on [DATE] at 4:42 PM: The POR included: F684: The facility failed to weigh Resident #1 daily as ordered. The facility failed to obtain ordered labs. Action: DON/ADON in serviced administrative staff and nursing staff regarding policy and procedures for weight tracking and management and methods for obtaining weights in supine, seated, standing in wheelchair or use of mechanical lift with signature response for comprehension. [DATE]. The resident's height and weight will be obtained upon admission, documented by nursing staff in electronic medical records and lab binder. The resident is then weighed at least weekly for at least 4 weeks [DATE]. The resident's weight will be obtained upon re admission, documented in EMR and weight binder by nursing staff. The resident is then weighed at least weekly for at least 4 weeks with discussion for completion during the morning meeting with administrative staff, DON/ADON [DATE]. The residents will have a monthly weight obtained. All monthly weights will be entered into PCC by the 10th of every month by DON/ADON with daily discussion for completion during the daily morning meeting [DATE]. Nursing staff will notify Physician, resident, and family of the weight loss/gain and documented in EMR [DATE]. Nursing staff will monitor residents' eating habits and documented in residents EMR by nursing staff. [DATE]. Weekly weights will be obtained for at least 4 weeks and documented by nursing staff in EMR [DATE]. Initiation of the Weight Surveillance Form for at least 4 weeks or all resident's weight has stabilized [DATE]. Any planned weight loss will be care planned and noted in the clinical record. The physician, dietitian, and nursing staff will collaborate in a planned weight loss [DATE]. Dietitian recommendations will be implemented or if needed, sent to the physician immediately upon receipt [DATE]. If the physician has not responded within 72 hours, a call will be placed to the physician's office on [DATE]. DON/ADON completed a 100% lab audit to ensure all labs ordered have been collected with results indicating no other residents to have labs that were ordered and not completed [DATE]. Start Date: [DATE] Completion Date: [DATE] Responsible: DON/designee will monitor and track residents' weight loss of 5% or greater with immediate notification sent to dieticians and physicians for recommendations and documented in EMR [DATE]. DON/ADON will maintain a current list of residents and a communication form will be provided to the dietary manager to notify them of extra assistance, encouragement, substitute meals, or supplements or any weight loss identified. The dietary manager will document in residents' EMR followed by a consultation call to Registered dietician for further instructions. Follow up during the morning meeting to ensure completion [DATE]. DON/ADON will in-service administrative staff, dietary management and staff regarding procedure with communication slips concerning weight loss, diet changes, new admits and readmits with documentation placed in residents EMR. Signature page completed to reflect comprehension. The Medical Director immediately made aware of IJ for noncompliance via telephone. Surveyor Monitoring: During interviews on [DATE] from 8:39 AM - 3:21 PM the activities director, social worker, one agency LVN, one RN, and 4 LVNs (from different shifts) all stated they were in-serviced by the DON or the ADON or designee regarding policy and procedures for weight tracking and management and methods for obtaining weights. The nurses stated they will notify physician, resident, and family of the weight loss/gain and document in the EMR. The resident's height and weight will be obtained upon admission, documented by nursing staff in the electronic medical records and lab binder. The resident will then be weighed at least weekly for at least 4 weeks and if the residents have a re-admission their weight will be obtained upon re admission, documented in EMR and weight binder by nursing staff. The resident will again be weighed at least weekly for at least 4 weeks with discussion for completion during the morning meeting with administrative staff, DON/ADON. The nursing staff will notify physician, resident, and family of any weight loss/gain and it will be documented in the EMR. The nursing staff will monitor residents' eating habits and document in residents EMR. Weekly weights will be obtained for at least 4 weeks and documented by nursing staff in EMR. They were in-serviced on the initiation of the Weight Surveillance Form regarding resident weight stabilization. Any planned weight loss will be care planned and noted in the clinical record. The physician, dietitian, and nursing staff will collaborate in a planned weight loss. Dietitian recommendations will be implemented or if needed, sent to the physician immediately upon receipt. If the physician has not responded within 72 hours, a call will be placed to the physician's office. The administrative staff, dietary management and staff were in-serviced regarding procedure with communication slips concerning weight loss, diet changes, new admits and readmits with documentation placed in residents EMR. In an interview on [DATE] with the ADM at 12:30 pm the ADM confirmed that: The DON/designee will monitor and track residents' weight loss of 5% or greater with immediate notification sent to dieticians and physicians for recommendations and documented in EMR [DATE]. The DON/ADON will maintain a current list of residents and a communication form will be provided to the dietary manager to notify them of extra assistance, encouragement, substitute meals, or supplements or any weight loss identified. The dietary manager will document in residents' EMR followed by a consultation call to Registered dietician for further instructions. Follow up during the morning meeting to ensure completion [DATE]. The Medical Director immediately made aware of IJ for noncompliance via telephone. On [DATE] at 1:35 pm the surveyor reviewed the QA plan to be developed by Administrator /DON to prevent recurrence of identified issues(s) that began [DATE]. On [DATE] the surveyor confirmed via telephone call that the medical director was informed about the IJ. Removal Plan On [DATE] an abbreviated survey was initiated at the community. On [DATE] the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to residents' health and safety. The facility failed to obtain ordered labs. Resident #1 is an [AGE] year-old male with a DX of chronic respiratory failure with hypoxia. [DATE] Action: DON/ADON completed a lab audit to ensure all labs ordered have been collected with results indicating no other residents to have labs that were ordered and not completed [DATE]. Report all lab results to MD/NP immediately, report abnormal lab results to MD/NP/DON or designee and documented in each resident EMR [DATE]. Lab tracking binder will be located at each Nurse's station. DON/ADON will perform lab audits to ensure all labs that are ordered are placed in the lab tracking binder. Proof of notification to be included on the lab report sheet via signature, date, time and route of notification and documented in the nurse's notes [DATE]. Lab draws that cannot be drawn that day will be communicated to the physician immediately, documented in residents EMR and checked daily by DON/ADON for completion of results. [DATE]. Lab results will be maintained in the resident's clinical record via Electric Medical Record integration documentation system [DATE]. Administrator/DON and ADON will in-service charge nurses on laboratory monitoring and management with signature for comprehension. Agency and PRN staff will be in- serviced prior to the start of shift in addition to the binder placed at nurses' station with lab policy and procedures [DATE]. Start Date: [DATE] Completion Date: [DATE] Responsible: The DON/designee will be responsible for monitoring lab orders to ensure that all ordered labs have been drawn as ordered by the physician [DATE]. The ADON/designee will be responsible for notifying the lab when a lab result is not received in a timely manner [DATE]. If issues are identified with the lab provider process, DON is to contact lab company immediately for corrective action [DATE]. The Administrator will check lab tracking books monthly via signature page of lab binder to ensure DON/designee is compliant with the laboratory monitoring and management tracking process [DATE]. QA plan to be developed by Administrator /DON to prevent recurrence of identified issues(s) [DATE]. Surveyor Monitoring: During interviews on [DATE] from 8:39 AM - 3:21 PM the activities director, social worker, one agency LVN, one RN, and 4 LVNs (from different shifts) all stated they were in-serviced by the DON or the ADON or designee to report all lab results to MD/NP immediately, to report abnormal lab results to MD/NP/DON or designee, to document labs in each resident EMR, and to document in the Lab tracking binder that will be located at each Nurse's station. The staff stated they understood that Proof of notification is needed and is to be included on the lab report sheets via signature, date, time and route of notification is to be documented in the nurse's notes beginning [DATE]. Staff further said they were in-serviced that lab draws that cannot be drawn that day will be communicated to the physician immediately, documented in residents EMR and checked daily by DON/ADON for completion of results. In an interview on [DATE] with the ADM at 12:30 pm the ADM confirmed that: The DON/designee will be responsible for monitoring lab orders to ensure that all ordered labs have been drawn as ordered by the physician beginning [DATE]. The ADON/designee will be responsible for notifying the lab when a lab result is not received in a timely manner beginning [DATE]. That if issues are identified with the lab provider process, DON, currently the ADM, is to contact lab company immediately for corrective action beginning [DATE]. The Lab tracking binder will be located at each Nurse's station. The Administrator will check lab tracking books monthly via signature page of lab binder to ensure DON/designee is compliant with the laboratory monitoring and management tracking process [DATE]. On [DATE] at 12:37 pm the surveyor reviewed completed lab audit to ensure all labs ordered have been collected with results indicating no other residents to have labs that were ordered and not completed [DATE]. On [DATE] at 1:02 pm the surveyor observed the lab tracking binder located at the nurse's station. On [DATE] at 1:10 pm the surveyor reviewed the QA plan to be developed by Administrator DON to prevent recurrence of identified issues(s) that began [DATE]. Interview on [DATE] with the facility medical director at 8:39 am stated he was informed of the immediate jeopardy. The ADM was notified on [DATE] 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 obtain laboratory services to meet the needs of its residents for 1 (Resident #1) of three residents reviewed for laboratory services. The facility failed to collect Resident #1's blood specimen as ordered by the physician on 11/12/24 until 12/02/24. The CBC results reflected multiple out of range readings and did not include a CMP test. Resident #1 suffered shortness of breath and altered mental status. Resident #1 was taken by EMS to the hospital on [DATE] and was diagnosed with sepsis. An IJ was identified on 01/29/25. The IJ template was provided to the facility on [DATE] at 5:37 pm. While the IJ was removed on 02/01/25, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because of the facility's need to evaluate the effectiveness of the corrective system. This failure could place residents at risk of a delay in receiving the necessary interventions to treat their medical condition(s). Findings Included: Review of Resident #1's face sheet dated 01/29/25 reflected an [AGE] year-old male who was originally admitted to the facility on [DATE] with diagnoses that included combined systolic and diastolic heart failure (systolic failure is a problem with the heart's pumping action, while diastolic failure is a problem with the heart's filling phase) and chronic respiratory failure with hypoxia (the body isn't getting enough oxygen due to impaired lung function). Review of Resident #1's MDS dated [DATE] reflected a BIMS score of 10, indicating moderate cognitive impairment, he used a wheelchair, and had an active diagnoses of congestive heart failure and respiratory failure. Review of Resident #1's care plan focus, goal, and interventions dated 11/06/24: Focus reflected regular diet, no added salt, 2000 ml fluid restriction. Goal reflected Resident #1 will have adequate nutrition and fluid intake throughout the review date. Review of Resident #1's care plan Focus dated 11/06/24: I have an activities of daily living self-care performance deficit related to the disease process - confusion. Review of social services progress note dated 11/06/24 reflected Resident #1 was a full code (a medical directive indicating that a patient wishes to receive all possible life-saving measures in the event of a medical emergency, such as cardiac or respiratory arrest). Review of Resident #1's nurses note by LVN A dated 12/03/24 revealed resident was with a therapist and became short of breath. Vital signs reflected O2 saturation (a measure of oxygen in the blood) levels between 88-90%, suggesting decreased oxygenation and intervention needed. Resident assessment revealed altered mental status and difficulty keeping eyes open. EMS arrived and transported resident to the ER at 11:52 am. Review of PA progress notes, located in the miscellaneous tab in of Resident#1's electronic medical records, PA encounter date 11/14/24 revealed, Patient seen today in person at [nursing facility] for evaluation and coordination of care. Staff reported noncompliance with 02 and is high risk for falls. Orders for labs, meds., etc., were faxed earlier this week were apparently not received so I provided a copy to the DON today. Review of copy of Resident #1's orders dated 11/12/24 included in PA progress notes encounter dated 11/14/24 reflected a stamp reading orders faxed on 11/13/24 to the facility. Order dated 11/12/24 reflected lab order to check: CBC (a common blood test that provides information about the different types of cells in the blood) CMP (a routine blood test that measures various substances in the body to assess overall metabolism and organ function) TSH (assess the function of the thyroid gland, which produces hormones that regulate metabolism) Digoxin (measure the amount of digoxin (a medication used to treat congestive heart failure)) Thiamine (measure the amount of thiamine (vitamin B1)) Folic Acid (measure the amount of folic acid (a B vitamin)) Review of Resident #1's hospital history of present illness from 12/03/24 reflected Resident #1 had a diagnosis of dementia and chronic mixed heart failure and came from his nursing facility with altered mental status and shortness of breath. He was seen at the facility by gerontology (the study of aging people and people who are aging) and had increased in water weight. EMS was called, vitals were notable for hypotension (a condition where the blood pressure is significantly lower than normal), hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues), and hypothermia (a life-threatening condition that occurs when the body loses heat faster than it can produce it, resulting in a dangerously low body temperature). He was transferred to another hospital due to altered mental status and concern for ability to protect airway and was intubated. CT scan (Computerized tomography a noninvasive medical examination or procedure that uses specialized X-ray equipment to produce cross-sectional images of the body) demonstrated bilateral pleural effusion (a condition where excess fluid accumulates in the pleural spaces on both sides of the lungs), volume overload (a condition where there is an excessive amount of fluid in the body, particularly in the bloodstream), and cystitis (a bladder infection) and was on minimal vent settings. Review of Nursing Home Documentation Form dated 12/03/24 reflected Resident #1 see today in person at [facility name] for evaluation and coordination of care. Documentation reflected history of present illness - Resident #1 seen for follow up. There was a delay in getting lab results that the MD ordered on 11/12/24. The CMP (comprehensive Metabolic Panel, a routine blood test that measures various substances in the blood to assess overall metabolism and organ function) was not done and the DON was aware it needed to be added. The weight was 4 lbs. higher than last week so ordered additional dose of Lasix (medication for the treatment of edema associated with congestive heart failure). Review of Resident #1's hospital records from 12/03/24 reflected principal problem: septic shock (a life-threatening condition that occurs when an infection spreads throughout the body and causes a dangerously low blood pressure). A review of Resident #1's lab results dated 12/03/24 reflected collection date 12/02/24 and test results for CBC, Digoxin, TSH, Thiamine, Folic Acid, and Free T4 . The lab results do not reflect results for CMP. The CBC reflected that out of 22 panels (a lab analysis of a blood sample that measures the levels of various substances in the blood) checked in the CBC, 13 panels had an outcome outside of normal range, either low or high. RBC (red blood cell count) - Low 3.98, normal range 4.63 - 6.08 Hemoglobin (a protein found in red blood cells that is responsible for transporting oxygen from the lungs to the body's tissues and carbon dioxide from the tissues back to the lungs) - Low 12, normal range 13.7 - 17.5 Hematocrit (a medical test that measures the percentage of red blood cells in the blood) - Low 36.6, normal range 40.1 - 51.0% Platelet (small colorless call fragments in the blood that play a crucial role in blood clotting) - Low 80, normal range 163-337 RDW (Red Cell Distribution Width - measures the variation in size of red blood cells) - High 15.7%, normal range 11.6 - 14.4% Neutrophil % (a type of white blood cell (leukocyte) that play a crucial role in the immune system) - High 82.2%, normal range 34.0 - 67.9% Lymphocyte# (a white blood cell that helps the body fight infection and disease) Low 0.49, normal range 1.32 - 3.57 Monocyte# (white blood cells that play a crucial role in the immune system) Low .23, normal range 0.30 - 0.82 Basophil% (a type of white blood cell (leukocyte) that play a crucial role in the immune system) Low 0.0%, normal range 0.2 - 1.2% Basophil# (a type of white blood cell (leukocyte) that play a crucial role in the immune system) Low 0.00, normal range 0.01 - 0.08 A review of Resident #1's electronic medical record from 11/12/24 through 12/03/24 reflected no notation of any communications to Resident #1's MD, PA, or family about of Resident #1's labs, collected 20 days after MD lab order. Interview on 01/28/25 with the PA at 12:48 pm revealed orders were written for labs for Resident #1 on, she thought, 11/13/24 and when Resident #1 was admitted to the hospital, they only had partial lab results. She said every week when she was at the facility, she verbally told the DON and the ADM that she needed the lab work for Resident #1. The facility did not have the results for the CMP blood test ordered on 11/12/24 that referred to Resident #1's level of calcium (an essential mineral that plays a vital role in maintaining strong bones, teeth, and other bodily function). The PA revealed that had they know the results of Resident #1's calcium level in a timely manner, they might have been able to reverse Resident #1's medical condition. The PA revealed Resident #1 was diagnosed at the hospital with sepsis (a lift-threatening condition that occurs when the body's immune system overacts to an infection) and his calcium level could have contribute to sepsis in addition to the fluid overload. She said because the facility was so poor with keeping track of resident labs, she would physically hand the nurses orders for a lab (unable to specifically detail resident names or dates). Interview on 01/31/25 with Resident #1's MD on 12:28 pm revealed he did not know if Resident #1's complete labs were received. He stated it is hard to monitor chronic conditions without lab work and felt that not having the lab work could have contributed to Resident #1's death. The MD stated that Resident #1 suffered from dementia and could not let people know when things were really wrong. He said he repeatedly had to ask for lab work and ask when they were going to draw the specimen for the lab work. He said he would go to the facility and specifically have to ask them to follow through with lab orders (at the time of the interview, he did not have access to resident records and did not have specifics). He said he had waited up to 3 weeks for lab work on stat lab orders. He said he had to beg for labs to be done. He said, it is a very disorganized facility. Interview on 1/29/25 with RN D at 10:37 am revealed the negative outcome of not getting labs processed would be not providing medication that was therapeutic. There is potential for harm if labs are not ordered and reported to the MD. Residents could be hospitalized or die if lab work is not handled properly. Interview on 01/31/25 with RN D at 8:57 am revealed there was no system for labs. The lab tracking was missing, and they thought it went with the former DON and they had to recreate a new one. He said that there are some labs that are signed and scanned into the resident electronic medical record, but the tracking book had been gone for about 2 weeks. He said the DON was responsible for the tracking book. He said nurses were told to, put the labs on the shelf until she picked them up in the morning. He said nursing staff did not have control of the lab book and it was not available to the nurses. He felt it was a failure in the system and the negative impact of this was that they could not keep account of the labs. He said the problem was the labs were not put in a system and that is why labs were missed. He said there were no lab communications put in the electronic medical record and this is how the ball got dropped. He said the facility needed to cross check the lab book and the electronic medical record. He said clearly there was a lack of organization with the labs and it was the responsibility of the nursing staff to keep up with the labs but there was no system set up by the DON, so it was ineffective. He said there was absolutely no follow up or follow through with the DON. Interview on 01/31/25 with the ADM at 4:32 pm revealed the former DON and the former ADON were responsible for the lab tracking and there was no daily lab tracking documentation. When asked for lab orders for Resident #1 and other residents, the ADM said she was unable to produce them. She said she could not locate the notebook that was supposed to contain the lab tracking. She said she thinks maybe the former DON took the lab tracking binder with her when she left but has no proof of this. The ADM said the former DON stopped working for the facility on 01/18/25. She told the surveyor she was able to produce records from the lab they contracted with that reflected resident labs were processed, but no resident lab orders were provided. She said not tracking labs was a problem because it could cause harm to a resident. She stated when labs were not tracked, someone could drop the ball, and something could be missed. The ADM felt the ADON was not trained properly by the DON, and everything was falling by the wayside. She said she wanted to terminate the DON, but she had to make sure she had someone else to take her spot. She said as a nurse you have to follow up and follow through and this was not happening. In an interview on 02/01/25 with the ADM at 12:36 she stated when the former DON left, she did not have DON supervision and she felt like that was a problem. She was told by the former DON that there were systems in place but, hindsight is 20 20 and she now found out that this was not the case at all. The ADM verbally reprimanded the DON and told her that things were being missed, but here we are now. The negative impact of not having systems in place is it could cause harm to the residents. The ADM said not having followed through with the labs could have potentially caused harm to Resident #1. The ADM said it was embarrassing that an MD had to come to the facility and ask for the labs. The ADM was responsible for making sure the DON was doing her duties and the DON not doing her duties was a detriment to the residents. It is a big detriment because nursing is the core of the nursing home. She said she had several conversations with the DON about accountability. She said she did not know that labs were not getting done. In morning meetings, it was not reported to her that labs were not getting done. Facility policy Lab management dated 08/01/21 reflected it is the policy of this community to provide or obtain laboratory services to meet the needs of its residents. The community is responsible for the timeliness of the services. The community must notify the attending physician of the lab results. Procedure All labs require a physician order. 12. The Designated Clinical Officer will be responsible to monitor lab orders to ensure that all ordered labs have been drawn as ordered by the physician. 13. Lab tracking is to be documented daily on the lab tracking form. 14. Ensure that all labs ordered have been collected with results communicated to MD/family in a timely manner. Proof of notification to be included on lab report sheet and slash or in the nurse's notes. 15. Lab personnel will be responsible to report to the charge nurse all labs that have been drawn or not drawn that day. Lab draws that cannot be drawn that day will be communicated to the physician and reordered if necessary. 16. The designated clinical officer will be responsible to notify the lab when a lab result is not received in a timely manner. 17. If issues are identified with the lab provider process. The designated clinical officer is to contact lab company immediately for corrective action. Quality assurance plan to be developed by lab provider to prevent recurrence of identified issue issue(s). 18. If issue with community process is identified, provide immediate staff in service and re-education regarding the importance of labs and their impact on residents. 19. Lab tracking process is to be monitored during scheduled QAPI meeting. The CDO must periodically check lab tracking book on a random basis to ensure the director of clinical office slash designee is compliant with the process. 20. Ensure lab provider conducts a lab audit per contract and provides community with access to routine labs and frequency. 21. The attending physician will be notified promptly of lab results. 22. Lab results will be maintained in the resident's clinical record. The ADM was notified on 01/29/25 at 5:42 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 01/31/25 at 4:42 PM: Removal Plan On 1/29/25 an abbreviated survey was initiated at the community. On 1/29/2025 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to residents' health and safety. F770: The facility failed to obtain ordered labs. Resident #1 is an [AGE] year-old male with a DX of chronic respiratory failure with hypoxia. 01/29/2025 Action: DON/ADON completed a lab audit to ensure all labs ordered have been collected with results indicating no other residents to have labs that were ordered and not completed 1/29/25. Report all lab results to MD/NP immediately, report abnormal lab results to MD/NP/DON or designee and documented in each resident EMR 1/29/25. Lab tracking binder will be located at each Nurse's station. DON/ADON will perform lab audits to ensure all labs that are ordered are placed in the lab tracking binder. Proof of notification to be included on the lab report sheet via signature, date, time and route of notification and documented in the nurse's notes 1/29/25. Lab draws that cannot be drawn that day will be communicated to the physician immediately, documented in residents EMR and checked daily by DON/ADON for completion of results. 1/29/25. Lab results will be maintained in the resident's clinical record via Electric Medical Record integration documentation system 01/29/2025. Administrator/DON and ADON will in-service charge nurses on laboratory monitoring and management with signature for comprehension. Agency and PRN staff will be in- serviced prior to the start of shift in addition to the binder placed at nurses' station with lab policy and procedures 1/30/25. Start Date: 01/29/2025 Completion Date: 01/31/25 Responsible: The DON/designee will be responsible for monitoring lab orders to ensure that all ordered labs have been drawn as ordered by the physician 1/29/25. The ADON/designee will be responsible for notifying the lab when a lab result is not received in a timely manner 1/29/25. If issues are identified with the lab provider process, DON is to contact lab company immediately for corrective action 1/29/25. The Administrator will check lab tracking books monthly via signature page of lab binder to ensure DON/designee is compliant with the laboratory monitoring and management tracking process 1/29/25. QA plan to be developed by Administrator /DON to prevent recurrence of identified issues(s) 1/29/25. Surveyor Monitoring: The surveyor monitored the POR from 02/01/25 from 8:39 AM - 3:21 PM as followed: the activities director, social worker, one agency LVN, one RN, and 4 LVNs (from different shifts) all stated they were in-serviced by the DON or the ADON or designee to report all lab results to MD/NP immediately, to report abnormal lab results to MD/NP/DON or designee, to document labs in each resident EMR, and to document in the Lab tracking binder that will be located at each Nurse's station. The staff stated they understood that Proof of notification is needed and is to be included on the lab report sheets via signature, date, time and route of notification is to be documented in the nurse's notes beginning 1/29/25. Staff further said they were in-serviced that lab draws that cannot be drawn that day will be communicated to the physician immediately, documented in residents EMR and checked daily by DON/ADON for completion of results. In an interview on 02/01/25 with the ADM at 12:30 pm the ADM confirmed that: The DON/designee will be responsible for monitoring lab orders to ensure that all ordered labs have been drawn as ordered by the physician beginning 1/29/25. The ADON/designee will be responsible for notifying the lab when a lab result is not received in a timely manner beginning 1/29/25. That if issues are identified with the lab provider process, DON, currently the ADM, is to contact lab company immediately for corrective action beginning 1/29/25. The Lab tracking binder will be located at each Nurse's station. The Administrator will check lab tracking books monthly via signature page of lab binder to ensure DON/designee is compliant with the laboratory monitoring and management tracking process 1/29/25. On 02/01/25 at 12:37 pm the surveyor reviewed completed lab audit to ensure all labs ordered have been collected with results indicating no other residents to have labs that were ordered and not completed 1/29/25. On 02/01/25 at 1:02 pm the surveyor observed the lab tracking binder located at the nurse's station. On 02/01/25 at 1:10 pm the surveyor reviewed the QA plan to be developed by Administrator DON to prevent recurrence of identified issues(s) that began 1/29/25. Interview on 02/01/25 with the facility medical director at 8:39 am stated he was informed of the immediate jeopardy. The ADM was notified on 02/01/25 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 implement their written policies and procedures regarding prohibiting and preventing abuse for one (Resident #1) of three residents reviewed for abuse and neglect, in that: The facility failed to prevent Resident #1 from acquiring a spiral ulna (a long bone found in the forearm that stretches from the elbow to the wrist) fracture to her left arm while a shower was being provided on 12/06/23. This failure resulted in an identification of an Immediate Jeopardy on 12/13/23 at 3:28 PM. While the IJ was removed on 12/15/23 at 11:30 AM, the facility remained at a level of 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 for pain, injury, and abuse. 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 Alzheimer's disease (a brain disorder that causes memory loss, thinking problems, behavior changes and brain cell death), anxiety disorder, epilepsy (seizures), and cognitive communication deficit. Review of Resident #1's quarterly MDS assessment, dated 11/18/23, reflected a BIMS of 1, indicating a severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent on staff for bathing. Review of Resident #1's quarterly care plan, revised 06/07/23, reflected she had an ADL self-care performance deficit with an intervention of providing a sponge bath when a full bath or shower could not be tolerated. There was nothing in her care plan regarding a history of combative behaviors until the incident occurred on 12/06/23. Review of Resident #1's progress notes, dated 12/06/23 at 1:21 PM and documented by LVN A, reflected the following: Tylenol Oral Tablet 325 MG - give 2 tablets by mouth every 6 hours as needed for pain. c/o LUE pain. Analgesic administered. Review of Resident #1's progress notes, dated 12/06/23 at 2:24 PM and documented by LVN A, reflected the following: OT and [Resident #1]'s [RP B] called writer into [Resident #1]'s room. OT notified writer that [Resident #1] is c/o of LUE pain. Upon assessment resident noted guarding LUE. Verbal c/o of pain when assessed. Purple discoloration and 0.6x0.1x0.1cm skin tear noted to left forearm . patted dry and left OTA. PRN Tylenol administered. [Resident #1] unable to inform writer how discoloration or skin tear occurred. A&Ox1. Writer requested x-ray of LUE . Review of Resident #1's progress notes, dated 12/06/23 at 2:32 PM and documented by LVN A, reflected the following: X-ray tech arrived, unable to complete x-ray. [Resident #1] sent to ER for evaluation and treatment. Review of Resident #1's progress notes, dated 12/06/23 at 2:38 PM and documented by LVN A, reflected the following: [Resident #1] assisted with shower by CNAs. CNA notified writer that [Resident #1] was physically aggressive with staff. [Resident #1] grabbed, scratched, and hit staff. [Resident #1] verbally redirected by staff. Review of Resident #1's progress notes, dated 12/07/23 at 8:17 AM and documented by LVN A, reflected the following: Tramadol-Acetaminophen Oral Tablet 37.5-325 MG - Give 1 tablet by mouth every 8 hours as needed for pain. Nonverbal signs of LUE pain. Analgesic administered. Review of Resident #1's progress notes, dated 12/07/23 at 12:20 PM and documented by LVN A, reflected the following: Per DON, x-ray at (hospital) was only taken of the left shoulder and elbow. [Resident #1]'s [RP C] is concerned regarding [Resident #1]'s left wrist. Requested n/o for wrist x-ray. Review of Resident #1's progress notes, dated 12/08/23 at 8:03 PM and documented by LVN A, reflected the following: Late entry: Writer received x-ray results (Moderate degenerative disease of the wrist without fracture of the carpal bones. There is an acute fracture of the distal 3rd of the ulna.) . Review of Resident #1's ER discharge paperwork, dated 12/06/23, reflected the following: [Resident #1] presents from her nursing home due to reported left arm pain. Apparent she complained to staff that her left upper arm was hurting . There is no report of any trauma or injury. Review of Resident #1's ER discharge paperwork, dated 12/08/23, reflected the following: [Resident #1] presents with fall and left lower arm pain. Differential diagnoses: fracture, strain, contusion Final Radiologist Interpretations: Essentially nondisplaced distal left ulnar shaft fracture Review of Resident #1's Orthopedic MD's assessment, dated 12/11/23, reflected the following: Plan: Discussed conservative and surgical treatment options. Fracture is well aligned and does not require surgical intervention. [Resident #1] to begin wearing long arm cast for the next 6 weeks. Repeat x-ray at next visit in cast to ensure fracture is still well-aligned. [Resident #1] with spiral fracture of ulna. Cause of break is unclear as there is not history from patient and nursing home is being somewhat cryptic about the exact events causing the break. [Resident #1]'s RP B and C are concerned that the break may have been caused by rough handling by staff at the nursing home. Spiral fractures have been shown to be associated with twisting/torsion injuries so this is certainly plausible. During a telephone interview on 12/13/23 at 10:04 AM, RP C stated RP B visited and had lunch with Resident #1 every day at the nursing facility. She stated when RP B saw her on 12/05/23, there was no discoloration to her left arm nor was she showing any signs or symptoms of pain. She stated when he saw her on 12/06/23, he noticed the bruise and laceration on her left arm and Resident #1 would not let RP B touch it. She stated after the ER concluded there was no fracture to Resident #1's left elbow or shoulder, she demanded an x-ray to her wrist. She stated if she would have not demanded that to happen, the facility probably would not have done anything. Review of the facility's incident/accident reports, from 09/01/23 - 12/06/23, reflected Resident #1 had not sustained a fall. Observation and interview on 12/13/23 at 11:57 AM revealed Resident #1 in the dining room with RP B. She was pleasantly confused. Her left arm was casted and, in a sling, and she was not showing any signs or symptoms of pain. During an interview on 12/13/23 at 12:00 PM, the OT stated she had provided therapy for Resident #1 on 12/05/23 and she was perfectly fine and had no trouble utilizing her arms. She stated Resident #1 had no history of being combative. She had assisted her with ADLs such as getting her dressed and taken her to the bathroom and she never had any issues. She stated she was easily re-directable. She stated on 12/06/23 around 12:30 PM - 12:45 PM she was asked by Resident #1's RP B in the dining room to assess her left arm as she was in a lot of pain. She stated she would scream if anyone got near it, was grimacing, and was guarding her arm. She stated there was a discolored area on the forearm with a skin tear that looked like a scratch. She stated she notified LVN A and noticed LVN A asking the aides if anything had happened in the shower earlier that morning. She stated she walked by when LVN A was talking to CNA D and she was demonstrating something by holding her left arm. She stated she did not hear what was said between the two. She stated she had never heard of a spiral fracture being acquired by a fall or hitting something - it was normally due to a twisting motion. She stated she had not heard if Resident #1 had a fall prior to lunch on 12/06/23. During a telephone interview on 12/13/23 at 12:11 PM, LVN A stated Resident #1 had been given a shower on the morning of 12/06/23. She stated she observed Resident #1 in the common area after her shower until lunch when she was in the dining room. She stated she was not notified of anything out of the ordinary from the aides after her shower. She stated after the OT notified her of Resident #1's laceration and arm pain, she questioned CNA D, E, and F. She stated CNA E was in orientation and was shadowing CNA D and CNA F was in there to assist. She stated when she interviewed the aides, it was brought to her attention that Resident #1 had become agitated in the shower and was combative. She stated she was told by the aides that while CNA D was washing Resident #1, CNA E and F had to hold her hands down to keep from hitting them. During a telephone interview on 12/13/23 at 12:27 PM, CNA E stated she was training and following CNA D on 12/06/23. She stated she was not sure how many staff members Resident #1 normally required for a shower due to her being new. She stated Resident #1 went into the shower room with no problem. She stated CNA D was behind Resident #1 and she was to the left of her. She stated when CNA D went to stand her up to bring her pants/brief down, her rollator moved a little bit and it might have scared her because she became combative and was punching and hitting. She stated that was when CNA D called for CNA F to assist. She stated they did have to pull her hands down to get her to stop hitting them but once Resident #1 got into the shower, she was completely calm for the rest of the activity. She stated she did see the bruise on Resident #1's forearm before the shower and did not see a laceration or bleeding. She stated it was her fault she did not say anything and she was unsure if anyone else saw it. During an interview on 12/13/23 at 12:53 PM, CNA F stated she also worked as the van driver and did not normally assist with ADL care, so she was not sure how many staff members Resident #1 normally required for showers. She stated CNA D asked if she could assist with Resident #1's shower since CNA E was in training. She stated when they went to pull her pants down, Resident #1 became combative and was swinging her arms and hitting them. She stated they were trying to hold her arms back but were really just blocking her hits. She stated she calmed down shortly after and was fine during the rest of the shower. She stated she did not notice anything to Resident #1's left forearm and she had not complained of pain during the shower. During an interview on 12/13/23 at 12:59 PM, ADM G stated she had just started at the facility two weeks ago and ADM H was and ADM at a sister facility and had been helping her get acquainted with the facility. When asked how they believed Resident #1's injury could have happened, ADM H stated that when Resident #1 became combative in the shower, swinging and punching her arms, she may have hit one of the aides or her rollator with her wrist. ADM H stated the shower occurred shortly after 8 AM on 12/06/23. ADM H stated Resident #1 was in the day room after her shower until lunch time. ADM H stated they did not suspend any of the aides because she did no believe they did anything to hurt Resident #1. During an interview on 12/13/23 at 1:26 PM, Resident #1's RP B stated Resident #1 was already in the dining room when he visited her on 12/06/23. He stated towards the end of the meal he noticed the discoloration and laceration on her left forearm. He stated when he went to assess it, she highly guarded her arm, and began grimacing and moaning. He stated the OT helped him get Resident #1 to her room and the OT notified LVN A. He stated the laceration looked like a fingernail scratch. He stated her arm was not like that nor had she been in pain the day before. He stated when he tried to get answers from the staff, he heard excuses like she may have fallen. He stated that would be impossible because if she had fallen, there would have been no way for her to have gotten back up by herself, and there was no documentation that she had fallen. He stated it also was not possible for her to have used her right arm to squeeze and twist her left arm, resulting in the fracture. He stated the Orthopedic Surgeon told him and RP C that the fracture could have only been caused by a twisting motion, so he had no other option to believe that she was held down and hurt while she was being combative in the shower on 12/06/23. Attempts were made to interview by telephone CNA D on 12/13/23 at 11:36 AM and 1:52 PM. A telephone call was not returned prior to the completion of the investigation. Attempts were made to interview by telephone Resident #1's MD on 12/13/23 at 11:41 AM and 1:58 PM. A telephone call was not returned prior to the completion of the investigation. Review of the facility's undated Abuse Policy, reflected the following: Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents . This includes physical, verbal, sexual, physical/chemical restraint. Training: All employees are required to be trained in issues related to abuse prohibition practices . Training will include appropriate interventions on how to deal with residents with aggression or combative behavior. ADM G and ADM H were notified on 12/23/23 at 3:28 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 12/14/23 at 1:09 PM: On 12/13/2023 an abbreviated survey was initiated at (facility). On 12/13/2023 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 resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to keep the resident free from abuse. Action: The Regional [NAME] President (RVP) will provide education on abuse and neglect and keeping residents safe with Executive Director of Operations (EDO/Administrator) and Director of Clinical Operations (DCO). 12/13/2023. EDO suspended all 3Certified Nursing Assistants (C.N.A's) involved in the incident effective 12/13/2023. EDO will immediately suspend any staff allegedly involved in any incident where a resident sustain an injury during any allegation of abuse. In-services on abuse and neglect and keeping resident's safe initiated by EDO on 12/13/2023. All Staff to include PRN and agency staff expected to be in serviced prior to the next shift worked. All staff expected to be in service by 12/14/2023. EDO and DCO to complete Daily Monitoring and review of incident and accident reports to ensure residents are free of abuse by 12/13/23. This process will be ongoing during the morning meeting with IDT. Daily Focus Care rounds will be completed by management staff (Director of Clinical Operations, Assistant Director of Clinical Operations, Executive Director of Operations, Maintenance Director, Activity Director, Dietary Director, Business Office Manager, Social Worker) to ensure residents are free of abuse and neglect through resident interviews and to ensure companies policy and procedures for abuse and neglect are being followed by 12/13/2023. Treatment nurse will report weekly skin issues during weekly skin assessments and prn if noted by CNAs during care. This process will be ongoing and reviewed during the morning meeting with IDT. Director of Clinical Operations completed staff education and training on 12/13/2023 proper handling of residents during ADL Care and how to safely perform ADL care once a resident becomes combative. Staff should ensure the resident is safe once they become combative and walk away and then try completing task again later or get another team member to attempt to complete task once resident has calmed down. Inservice completed for all staff to include agency and prn by 12/14/2023. The Medical Director has been notified of the alleged allegation facility failure to follow abuse and neglect policy and procedures to keep residents safe from abuse. Current Policy was reviewed with Medical Director by EDO. There will be no changes to current policy at this time. The EDO reviewed facilities Plan of action regarding failure going forward with Medical Director. 12/14/23 QA Committee to meet monthly x 3 months to review facility compliance with abuse and neglect policy and procedures and continue safety and prevention of resident from abuse 12/14/2023. Executive Director of Operations and Director of Operations Safe Surveys conducted with residents on abuse and neglect, residents' rights, who the abuse coordinator and how to report allegations of abuse and to identify if any other allegations of abuse exist to be completed by 12/13/2023.Director of Clinical Operations completed Head to toe assessments 12/14/23 on nonverbal residents to ensure no injuries of unknown origin exists. All new hires will be trained in abuse and neglect policy during orientation conducted by Human Resources Director prior to working shift. 12/14/2023 The Surveyor monitored the POR from 12/14/23 - 12/15/23 as followed: During interviews on 12/14/23 from 9:22 AM - 11:04 AM with three male residents and three female residents, all stated they felt safe at the facility and that the staff treated them well. During an interview on 12/15/23 at 9:05 AM, ADM G stated all staff had been in-serviced before working their shift or by phone. She stated CNA D, E, and F were suspended on 12/13/23. She stated a QAPI meeting was held on 12/14/23 and the MD for the facility was in attendance. During interviews on 12/15/23 from 10:10 AM - 11:14 AM with one HSKA, two RNs, one LVN, and two CNAs revealed they were all in-serviced before their shifts on abuse and neglect, different types of abuse such as sexual, verbal, and physical, and who their Abuse and Neglect Coordinator was. All were able to give examples of non-verbal cues of pain such as grimacing, flinching, and guarding. They all stated if a resident was combative, they were to stop the care being provided and to get the nurse. They all stated they were to notify the nurse if there was an injury or any skin integrity issues observed on a resident. Review of Safe Surveys conducted on 12/13/23 with interviewable residents revealed no concerns regarding safety. Review of skin assessments, dated 12/13/23, conducted on non-interviewable residents revealed no concerns. Review of in-services conducted, from 12/13/23 - 12/15/23, reflected staff were reeducated on abuse and neglect, ADL care, handling aggressive residents during care, resident rights, and dementia sensitivity training. While the IJ was removed on 12/15/23 at 11:30 AM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for one (Resident #1) of three residents reviewed for abuse and neglect, in that: The facility failed to follow their Abuse and Neglect policy by removing three staff members from the facility who were last involved with Resident #1 before she was diagnosed with a spiral ulna (a long bone found in the forearm that stretches from the elbow to the wrist) fracture to her left arm on 12/06/23. The facility failed to report and investigate the incident prior to entrance. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/13/23 at 3:28 PM. While the IJ was removed on 12/15/23 at 11:30 AM, the facility remained at a level of 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 for pain, injury, and abuse. 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 Alzheimer's disease (a brain disorder that causes memory loss, thinking problems, behavior changes and brain cell death), anxiety disorder, epilepsy (seizures), and cognitive communication deficit. Review of Resident #1's quarterly MDS assessment, dated 11/18/23, reflected a BIMS of 1, indicating a severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent on staff for bathing. Review of Resident #1's quarterly care plan, revised 06/07/23, reflected she had an ADL self-care performance deficit with an intervention of providing a sponge bath when a full bath or shower could not be tolerated. There was nothing in her care plan regarding a history of combative behaviors until the incident occurred on 12/06/23. Review of Resident #1's progress notes, dated 12/06/23 at 1:21 PM and documented by LVN A, reflected the following: Tylenol Oral Tablet 325 MG - give 2 tablets by mouth every 6 hours as needed for pain. c/o LUE pain. Analgesic administered. Review of Resident #1's progress notes, dated 12/06/23 at 2:24 PM and documented by LVN A, reflected the following: OT and [Resident #1]'s [RP B] called writer into [Resident #1]'s room. OT notified writer that [Resident #1] is c/o of LUE pain. Upon assessment resident noted guarding LUE. Verbal c/o of pain when assessed. Purple discoloration and 0.6x0.1x0.1cm skin tear noted to left forearm . patted dry and left OTA. PRN Tylenol administered. [Resident #1] unable to inform writer how discoloration or skin tear occurred. A&Ox1. Writer requested x-ray of LUE . Review of Resident #1's progress notes, dated 12/06/23 at 2:32 PM and documented by LVN A, reflected the following: X-ray tech arrived, unable to complete x-ray. [Resident #1] sent to ER for evaluation and treatment. Review of Resident #1's progress notes, dated 12/06/23 at 2:38 PM and documented by LVN A, reflected the following: [Resident #1] assisted with shower by CNAs. CNA notified writer that [Resident #1] was physically aggressive with staff. [Resident #1] grabbed, scratched, and hit staff. [Resident #1] verbally redirected by staff. Review of Resident #1's progress notes, dated 12/07/23 at 8:17 AM and documented by LVN A, reflected the following: Tramadol-Acetaminophen Oral Tablet 37.5-325 MG - Give 1 tablet by mouth every 8 hours as needed for pain. Nonverbal signs of LUE pain. Analgesic administered. Review of Resident #1's progress notes, dated 12/07/23 at 12:20 PM and documented by LVN A, reflected the following: Per DON, x-ray at (hospital) was only taken of the left shoulder and elbow. [Resident #1]'s [RP C] is concerned regarding [Resident #1]'s left wrist. Requested n/o for wrist x-ray. Review of Resident #1's progress notes, dated 12/08/23 at 8:03 PM and documented by LVN A, reflected the following: Late entry: Writer received x-ray results (Moderate degenerative disease of the wrist without fracture of the carpal bones. There is an acute fracture of the distal 3rd of the ulna.) . Review of Resident #1's ER discharge paperwork, dated 12/06/23, reflected the following: [Resident #1] presents from her nursing home due to reported left arm pain. Apparent she complained to staff that her left upper arm was hurting . There is no report of any trauma or injury. Review of Resident #1's ER discharge paperwork, dated 12/08/23, reflected the following: [Resident #1] presents with fall and left lower arm pain. Differential diagnoses: fracture, strain, contusion Final Radiologist Interpretations: Essentially nondisplaced distal left ulnar shaft fracture Review of Resident #1's Orthopedic MD's assessment, dated 12/11/23, reflected the following: Plan: Discussed conservative and surgical treatment options. Fracture is well aligned and does not require surgical intervention. [Resident #1] to begin wearing long arm cast for the next 6 weeks. Repeat x-ray at next visit in cast to ensure fracture is still well-aligned. [Resident #1] with spiral fracture of ulna. Cause of break is unclear as there is not history from patient and nursing home is being somewhat cryptic about the exact events causing the break. [Resident #1]'s RP B and C are concerned that the break may have been caused by rough handling by staff at the nursing home. Spiral fractures have been shown to be associated with twisting/torsion injuries so this is certainly plausible. During a telephone interview on 12/13/23 at 10:04 AM, RP C stated RP B visited and had lunch with Resident #1 every day at the nursing facility. She stated when RP B saw her on 12/05/23, there was no discoloration to her left arm nor was she showing any signs or symptoms of pain. She stated when he saw her on 12/06/23, he noticed the bruise and laceration on her left arm and Resident #1 would not let RP B touch it. She stated after the ER concluded there was no fracture to Resident #1's left elbow or shoulder, she demanded an x-ray to her wrist. She stated if she would have not demanded that to happen, the facility probably would not have done anything. Review of the facility's incident/accident reports, from 09/01/23 - 12/06/23, reflected Resident #1 had not sustained a fall. Observation and interview on 12/13/23 at 11:57 AM revealed Resident #1 in the dining room with RP B. She was pleasantly confused. Her left arm was casted and, in a sling, and she was not showing any signs or symptoms of pain. During an interview on 12/13/23 at 12:00 PM, the OT stated she had provided therapy for Resident #1 on 12/05/23 and she was perfectly fine and had no trouble utilizing her arms. She stated Resident #1 had no history of being combative. She had assisted her with ADLs such as getting her dressed and taken her to the bathroom and she never had any issues. She stated she was easily re-directable. She stated on 12/06/23 around 12:30 PM - 12:45 PM she was asked by Resident #1's RP B in the dining room to assess her left arm as she was in a lot of pain. She stated she would scream if anyone got near it, was grimacing, and was guarding her arm. She stated there was a discolored area on the forearm with a skin tear that looked like a scratch. She stated she notified LVN A and noticed LVN A asking the aides if anything had happened in the shower earlier that morning. She stated she walked by when LVN A was talking to CNA D and she was demonstrating something by holding her left arm. She stated she did not hear what was said between the two. She stated she had never heard of a spiral fracture being acquired by a fall or hitting something - it was normally due to a twisting motion. She stated she had not heard if Resident #1 had a fall prior to lunch on 12/06/23. During a telephone interview on 12/13/23 at 12:11 PM, LVN A stated Resident #1 had been given a shower on the morning of 12/06/23. She stated she observed Resident #1 in the common area after her shower until lunch when she was in the dining room. She stated she was not notified of anything out of the ordinary from the aides after her shower. She stated after the OT notified her of Resident #1's laceration and arm pain, she questioned CNA D, E, and F. She stated CNA E was in orientation and was shadowing CNA D and CNA F was in there to assist. She stated when she interviewed the aides, it was brought to her attention that Resident #1 had become agitated in the shower and was combative. She stated she was told by the aides that while CNA D was washing Resident #1, CNA E and F had to hold her hands down to keep from hitting them. During a telephone interview on 12/13/23 at 12:27 PM, CNA E stated she was training and following CNA D on 12/06/23. She stated she was not sure how many staff members Resident #1 normally required for a shower due to her being new. She stated Resident #1 went into the shower room with no problem. She stated CNA D was behind Resident #1 and she was to the left of her. She stated when CNA D went to stand her up to bring her pants/brief down, her rollator moved a little bit and it might have scared her because she became combative and was punching and hitting. She stated that was when CNA D called for CNA F to assist. She stated they did have to pull her hands down to get her to stop hitting them but once Resident #1 got into the shower, she was completely calm for the rest of the activity. She stated she did see the bruise on Resident #1's forearm before the shower and did not see a laceration or bleeding. She stated it was her fault she did not say anything and she was unsure if anyone else saw it. During an interview on 12/13/23 at 12:53 PM, CNA F stated she also worked as the van driver and did not normally assist with ADL care, so she was not sure how many staff members Resident #1 normally required for showers. She stated CNA D asked if she could assist with Resident #1's shower since CNA E was in training. She stated when they went to pull her pants down, Resident #1 became combative and was swinging her arms and hitting them. She stated they were trying to hold her arms back but were really just blocking her hits. She stated she calmed down shortly after and was fine during the rest of the shower. She stated she did not notice anything to Resident #1's left forearm and she had not complained of pain during the shower. During an interview on 12/13/23 at 12:59 PM, ADM G stated she had just started at the facility two weeks ago and ADM H was and ADM at a sister facility and had been helping her get acquainted with the facility. When asked how they believed Resident #1's injury could have happened, ADM H stated that when Resident #1 became combative in the shower, swinging and punching her arms, she may have hit one of the aides or her rollator with her wrist. ADM H stated the shower occurred shortly after 8 AM on 12/06/23. ADM H stated Resident #1 was in the day room after her shower until lunch time. ADM H stated they did not suspend any of the aides because she did no believe they did anything to hurt Resident #1. During an interview on 12/13/23 at 1:26 PM, Resident #1's RP B stated Resident #1 was already in the dining room when he visited her on 12/06/23. He stated towards the end of the meal he noticed the discoloration and laceration on her left forearm. He stated when he went to assess it, she highly guarded her arm, and began grimacing and moaning. He stated the OT helped him get Resident #1 to her room and the OT notified LVN A. He stated the laceration looked like a fingernail scratch. He stated her arm was not like that nor had she been in pain the day before. He stated when he tried to get answers from the staff, he heard excuses like she may have fallen. He stated that would be impossible because if she had fallen, there would have been no way for her to have gotten back up by herself, and there was no documentation that she had fallen. He stated it also was not possible for her to have used her right arm to squeeze and twist her left arm, resulting in the fracture. He stated the Orthopedic Surgeon told him and RP C that the fracture could have only been caused by a twisting motion, so he had no other option to believe that she was held down and hurt while she was being combative in the shower on 12/06/23. Attempts were made to interview by telephone CNA D on 12/13/23 at 11:36 AM and 1:52 PM. A telephone call was not returned prior to the completion of the investigation. Attempts were made to interview by telephone Resident #1's MD on 12/13/23 at 11:41 AM and 1:58 PM. A telephone call was not returned prior to the completion of the investigation. Review of the facility's undated Abuse Policy, reflected the following: The purpose of this policy is to ensure that each resident has the right to be free from any type of abuse . .Identify the perpetrator that is identified and remove the perpetrator from further contact with the resident pending outcome of investigation. . Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation caused by another person to report the abuse, neglect or exploitation. . All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation. ADM G and ADM H were notified on 12/23/23 at 3:28 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 12/14/23 at 1:09 PM: On 12/13/2023 an abbreviated survey was initiated at (facility). On 12/13/2023 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 resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to keep the resident free from abuse. Action: The Regional [NAME] President (RVP) will provide education on abuse and neglect and keeping residents safe with Executive Director of Operations (EDO/Administrator) and Director of Clinical Operations (DCO). 12/13/2023. EDO suspended all 3Certified Nursing Assistants (C.N.A's) involved in the incident effective 12/13/2023. EDO will immediately suspend any staff allegedly involved in any incident where a resident sustain an injury during any allegation of abuse. In-services on abuse and neglect and keeping resident's safe initiated by EDO on 12/13/2023. All Staff to include PRN and agency staff expected to be in serviced prior to the next shift worked. All staff expected to be in service by 12/14/2023. EDO and DCO to complete Daily Monitoring and review of incident and accident reports to ensure residents are free of abuse by 12/13/23. This process will be ongoing during the morning meeting with IDT. Daily Focus Care rounds will be completed by management staff (Director of Clinical Operations, Assistant Director of Clinical Operations, Executive Director of Operations, Maintenance Director, Activity Director, Dietary Director, Business Office Manager, Social Worker) to ensure residents are free of abuse and neglect through resident interviews and to ensure companies policy and procedures for abuse and neglect are being followed by 12/13/2023. Treatment nurse will report weekly skin issues during weekly skin assessments and prn if noted by CNAs during care. This process will be ongoing and reviewed during the morning meeting with IDT. Director of Clinical Operations completed staff education and training on 12/13/2023 proper handling of residents during ADL Care and how to safely perform ADL care once a resident becomes combative. Staff should ensure the resident is safe once they become combative and walk away and then try completing task again later or get another team member to attempt to complete task once resident has calmed down. Inservice completed for all staff to include agency and prn by 12/14/2023. The Medical Director has been notified of the alleged allegation facility failure to follow abuse and neglect policy and procedures to keep residents safe from abuse. Current Policy was reviewed with Medical Director by EDO. There will be no changes to current policy at this time. The EDO reviewed facilities Plan of action regarding failure going forward with Medical Director. 12/14/23 QA Committee to meet monthly x 3 months to review facility compliance with abuse and neglect policy and procedures and continue safety and prevention of resident from abuse 12/14/2023. Executive Director of Operations and Director of Operations Safe Surveys conducted with residents on abuse and neglect, residents' rights, who the abuse coordinator and how to report allegations of abuse and to identify if any other allegations of abuse exist to be completed by 12/13/2023.Director of Clinical Operations completed Head to toe assessments 12/14/23 on nonverbal residents to ensure no injuries of unknown origin exists. All new hires will be trained in abuse and neglect policy during orientation conducted by Human Resources Director prior to working shift. 12/14/2023 The Surveyor monitored the POR from 12/14/23 - 12/15/23 as followed: During interviews on 12/14/23 from 9:22 AM - 11:04 AM with three male residents and three female residents, all stated they felt safe at the facility and that the staff treated them well. During an interview on 12/15/23 at 9:05 AM, ADM G stated all staff had been in-serviced before working their shift or by phone. She stated CNA D, E, and F were suspended on 12/13/23. She stated a QAPI meeting was held on 12/14/23 and the MD for the facility was in attendance. During interviews on 12/15/23 from 10:10 AM - 11:14 AM with one HSKA, two RNs, one LVN, and two CNAs revealed they were all in-serviced before their shifts on abuse and neglect, different types of abuse such as sexual, verbal, and physical, and who their Abuse and Neglect Coordinator was. All were able to give examples of non-verbal cues of pain such as grimacing, flinching, and guarding. They all stated if a resident was combative, they were to stop the care being provided and to get the nurse. They all stated they were to notify the nurse if there was an injury or any skin integrity issues observed on a resident. Review of Safe Surveys conducted on 12/13/23 with interviewable residents revealed no concerns regarding safety. Review of skin assessments, dated 12/13/23, conducted on non-interviewable residents revealed no concerns. Review of in-services conducted, from 12/13/23 - 12/15/23, reflected staff were reeducated on abuse and neglect, ADL care, handling aggressive residents during care, resident rights, and dementia sensitivity training. While the IJ was removed on 12/15/23 at 11:30 AM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for one (Resident #1) of three residents reviewed for abuse and neglect, in that: The facility failed to follow their Abuse and Neglect policy by removing three staff members from the facility who were last involved with Resident #1 before she was diagnosed with a spiral ulna (a long bone found in the forearm that stretches from the elbow to the wrist) fracture to her left arm on 12/06/23. The facility failed to report and investigate the incident prior to entrance. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/13/23 at 3:28 PM. While the IJ was removed on 12/15/23 at 11:30 AM, the facility remained at a level of 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 for pain, injury, and abuse. 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 Alzheimer's disease (a brain disorder that causes memory loss, thinking problems, behavior changes and brain cell death), anxiety disorder, epilepsy (seizures), and cognitive communication deficit. Review of Resident #1's quarterly MDS assessment, dated 11/18/23, reflected a BIMS of 1, indicating a severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent on staff for bathing. Review of Resident #1's quarterly care plan, revised 06/07/23, reflected she had an ADL self-care performance deficit with an intervention of providing a sponge bath when a full bath or shower could not be tolerated. There was nothing in her care plan regarding a history of combative behaviors until the incident occurred on 12/06/23. Review of Resident #1's progress notes, dated 12/06/23 at 1:21 PM and documented by LVN A, reflected the following: Tylenol Oral Tablet 325 MG - give 2 tablets by mouth every 6 hours as needed for pain. c/o LUE pain. Analgesic administered. Review of Resident #1's progress notes, dated 12/06/23 at 2:24 PM and documented by LVN A, reflected the following: OT and [Resident #1]'s [RP B] called writer into [Resident #1]'s room. OT notified writer that [Resident #1] is c/o of LUE pain. Upon assessment resident noted guarding LUE. Verbal c/o of pain when assessed. Purple discoloration and 0.6x0.1x0.1cm skin tear noted to left forearm . patted dry and left OTA. PRN Tylenol administered. [Resident #1] unable to inform writer how discoloration or skin tear occurred. A&Ox1. Writer requested x-ray of LUE . Review of Resident #1's progress notes, dated 12/06/23 at 2:32 PM and documented by LVN A, reflected the following: X-ray tech arrived, unable to complete x-ray. [Resident #1] sent to ER for evaluation and treatment. Review of Resident #1's progress notes, dated 12/06/23 at 2:38 PM and documented by LVN A, reflected the following: [Resident #1] assisted with shower by CNAs. CNA notified writer that [Resident #1] was physically aggressive with staff. [Resident #1] grabbed, scratched, and hit staff. [Resident #1] verbally redirected by staff. Review of Resident #1's progress notes, dated 12/07/23 at 8:17 AM and documented by LVN A, reflected the following: Tramadol-Acetaminophen Oral Tablet 37.5-325 MG - Give 1 tablet by mouth every 8 hours as needed for pain. Nonverbal signs of LUE pain. Analgesic administered. Review of Resident #1's progress notes, dated 12/07/23 at 12:20 PM and documented by LVN A, reflected the following: Per DON, x-ray at (hospital) was only taken of the left shoulder and elbow. [Resident #1]'s [RP C] is concerned regarding [Resident #1]'s left wrist. Requested n/o for wrist x-ray. Review of Resident #1's progress notes, dated 12/08/23 at 8:03 PM and documented by LVN A, reflected the following: Late entry: Writer received x-ray results (Moderate degenerative disease of the wrist without fracture of the carpal bones. There is an acute fracture of the distal 3rd of the ulna.) . Review of Resident #1's ER discharge paperwork, dated 12/06/23, reflected the following: [Resident #1] presents from her nursing home due to reported left arm pain. Apparent she complained to staff that her left upper arm was hurting . There is no report of any trauma or injury. Review of Resident #1's ER discharge paperwork, dated 12/08/23, reflected the following: [Resident #1] presents with fall and left lower arm pain. Differential diagnoses: fracture, strain, contusion Final Radiologist Interpretations: Essentially nondisplaced distal left ulnar shaft fracture Review of Resident #1's Orthopedic MD's assessment, dated 12/11/23, reflected the following: Plan: Discussed conservative and surgical treatment options. Fracture is well aligned and does not require surgical intervention. [Resident #1] to begin wearing long arm cast for the next 6 weeks. Repeat x-ray at next visit in cast to ensure fracture is still well-aligned. [Resident #1] with spiral fracture of ulna. Cause of break is unclear as there is not history from patient and nursing home is being somewhat cryptic about the exact events causing the break. [Resident #1]'s RP B and C are concerned that the break may have been caused by rough handling by staff at the nursing home. Spiral fractures have been shown to be associated with twisting/torsion injuries so this is certainly plausible. Review of HHSC's reporting system, reflected no self-report made by the facility regarding the injury. During a telephone interview on 12/13/23 at 10:04 AM, RP C stated RP B visited and had lunch with Resident #1 every day at the nursing facility. She stated when RP B saw her on 12/05/23, there was no discoloration to her left arm nor was she showing any signs or symptoms of pain. She stated when he saw her on 12/06/23, he noticed the bruise and laceration on her left arm and Resident #1 would not let RP B touch it. She stated after the ER concluded there was no fracture to Resident #1's left elbow or shoulder, she demanded an x-ray to her wrist. She stated if she would have not demanded that to happen, the facility probably would not have done anything. Review of the facility's incident/accident reports, from 09/01/23 - 12/06/23, reflected Resident #1 had not sustained a fall. Observation and interview on 12/13/23 at 11:57 AM revealed Resident #1 in the dining room with RP B. She was pleasantly confused. Her left arm was casted and, in a sling, and she was not showing any signs or symptoms of pain. During an interview on 12/13/23 at 12:00 PM, the OT stated she had provided therapy for Resident #1 on 12/05/23 and she was perfectly fine and had no trouble utilizing her arms. She stated Resident #1 had no history of being combative. She had assisted her with ADLs such as getting her dressed and taken her to the bathroom and she never had any issues. She stated she was easily re-directable. She stated on 12/06/23 around 12:30 PM - 12:45 PM she was asked by Resident #1's RP B in the dining room to assess her left arm as she was in a lot of pain. She stated she would scream if anyone got near it, was grimacing, and was guarding her arm. She stated there was a discolored area on the forearm with a skin tear that looked like a scratch. She stated she notified LVN A and noticed LVN A asking the aides if anything had happened in the shower earlier that morning. She stated she walked by when LVN A was talking to CNA D and she was demonstrating something by holding her left arm. She stated she did not hear what was said between the two. She stated she had never heard of a spiral fracture being acquired by a fall or hitting something - it was normally due to a twisting motion. She stated she had not heard if Resident #1 had a fall prior to lunch on 12/06/23. During a telephone interview on 12/13/23 at 12:11 PM, LVN A stated Resident #1 had been given a shower on the morning of 12/06/23. She stated she observed Resident #1 in the common area after her shower until lunch when she was in the dining room. She stated she was not notified of anything out of the ordinary from the aides after her shower. She stated after the OT notified her of Resident #1's laceration and arm pain, she questioned CNA D, E, and F. She stated CNA E was in orientation and was shadowing CNA D and CNA F was in there to assist. She stated when she interviewed the aides, it was brought to her attention that Resident #1 had become agitated in the shower and was combative. She stated she was told by the aides that while CNA D was washing Resident #1, CNA E and F had to hold her hands down to keep from hitting them. During a telephone interview on 12/13/23 at 12:27 PM, CNA E stated she was training and following CNA D on 12/06/23. She stated she was not sure how many staff members Resident #1 normally required for a shower due to her being new. She stated Resident #1 went into the shower room with no problem. She stated CNA D was behind Resident #1 and she was to the left of her. She stated when CNA D went to stand her up to bring her pants/brief down, her rollator moved a little bit and it might have scared her because she became combative and was punching and hitting. She stated that was when CNA D called for CNA F to assist. She stated they did have to pull her hands down to get her to stop hitting them but once Resident #1 got into the shower, she was completely calm for the rest of the activity. She stated she did see the bruise on Resident #1's forearm before the shower and did not see a laceration or bleeding. She stated it was her fault she did not say anything and she was unsure if anyone else saw it. During an interview on 12/13/23 at 12:53 PM, CNA F stated she also worked as the van driver and did not normally assist with ADL care, so she was not sure how many staff members Resident #1 normally required for showers. She stated CNA D asked if she could assist with Resident #1's shower since CNA E was in training. She stated when they went to pull her pants down, Resident #1 became combative and was swinging her arms and hitting them. She stated they were trying to hold her arms back but were really just blocking her hits. She stated she calmed down shortly after and was fine during the rest of the shower. She stated she did not notice anything to Resident #1's left forearm and she had not complained of pain during the shower. During an interview on 12/13/23 at 12:59 PM, ADM G stated she had just started at the facility two weeks ago and ADM H was and ADM at a sister facility and had been helping her get acquainted with the facility. When asked how they believed Resident #1's injury could have happened, ADM H stated that when Resident #1 became combative in the shower, swinging and punching her arms, she may have hit one of the aides or her rollator with her wrist. ADM H stated the shower occurred shortly after 8 AM on 12/06/23. ADM H stated Resident #1 was in the day room after her shower until lunch time. ADM H stated they did not suspend any of the aides because she did no believe they did anything to hurt Resident #1. During an interview on 12/13/23 at 1:26 PM, Resident #1's RP B stated Resident #1 was already in the dining room when he visited her on 12/06/23. He stated towards the end of the meal he noticed the discoloration and laceration on her left forearm. He stated when he went to assess it, she highly guarded her arm, and began grimacing and moaning. He stated the OT helped him get Resident #1 to her room and the OT notified LVN A. He stated the laceration looked like a fingernail scratch. He stated her arm was not like that nor had she been in pain the day before. He stated when he tried to get answers from the staff, he heard excuses like she may have fallen. He stated that would be impossible because if she had fallen, there would have been no way for her to have gotten back up by herself, and there was no documentation that she had fallen. He stated it also was not possible for her to have used her right arm to squeeze and twist her left arm, resulting in the fracture. He stated the Orthopedic Surgeon told him and RP C that the fracture could have only been caused by a twisting motion, so he had no other option to believe that she was held down and hurt while she was being combative in the shower on 12/06/23. Attempts were made to interview by telephone CNA D on 12/13/23 at 11:36 AM and 1:52 PM. A telephone call was not returned prior to the completion of the investigation. Attempts were made to interview by telephone Resident #1's MD on 12/13/23 at 11:41 AM and 1:58 PM. A telephone call was not returned prior to the completion of the investigation. Review of the facility's undated Abuse Policy, reflected the following: The purpose of this policy is to ensure that each resident has the right to be free from any type of abuse . .Identify the perpetrator that is identified and remove the perpetrator from further contact with the resident pending outcome of investigation. . Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation caused by another person to report the abuse, neglect or exploitation. . All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation. ADM G and ADM H were notified on 12/23/23 at 3:28 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 12/14/23 at 1:09 PM: On 12/13/2023 an abbreviated survey was initiated at (facility). On 12/13/2023 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 resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to keep the resident free from abuse. Action: The Regional [NAME] President (RVP) will provide education on abuse and neglect and keeping residents safe with Executive Director of Operations (EDO/Administrator) and Director of Clinical Operations (DCO). 12/13/2023. EDO suspended all 3Certified Nursing Assistants (C.N.A's) involved in the incident effective 12/13/2023. EDO will immediately suspend any staff allegedly involved in any incident where a resident sustain an injury during any allegation of abuse. In-services on abuse and neglect and keeping resident's safe initiated by EDO on 12/13/2023. All Staff to include PRN and agency staff expected to be in serviced prior to the next shift worked. All staff expected to be in service by 12/14/2023. EDO and DCO to complete Daily Monitoring and review of incident and accident reports to ensure residents are free of abuse by 12/13/23. This process will be ongoing during the morning meeting with IDT. Daily Focus Care rounds will be completed by management staff (Director of Clinical Operations, Assistant Director of Clinical Operations, Executive Director of Operations, Maintenance Director, Activity Director, Dietary Director, Business Office Manager, Social Worker) to ensure residents are free of abuse and neglect through resident interviews and to ensure companies policy and procedures for abuse and neglect are being followed by 12/13/2023. Treatment nurse will report weekly skin issues during weekly skin assessments and prn if noted by CNAs during care. This process will be ongoing and reviewed during the morning meeting with IDT. Director of Clinical Operations completed staff education and training on 12/13/2023 proper handling of residents during ADL Care and how to safely perform ADL care once a resident becomes combative. Staff should ensure the resident is safe once they become combative and walk away and then try completing task again later or get another team member to attempt to complete task once resident has calmed down. Inservice completed for all staff to include agency and prn by 12/14/2023. The Medical Director has been notified of the alleged allegation facility failure to follow abuse and neglect policy and procedures to keep residents safe from abuse. Current Policy was reviewed with Medical Director by EDO. There will be no changes to current policy at this time. The EDO reviewed facilities Plan of action regarding failure going forward with Medical Director. 12/14/23 QA Committee to meet monthly x 3 months to review facility compliance with abuse and neglect policy and procedures and continue safety and prevention of resident from abuse 12/14/2023. Executive Director of Operations and Director of Operations Safe Surveys conducted with residents on abuse and neglect, residents' rights, who the abuse coordinator and how to report allegations of abuse and to identify if any other allegations of abuse exist to be completed by 12/13/2023.Director of Clinical Operations completed Head to toe assessments 12/14/23 on nonverbal residents to ensure no injuries of unknown origin exists. All new hires will be trained in abuse and neglect policy during orientation conducted by Human Resources Director prior to working shift. 12/14/2023 The Surveyor monitored the POR from 12/14/23 - 12/15/23 as followed: During interviews on 12/14/23 from 9:22 AM - 11:04 AM with three male residents and three female residents, all stated they felt safe at the facility and that the staff treated them well. During an interview on 12/15/23 at 9:05 AM, ADM G stated all staff had been in-serviced before working their shift or by phone. She stated CNA D, E, and F were suspended on 12/13/23. She stated a QAPI meeting was held on 12/14/23 and the MD for the facility was in attendance. During interviews on 12/15/23 from 10:10 AM - 11:14 AM with one HSKA, two RNs, one LVN, and two CNAs revealed they were all in-serviced before their shifts on abuse and neglect, different types of abuse such as sexual, verbal, and physical, and who their Abuse and Neglect Coordinator was. All were able to give examples of non-verbal cues of pain such as grimacing, flinching, and guarding. They all stated if a resident was combative, they were to stop the care being provided and to get the nurse. They all stated they were to notify the nurse if there was an injury or any skin integrity issues observed on a resident. Review of Safe Surveys conducted on 12/13/23 with interviewable residents revealed no concerns regarding safety. Review of skin assessments, dated 12/13/23, conducted on non-interviewable residents revealed no concerns. Review of in-services conducted, from 12/13/23 - 12/15/23, reflected staff were reeducated on abuse and neglect, ADL care, handling aggressive residents during care, resident rights, and dementia sensitivity training. While the IJ was removed on 12/15/23 at 11:30 AM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for one (Resident #1) of three residents reviewed for abuse and neglect, in that: The facility failed to follow their Abuse and Neglect policy by removing three staff members from the facility who were last involved with Resident #1 before she was diagnosed with a spiral ulna (a long bone found in the forearm that stretches from the elbow to the wrist) fracture to her left arm on 12/06/23. The facility failed to report and investigate the incident prior to entrance. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/13/23 at 3:28 PM. While the IJ was removed on 12/15/23 at 11:30 AM, the facility remained at a level of 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 for pain, injury, and abuse. 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 Alzheimer's disease (a brain disorder that causes memory loss, thinking problems, behavior changes and brain cell death), anxiety disorder, epilepsy (seizures), and cognitive communication deficit. Review of Resident #1's quarterly MDS assessment, dated 11/18/23, reflected a BIMS of 1, indicating a severe cognitive impairment. Section GG (Functional Abilities and Goals) reflected she was dependent on staff for bathing. Review of Resident #1's quarterly care plan, revised 06/07/23, reflected she had an ADL self-care performance deficit with an intervention of providing a sponge bath when a full bath or shower could not be tolerated. There was nothing in her care plan regarding a history of combative behaviors until the incident occurred on 12/06/23. Review of Resident #1's progress notes, dated 12/06/23 at 1:21 PM and documented by LVN A, reflected the following: Tylenol Oral Tablet 325 MG - give 2 tablets by mouth every 6 hours as needed for pain. c/o LUE pain. Analgesic administered. Review of Resident #1's progress notes, dated 12/06/23 at 2:24 PM and documented by LVN A, reflected the following: OT and [Resident #1]'s [RP B] called writer into [Resident #1]'s room. OT notified writer that [Resident #1] is c/o of LUE pain. Upon assessment resident noted guarding LUE. Verbal c/o of pain when assessed. Purple discoloration and 0.6x0.1x0.1cm skin tear noted to left forearm . patted dry and left OTA. PRN Tylenol administered. [Resident #1] unable to inform writer how discoloration or skin tear occurred. A&Ox1. Writer requested x-ray of LUE . Review of Resident #1's progress notes, dated 12/06/23 at 2:32 PM and documented by LVN A, reflected the following: X-ray tech arrived, unable to complete x-ray. [Resident #1] sent to ER for evaluation and treatment. Review of Resident #1's progress notes, dated 12/06/23 at 2:38 PM and documented by LVN A, reflected the following: [Resident #1] assisted with shower by CNAs. CNA notified writer that [Resident #1] was physically aggressive with staff. [Resident #1] grabbed, scratched, and hit staff. [Resident #1] verbally redirected by staff. Review of Resident #1's progress notes, dated 12/07/23 at 8:17 AM and documented by LVN A, reflected the following: Tramadol-Acetaminophen Oral Tablet 37.5-325 MG - Give 1 tablet by mouth every 8 hours as needed for pain. Nonverbal signs of LUE pain. Analgesic administered. Review of Resident #1's progress notes, dated 12/07/23 at 12:20 PM and documented by LVN A, reflected the following: Per DON, x-ray at (hospital) was only taken of the left shoulder and elbow. [Resident #1]'s [RP C] is concerned regarding [Resident #1]'s left wrist. Requested n/o for wrist x-ray. Review of Resident #1's progress notes, dated 12/08/23 at 8:03 PM and documented by LVN A, reflected the following: Late entry: Writer received x-ray results (Moderate degenerative disease of the wrist without fracture of the carpal bones. There is an acute fracture of the distal 3rd of the ulna.) . Review of Resident #1's ER discharge paperwork, dated 12/06/23, reflected the following: [Resident #1] presents from her nursing home due to reported left arm pain. Apparent she complained to staff that her left upper arm was hurting . There is no report of any trauma or injury. Review of Resident #1's ER discharge paperwork, dated 12/08/23, reflected the following: [Resident #1] presents with fall and left lower arm pain. Differential diagnoses: fracture, strain, contusion Final Radiologist Interpretations: Essentially nondisplaced distal left ulnar shaft fracture Review of Resident #1's Orthopedic MD's assessment, dated 12/11/23, reflected the following: Plan: Discussed conservative and surgical treatment options. Fracture is well aligned and does not require surgical intervention. [Resident #1] to begin wearing long arm cast for the next 6 weeks. Repeat x-ray at next visit in cast to ensure fracture is still well-aligned. [Resident #1] with spiral fracture of ulna. Cause of break is unclear as there is not history from patient and nursing home is being somewhat cryptic about the exact events causing the break. [Resident #1]'s RP B and C are concerned that the break may have been caused by rough handling by staff at the nursing home. Spiral fractures have been shown to be associated with twisting/torsion injuries so this is certainly plausible. Review of HHSC's reporting system, reflected no self-report made by the facility regarding the injury. During a telephone interview on 12/13/23 at 10:04 AM, RP C stated RP B visited and had lunch with Resident #1 every day at the nursing facility. She stated when RP B saw her on 12/05/23, there was no discoloration to her left arm nor was she showing any signs or symptoms of pain. She stated when he saw her on 12/06/23, he noticed the bruise and laceration on her left arm and Resident #1 would not let RP B touch it. She stated after the ER concluded there was no fracture to Resident #1's left elbow or shoulder, she demanded an x-ray to her wrist. She stated if she would have not demanded that to happen, the facility probably would not have done anything. Review of the facility's incident/accident reports, from 09/01/23 - 12/06/23, reflected Resident #1 had not sustained a fall. Observation and interview on 12/13/23 at 11:57 AM revealed Resident #1 in the dining room with RP B. She was pleasantly confused. Her left arm was casted and, in a sling, and she was not showing any signs or symptoms of pain. During an interview on 12/13/23 at 12:00 PM, the OT stated she had provided therapy for Resident #1 on 12/05/23 and she was perfectly fine and had no trouble utilizing her arms. She stated Resident #1 had no history of being combative. She had assisted her with ADLs such as getting her dressed and taken her to the bathroom and she never had any issues. She stated she was easily re-directable. She stated on 12/06/23 around 12:30 PM - 12:45 PM she was asked by Resident #1's RP B in the dining room to assess her left arm as she was in a lot of pain. She stated she would scream if anyone got near it, was grimacing, and was guarding her arm. She stated there was a discolored area on the forearm with a skin tear that looked like a scratch. She stated she notified LVN A and noticed LVN A asking the aides if anything had happened in the shower earlier that morning. She stated she walked by when LVN A was talking to CNA D and she was demonstrating something by holding her left arm. She stated she did not hear what was said between the two. She stated she had never heard of a spiral fracture being acquired by a fall or hitting something - it was normally due to a twisting motion. She stated she had not heard if Resident #1 had a fall prior to lunch on 12/06/23. During a telephone interview on 12/13/23 at 12:11 PM, LVN A stated Resident #1 had been given a shower on the morning of 12/06/23. She stated she observed Resident #1 in the common area after her shower until lunch when she was in the dining room. She stated she was not notified of anything out of the ordinary from the aides after her shower. She stated after the OT notified her of Resident #1's laceration and arm pain, she questioned CNA D, E, and F. She stated CNA E was in orientation and was shadowing CNA D and CNA F was in there to assist. She stated when she interviewed the aides, it was brought to her attention that Resident #1 had become agitated in the shower and was combative. She stated she was told by the aides that while CNA D was washing Resident #1, CNA E and F had to hold her hands down to keep from hitting them. During a telephone interview on 12/13/23 at 12:27 PM, CNA E stated she was training and following CNA D on 12/06/23. She stated she was not sure how many staff members Resident #1 normally required for a shower due to her being new. She stated Resident #1 went into the shower room with no problem. She stated CNA D was behind Resident #1 and she was to the left of her. She stated when CNA D went to stand her up to bring her pants/brief down, her rollator moved a little bit and it might have scared her because she became combative and was punching and hitting. She stated that was when CNA D called for CNA F to assist. She stated they did have to pull her hands down to get her to stop hitting them but once Resident #1 got into the shower, she was completely calm for the rest of the activity. She stated she did see the bruise on Resident #1's forearm before the shower and did not see a laceration or bleeding. She stated it was her fault she did not say anything and she was unsure if anyone else saw it. During an interview on 12/13/23 at 12:53 PM, CNA F stated she also worked as the van driver and did not normally assist with ADL care, so she was not sure how many staff members Resident #1 normally required for showers. She stated CNA D asked if she could assist with Resident #1's shower since CNA E was in training. She stated when they went to pull her pants down, Resident #1 became combative and was swinging her arms and hitting them. She stated they were trying to hold her arms back but were really just blocking her hits. She stated she calmed down shortly after and was fine during the rest of the shower. She stated she did not notice anything to Resident #1's left forearm and she had not complained of pain during the shower. During an interview on 12/13/23 at 12:59 PM, ADM G stated she had just started at the facility two weeks ago and ADM H was and ADM at a sister facility and had been helping her get acquainted with the facility. When asked how they believed Resident #1's injury could have happened, ADM H stated that when Resident #1 became combative in the shower, swinging and punching her arms, she may have hit one of the aides or her rollator with her wrist. ADM H stated the shower occurred shortly after 8 AM on 12/06/23. ADM H stated Resident #1 was in the day room after her shower until lunch time. ADM H stated they did not suspend any of the aides because she did no believe they did anything to hurt Resident #1. During an interview on 12/13/23 at 1:26 PM, Resident #1's RP B stated Resident #1 was already in the dining room when he visited her on 12/06/23. He stated towards the end of the meal he noticed the discoloration and laceration on her left forearm. He stated when he went to assess it, she highly guarded her arm, and began grimacing and moaning. He stated the OT helped him get Resident #1 to her room and the OT notified LVN A. He stated the laceration looked like a fingernail scratch. He stated her arm was not like that nor had she been in pain the day before. He stated when he tried to get answers from the staff, he heard excuses like she may have fallen. He stated that would be impossible because if she had fallen, there would have been no way for her to have gotten back up by herself, and there was no documentation that she had fallen. He stated it also was not possible for her to have used her right arm to squeeze and twist her left arm, resulting in the fracture. He stated the Orthopedic Surgeon told him and RP C that the fracture could have only been caused by a twisting motion, so he had no other option to believe that she was held down and hurt while she was being combative in the shower on 12/06/23. Attempts were made to interview by telephone CNA D on 12/13/23 at 11:36 AM and 1:52 PM. A telephone call was not returned prior to the completion of the investigation. Attempts were made to interview by telephone Resident #1's MD on 12/13/23 at 11:41 AM and 1:58 PM. A telephone call was not returned prior to the completion of the investigation. Review of the facility's undated Abuse Policy, reflected the following: The purpose of this policy is to ensure that each resident has the right to be free from any type of abuse . .Identify the perpetrator that is identified and remove the perpetrator from further contact with the resident pending outcome of investigation. . Reporting/Investigation: The law requires the abuse coordinator/designee, or employee of the facility who believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation caused by another person to report the abuse, neglect or exploitation. . All events that involve an allegation of abuse or involve a suspicious serious bodily injury of unknown origin must be reported immediately or not later than 2 hours of alleged violation. ADM G and ADM H were notified on 12/23/23 at 3:28 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 12/14/23 at 1:09 PM: On 12/13/2023 an abbreviated survey was initiated at (facility). On 12/13/2023 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 resident health and safety. The notification of Immediate Jeopardy states as follows: The facility failed to keep the resident free from abuse. Action: The Regional [NAME] President (RVP) will provide education on abuse and neglect and keeping residents safe with Executive Director of Operations (EDO/Administrator) and Director of Clinical Operations (DCO). 12/13/2023. EDO suspended all 3Certified Nursing Assistants (C.N.A's) involved in the incident effective 12/13/2023. EDO will immediately suspend any staff allegedly involved in any incident where a resident sustain an injury during any allegation of abuse. In-services on abuse and neglect and keeping resident's safe initiated by EDO on 12/13/2023. All Staff to include PRN and agency staff expected to be in serviced prior to the next shift worked. All staff expected to be in service by 12/14/2023. EDO and DCO to complete Daily Monitoring and review of incident and accident reports to ensure residents are free of abuse by 12/13/23. This process will be ongoing during the morning meeting with IDT. Daily Focus Care rounds will be completed by management staff (Director of Clinical Operations, Assistant Director of Clinical Operations, Executive Director of Operations, Maintenance Director, Activity Director, Dietary Director, Business Office Manager, Social Worker) to ensure residents are free of abuse and neglect through resident interviews and to ensure companies policy and procedures for abuse and neglect are being followed by 12/13/2023. Treatment nurse will report weekly skin issues during weekly skin assessments and prn if noted by CNAs during care. This process will be ongoing and reviewed during the morning meeting with IDT. Director of Clinical Operations completed staff education and training on 12/13/2023 proper handling of residents during ADL Care and how to safely perform ADL care once a resident becomes combative. Staff should ensure the resident is safe once they become combative and walk away and then try completing task again later or get another team member to attempt to complete task once resident has calmed down. Inservice completed for all staff to include agency and prn by 12/14/2023. The Medical Director has been notified of the alleged allegation facility failure to follow abuse and neglect policy and procedures to keep residents safe from abuse. Current Policy was reviewed with Medical Director by EDO. There will be no changes to current policy at this time. The EDO reviewed facilities Plan of action regarding failure going forward with Medical Director. 12/14/23 QA Committee to meet monthly x 3 months to review facility compliance with abuse and neglect policy and procedures and continue safety and prevention of resident from abuse 12/14/2023. Executive Director of Operations and Director of Operations Safe Surveys conducted with residents on abuse and neglect, residents' rights, who the abuse coordinator and how to report allegations of abuse and to identify if any other allegations of abuse exist to be completed by 12/13/2023.Director of Clinical Operations completed Head to toe assessments 12/14/23 on nonverbal residents to ensure no injuries of unknown origin exists. All new hires will be trained in abuse and neglect policy during orientation conducted by Human Resources Director prior to working shift. 12/14/2023 The Surveyor monitored the POR from 12/14/23 - 12/15/23 as followed: During interviews on 12/14/23 from 9:22 AM - 11:04 AM with three male residents and three female residents, all stated they felt safe at the facility and that the staff treated them well. During an interview on 12/15/23 at 9:05 AM, ADM G stated all staff had been in-serviced before working their shift or by phone. She stated CNA D, E, and F were suspended on 12/13/23. She stated a QAPI meeting was held on 12/14/23 and the MD for the facility was in attendance. During interviews on 12/15/23 from 10:10 AM - 11:14 AM with one HSKA, two RNs, one LVN, and two CNAs revealed they were all in-serviced before their shifts on abuse and neglect, different types of abuse such as sexual, verbal, and physical, and who their Abuse and Neglect Coordinator was. All were able to give examples of non-verbal cues of pain such as grimacing, flinching, and guarding. They all stated if a resident was combative, they were to stop the care being provided and to get the nurse. They all stated they were to notify the nurse if there was an injury or any skin integrity issues observed on a resident. Review of Safe Surveys conducted on 12/13/23 with interviewable residents revealed no concerns regarding safety. Review of skin assessments, dated 12/13/23, conducted on non-interviewable residents revealed no concerns. Review of in-services conducted, from 12/13/23 - 12/15/23, reflected staff were reeducated on abuse and neglect, ADL care, handling aggressive residents during care, resident rights, and dementia sensitivity training. While the IJ was removed on 12/15/23 at 11:30 AM, the facility remained at a level of actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to protect the residents right to request, refuse, and/or discontinue treatment for one (Resident #1) out of three residents reviewed for advanced directives, in that: The facility failed to honor Resident #1's OOHDNR when she was found unresponsive by LVN A, and CPR was initiated. The deficient practice was determined to be a past non-compliance Immediate Jeopardy (IJ) as the facility had implemented actions that corrected the non-compliance prior to the beginning of the investigation. This deficient practice placed residents at risk of not having their end of life wishes implemented or respected. 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 chronic kidney disease, congestive heart failure, repeated falls, and osteoporosis (a condition that causes bones to become weak and brittle). It further reflected her code status as DNR. Review of Resident #1's OOHDNR, reflected it had been completed and notarized on [DATE]. Review of Resident #1's initial care plan, dated [DATE], reflected she requested a code status of DNR with an intervention of informing staff of code status. Review of Resident #1's physician order, dated [DATE], reflected DNR status. Review of Resident #1's MDS assessment for a significant change in status, dated [DATE], reflected a BIMS of 7, indicating a severe cognitive impairment. Section O (Special Treatments, Procedures, and Programs) reflected she was receiving hospice care. Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 4:50 AM, reflected the following: [LVN A] at nurse's station when a loud commotion was heard coming from down the hall, followed by faint moaning. [LVN A] arrived at [Resident #1]'s room and noted her to be lying prone on the floor next to her bed, but on the right side of her face . [Resident #1] lay motionless for a few seconds, then started moving around . Noted blood starting to ooze out from around [Resident #1]'s head and both legs . [LVN A] decided not to move [Resident #1] to prevent further possible neck injury . As [CNA C and CNA D] arrived at [Resident #1]'s room, [LVN A] left the room to make some phones calls regarding to [Resident #1]'s condition. Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 5:05 AM, reflected the following: [LVN A] placed a call to the on-call triage nurse for (hospice agency) informing them of [Resident #1]'s unwitnessed fall and injuries she sustained .advised her to contact EMS. Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 5:08 AM, reflected the following: [LVN A] called EMS for emergency response and transport . Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 5:14 AM, reflected the following: Upon returning to [Resident #1]'s room, her breathing pattern had changed. She was appearing to be in agonal breathing and her skin color was changing to a dark bluish color. EMS called again to notify them of change in her condition . Dispatcher instructed [LVN A] to do CPR. [LVN A] said [Resident #1] is a DNR . Chest compressions started. Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 5:22 AM, reflected the following that EMS arrived at the facility and asked about her DNR. LVN A left the room to retrieve the form, passing off chest compressions to the EMT's. They continued to work on Resident #1. Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 5:36 AM, reflected the following that she left on a stretcher with EMS to the hospital. Review of Resident #1's EMS documentation, dated [DATE], reflected the following: EMS dispatched to (facility) for [Resident #1] . CPR in progress. Upon entry to [Resident #1]'s room, EMS asked if the nursing staff if [Resident #1] had a DNR. The staff responded with yes and was asked to retrieve the DNR . EMS checked for a pulse and at this time no pulse was present in the carotid location. Due to no present DNR for EMS staff, CPR was continued at this time. Ventilations were performed with a BVM suppled with O2, AED monitor attached, and a 30:2 compression ratio was performed. EMS continued 2 minutes of CPR and at pulse check, no pulse was present. EMS continue compressions and ventilations. The nursing facility staff provided EMS staff with an active DNR. CPR efforts were stopped at this time to honor [Resident #1]'s request. When discontinued, EMS noted agonal respirations. ROSC time: 5:28 AM The hospital records further reflected she was in critical care and given IV fluid (oxygen). Resident #1's FM declined imaging and intubation and requested hospice care. She passed away at the hospital on [DATE]. Review of Resident #1's hospital medical records, dated [DATE], reflected the following: Cardiac Arrest: ROSC obtained after 20 minutes of CPR (at the facility); valid DNR found by (facility) staff after ROSC. During a telephone interview on [DATE] at 3:35 PM, Resident #1's CA stated she was appalled Resident #1's wishes to be a DNR was not respected or honored. She stated Resident #1 was [AGE] years old, on hospice, and she should have not had to go through that. During an interview on [DATE] at 9:56 AM, CNA E stated to determine the code status of a resident, she would look to see what color sticker was on their name plate (red for DNR, green for full code). She stated she had been educated on the process upon hire. During an interview on [DATE] at 10:02 AM, LVN B stated that a resident's code status was easy to determine by looking at the color of the sticker on their name plate by their door. She stated she would absolutely never listen to a 911 Operator, or anyone, for that matter, if they requested she perform CPR on a resident with a DNR. During an interview on [DATE] at 10:08 AM, PTA stated to determine a resident's code status, he look at the color of the sticker on their door but would also verify the status with a nurse. During a telephone interview on [DATE] at 10:15 AM, Resident #1's FM started crying and stated when she was notified that CPR had been initiated at the facility she was horrified. She stated it was awful to watch over her at the hospital for a full day with her just lying there with her mouth open. She stated Resident #1 was diagnosed with a broken shoulder and nose and was told by the ER doctor that they were a result of the CPR. She stated she had called the facility and went off on whoever she talked to. She stated she was told that the nurse (LVN A) would be 'reprimanded', as if that was supposed to make everything okay. She stated neither herself, the rest of the family, or Resident #1 wanted to go out that way. She stated the fact that she (Resident #1) endured what she did at the end of her life made her feel physically ill. During a telephone interview on [DATE] at 10:32 AM, LVN A stated she knew Resident #1 was a DNR because she had a red sticker on her name plate, explaining that a red sticker meant DNR, and a green sticker meant full code. She stated she initially called 911 to request assistance with maneuvering Resident #1, as she had fallen in an awkward position. She stated when Resident #1 started to turn blue and stopped breathing, she called 911 again. LVN A stated the Operator encouraged her to do CPR. She stated the Operator did not know Resident #1 was a DNR and could not explain why she went along with it. She stated when EMS arrived, she told them she was a DNR, and they requested the physical form. She stated by the time she got back with the DNR, she heard an EMT yell, We got her back! This Surveyor asked LVN A why she waited 18 minutes to make the initial call to 911. LVN A stated there had been a similar incident with Resident #1 in the past, and the DON told her she could not call 911 because she was a hospice patient. She stated at that time, she was using that line of reasoning, otherwise she would not have waited that long. She stated she was written up and terminated from the facility. During an interview on [DATE] at 10:43 AM, the DON stated resident CPR statuses were located on their name plates by their door (red for DNR, green for full code), in their EMR, and in a code status book on the crash cart. She stated if a resident was unresponsive, her expectations were that their code status be checked by the nurse and if the resident had a DNR, no interventions such as CPR would be performed. She stated if a resident was on hospice care, and emergency care was needed, 911 should definitely be called. She stated if the resident on hospice care was stable, comfortable, and the nurse was able to provide first aide, EMS may not be necessary. She stated she did not believe there had been a similar situation (mirroring the incident on [DATE]) in the past with Resident #1. She stated she had not been made aware by LVN A that CPR had been performed on Resident #1 until she had already arrived at the hospital. This Surveyor asked the DON if it was normal for a nurse to follow the orders of a 911 Operator. The DON stated it was not, especially because no one could be sure they even had any medical knowledge or background. She stated she believed LVN A just panicked. She stated it was extremely important to follow resident wishes, especially when it came to end of life situations. During an interview on [DATE] at 11:02 AM, the ADM stated she was made aware that CPR was performed on Resident #1 after the DON was notified. She stated her expectations were to follow resident and family wishes on how they want their loved one to be treated and taking care of; it was extremely important to honor their wishes. She stated staff are educated on the red/green sticker (code status) upon hire. She stated the nurse (LVN A) had been terminated from their company. She stated an ad hoc QAPI meeting had been held and in-services were conducted with staff that same day, [DATE]. An attempt was made on [DATE] at 11:22 AM to interview CNA C. A message was left requesting a call back. An attempt was made on [DATE] at 11:26 AM to interview CNA D. A message was left requesting a call back. During an interview on [DATE] at 11:42 AM, the Director of Resident #1's hospice agency stated Resident #1's nurse was out for the day, but she was very familiar with the incident that occurred on [DATE]. She stated it was her expectation was that DNR's were abided by, and it was absolutely unacceptable that CPR had been conducted on Resident #1 for approximately 20 minutes, especially since she was a hospice patient. She stated the most jarring comments in Resident #1's hospice nurse's notes were the following, when she was at the ER: At 6:41 AM, [Resident #1] started showing signs of posturing (an involuntary flexion or extension of the arms and legs, indicating severe brain injury). At 6:56 AM, [Resident #1] being crying out as if she was in pain. At 7:19 AM, [Resident #1] continued to show signs of posturing and crying out. She stated her notes continued in that manner throughout the day on [DATE]. Review of the facility's Ad Hoc QAPI meeting notes, dated [DATE], reflected there was discussion of the system for resident code status and the importance of following resident's wishes at end of life. Review of an in-service conducted on [DATE], titled Resident Code Status, reflected all staff (with signatures) had been educated on the facility's Resident Code Status Order Policy and the following: - Resident code status is in (EMR system) in resident's chart. - Resident code status is in binder placed on crash cart. - Resident code status is located by resident's name on door and can be identified by red or green dot. - Red dot represents DNR (Do Not Resuscitate). - [NAME] dot represents Full Code (Resuscitate). Review of an in-service conducted on [DATE], titled Resident Code Status, reflected all staff (with signatures) had been educated on the facility's Advanced Directives Policy. Review of the facility's undated Do No Resuscitate Order Policy reflected the following: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a DNR in effect. Review of the facility's Advanced Directives Policy, dated 04/2020, reflected the following: e. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident or legal guardian has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatment or methods are to be used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, 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 one (Resident #1) out of four residents reviewed for quality of care, in that: The facility failed to ensure Resident #1 received services according to her care plan and wishes. The deficient practice was determined to be a past non-compliance Immediate Jeopardy (IJ) as the facility had implemented actions that corrected the non-compliance prior to the beginning of the investigation. This deficient practice placed residents at risk of not having their end of life wishes implemented or respected. 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 chronic kidney disease, congestive heart failure, repeated falls, and osteoporosis (a condition that causes bones to become weak and brittle). It further reflected her code status as DNR. Review of Resident #1's OOHDNR, reflected it had been completed and notarized on [DATE]. Review of Resident #1's initial care plan, dated [DATE], reflected she requested a code status of DNR with an intervention of informing staff of code status. Review of Resident #1's physician order, dated [DATE], reflected DNR status. Review of Resident #1's MDS assessment for a significant change in status, dated [DATE], reflected a BIMS of 7, indicating a severe cognitive impairment. Section O (Special Treatments, Procedures, and Programs) reflected she was receiving hospice care. Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 4:50 AM, reflected the following: [LVN A] at nurse's station when a loud commotion was heard coming from down the hall, followed by faint moaning. [LVN A] arrived at [Resident #1]'s room and noted her to be lying prone on the floor next to her bed, but on the right side of her face . [Resident #1] lay motionless for a few seconds, then started moving around . Noted blood starting to ooze out from around [Resident #1]'s head and both legs . [LVN A] decided not to move [Resident #1] to prevent further possible neck injury . As [CNA C and CNA D] arrived at [Resident #1]'s room, [LVN A] left the room to make some phones calls regarding to [Resident #1]'s condition. Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 5:05 AM, reflected the following: [LVN A] placed a call to the on-call triage nurse for (hospice agency) informing them of [Resident #1]'s unwitnessed fall and injuries she sustained .advised her to contact EMS. Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 5:08 AM, reflected the following: [LVN A] called EMS for emergency response and transport . Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 5:14 AM, reflected the following: Upon returning to [Resident #1]'s room, her breathing pattern had changed. She was appearing to be in agonal breathing and her skin color was changing to a dark bluish color. EMS called again to notify them of change in her condition . Dispatcher instructed [LVN A] to do CPR. [LVN A] said [Resident #1] is a DNR . Chest compressions started. Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 5:22 AM, reflected the following that EMS arrived at the facility and asked about her DNR. LVN A left the room to retrieve the form, passing off chest compressions to the EMT's. They continued to work on Resident #1. Review of Resident #1's nursing note documented by LVN A, dated [DATE] at 5:36 AM, reflected the following that she left on a stretcher with EMS to the hospital. Review of Resident #1's EMS documentation, dated [DATE], reflected the following: EMS dispatched to (facility) for [Resident #1] . CPR in progress. Upon entry to [Resident #1]'s room, EMS asked if the nursing staff if [Resident #1] had a DNR. The staff responded with yes and was asked to retrieve the DNR . EMS checked for a pulse and at this time no pulse was present in the carotid location. Due to no present DNR for EMS staff, CPR was continued at this time. Ventilations were performed with a BVM suppled with O2, AED monitor attached, and a 30:2 compression ratio was performed. EMS continued 2 minutes of CPR and at pulse check, no pulse was present. EMS continue compressions and ventilations. The nursing facility staff provided EMS staff with an active DNR. CPR efforts were stopped at this time to honor [Resident #1]'s request. When discontinued, EMS noted agonal respirations. ROSC time: 5:28 AM The hospital records further reflected she was in critical care and given IV fluid (oxygen). Resident #1's FM declined imaging and intubation and requested hospice care. She passed away at the hospital on [DATE]. Review of Resident #1's hospital medical records, dated [DATE], reflected the following: Cardiac Arrest: ROSC obtained after 20 minutes of CPR (at the facility); valid DNR found by (facility) staff after ROSC. During a telephone interview on [DATE] at 3:35 PM, Resident #1's CA stated she was appalled Resident #1's wishes to be a DNR was not respected or honored. She stated Resident #1 was [AGE] years old, on hospice, and she should have not had to go through that. During an interview on [DATE] at 9:56 AM, CNA E stated to determine the code status of a resident, she would look to see what color sticker was on their name plate (red for DNR, green for full code). She stated she had been educated on the process upon hire. During an interview on [DATE] at 10:02 AM, LVN B stated that a resident's code status was easy to determine by looking at the color of the sticker on their name plate by their door. She stated she would absolutely never listen to a 911 Operator, or anyone, for that matter, if they requested she perform CPR on a resident with a DNR. During an interview on [DATE] at 10:08 AM, PTA stated to determine a resident's code status, he look at the color of the sticker on their door but would also verify the status with a nurse. During a telephone interview on [DATE] at 10:15 AM, Resident #1's FM started crying and stated when she was notified that CPR had been initiated at the facility she was horrified. She stated it was awful to watch over her at the hospital for a full day with her just lying there with her mouth open. She stated Resident #1 was diagnosed with a broken shoulder and nose and was told by the ER doctor that they were a result of the CPR. She stated she had called the facility and went off on whoever she talked to. She stated she was told that the nurse (LVN A) would be 'reprimanded', as if that was supposed to make everything okay. She stated neither herself, the rest of the family, or Resident #1 wanted to go out that way. She stated the fact that she (Resident #1) endured what she did at the end of her life made her feel physically ill. During a telephone interview on [DATE] at 10:32 AM, LVN A stated she knew Resident #1 was a DNR because she had a red sticker on her name plate, explaining that a red sticker meant DNR, and a green sticker meant full code. She stated she initially called 911 to request assistance with maneuvering Resident #1, as she had fallen in an awkward position. She stated when Resident #1 started to turn blue and stopped breathing, she called 911 again. LVN A stated the Operator encouraged her to do CPR. She stated the Operator did not know Resident #1 was a DNR and could not explain why she went along with it. She stated when EMS arrived, she told them she was a DNR, and they requested the physical form. She stated by the time she got back with the DNR, she heard an EMT yell, We got her back! This Surveyor asked LVN A why she waited 18 minutes to make the initial call to 911. LVN A stated there had been a similar incident with Resident #1 in the past, and the DON told her she could not call 911 because she was a hospice patient. She stated at that time, she was using that line of reasoning, otherwise she would not have waited that long. She stated she was written up and terminated from the facility. During an interview on [DATE] at 10:43 AM, the DON stated resident CPR statuses were located on their name plates by their door (red for DNR, green for full code), in their EMR, and in a code status book on the crash cart. She stated if a resident was unresponsive, her expectations were that their code status be checked by the nurse and if the resident had a DNR, no interventions such as CPR would be performed. She stated if a resident was on hospice care, and emergency care was needed, 911 should definitely be called. She stated if the resident on hospice care was stable, comfortable, and the nurse was able to provide first aide, EMS may not be necessary. She stated she did not believe there had been a similar situation (mirroring the incident on [DATE]) in the past with Resident #1. She stated she had not been made aware by LVN A that CPR had been performed on Resident #1 until she had already arrived at the hospital. This Surveyor asked the DON if it was normal for a nurse to follow the orders of a 911 Operator. The DON stated it was not, especially because no one could be sure they even had any medical knowledge or background. She stated she believed LVN A just panicked. She stated it was extremely important to follow resident wishes, especially when it came to end of life situations. During an interview on [DATE] at 11:02 AM, the ADM stated she was made aware that CPR was performed on Resident #1 after the DON was notified. She stated her expectations were to follow resident and family wishes on how they want their loved one to be treated and taking care of; it was extremely important to honor their wishes. She stated staff are educated on the red/green sticker (code status) upon hire. She stated the nurse (LVN A) had been terminated from their company. She stated an ad hoc QAPI meeting had been held and in-services were conducted with staff that same day, [DATE]. An attempt was made on [DATE] at 11:22 AM to interview CNA C. A message was left requesting a call back. An attempt was made on [DATE] at 11:26 AM to interview CNA D. A message was left requesting a call back. During an interview on [DATE] at 11:42 AM, the Director of Resident #1's hospice agency stated Resident #1's nurse was out for the day, but she was very familiar with the incident that occurred on [DATE]. She stated it was her expectation was that DNR's were abided by, and it was absolutely unacceptable that CPR had been conducted on Resident #1 for approximately 20 minutes, especially since she was a hospice patient. She stated the most jarring comments in Resident #1's hospice nurse's notes were the following, when she was at the ER: At 6:41 AM, [Resident #1] started showing signs of posturing (an involuntary flexion or extension of the arms and legs, indicating severe brain injury). At 6:56 AM, [Resident #1] being crying out as if she was in pain. At 7:19 AM, [Resident #1] continued to show signs of posturing and crying out. She stated her notes continued in that manner throughout the day on [DATE]. Review of the facility's Ad Hoc QAPI meeting notes, dated [DATE], reflected there was discussion of the system for resident code status and the importance of following resident's wishes at end of life. Review of an in-service conducted on [DATE], titled Resident Code Status, reflected all staff (with signatures) had been educated on the facility's Resident Code Status Order Policy and the following: - Resident code status is in (EMR system) in resident's chart. - Resident code status is in binder placed on crash cart. - Resident code status is located by resident's name on door and can be identified by red or green dot. - Red dot represents DNR (Do Not Resuscitate). - [NAME] dot represents Full Code (Resuscitate). Review of an in-service conducted on [DATE], titled Resident Code Status, reflected all staff (with signatures) had been educated on the facility's Advanced Directives Policy. Review of the facility's undated Do No Resuscitate Order Policy reflected the following: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a DNR in effect. Review of the facility's Advanced Directives Policy, dated 04/2020, reflected the following: e. Do Not Resuscitate - indicates that, in case of respiratory or cardiac failure, the resident or legal guardian has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatment or methods are to be used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents received food in a form to meet their individual needs for 1 (Resident #1) of 7 residents reviewed for food and nutrition services. The facility failed to provide Resident #1 with a mech soft w/ground meat texture diet as ordered by the physician, causing him to choke. This was determined to be a past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. The deficient practice placed residents at risk of receiving incorrect diets, which could leading to choking, hospitalization or death. Findings Included: It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation on 10/24/2022. Facility provided admission Record dated 9-27-22 reflected, Resident #1 is a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 diagnosis is dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and or the throat, resulting from impaired muscle function, sensory changes, or growths and obstructions in the mouth and throat), vascular dementia (problems with reasoning, planning, judgment and other thought processes caused by brain damage from impaired blood flow to the brain), moderate, with mood disturbance, and muscle weakness. Resident #1 was discharged and transferred to another facility on 12-10-22. Record review of Resident #1's Care Plan initial date of 9-28-22 reflected, he was on a regular, mechanical soft with ground texture, regular liquids diet. Serve diet as ordered. Record review of Resident #1's diet order entry dated 09-28-22 and ordered by [NAME] Primary Physician reflected, Resident #1 was on a regular diet, mech soft w/ground meat texture, regular consistency, thin liquid consistency minced and moist ( mech soft with ground meat texture). Record review of Resident #1's physician orders dated 9-28-22 reflected, a start date of 9-28-22 and an open end date for regular diet, mech soft w/ground meat texture, regular consistency, thin liquid consistency . Record review of Resident #1's Significant Change MDS assessment dated [DATE] reflected a BIMS score of 02 and his cognitive abilities were assessed to be severely impaired. His functional assessment reflected he required supervision for eating. Record review of Resident #1's progress note dated 10-24-22/13:01 (1:01pm) reflected at approx. 1215pm this nurse was in the dining room assisting with feeding patients. After giving a bite to another patient at the table this nurse turned to give this patient a bite this nurse noted patient choking. This nurse had therapist and aid help hold the patient up while giving the Heimlich maneuver to patient. After multiple attempts a Brussel sprout finally became dislodged and fell out of the patients mouth. NP informed and new order received for CXray to R/O aspiration. Record review of Resident #1's progress note dated 10-24-22/17:44 (5:44pm) reflected GHC imaging here to complete xray. Pending results at this time. Pt up in WC at this time. Record review of Resident #1's progress note dated 10-25-22/4:35 reflected Chest X-Ray results came back normal. MD notified at 2144 [9:44pm] on 10-24-22. No new orders. During an interview on 12-12-22 at 8:45 AM, the FM stated a call had been received from the facility notifying the FM Resident #1 had choked on a Brussel sprout and the Heimlich maneuver had been applied. The FM stated Resident #1 had been eating soft or pureed foods. During an interview on 12-12-22 at 10:30 AM, the Director of Food Services stated she was responsible for the overall operation of dietary services for the facility. The Director of Food Services stated she had access to PCC and reviewed Resident #1's diet order on a weekly basis, and followed the diet as ordered by the physician. The Director of Food Services stated Resident #1 had his own pre-printed meal ticket which provided the dietary information and included diet consistency. The Director of Food Services stated the cook was responsible for cooking, chopping, and pureeing all foods before placing them on the warming table. The Director of Food Services stated she was the cook on 10-24-22 and the menu called for savory Brussel sprouts which had been cooked to a soft consistency. The Director of Food Services stated she had not chopped the Brussel sprouts for Resident #1 before placing them on the warming table. The Director of Food Services stated the dietary aide was responsible for reading Resident #1's meal ticket and plating the food according to his meal ticket. The Director of Food Services stated the facility nurse was responsible for checking Resident #1's meal ticket against what had been served before giving it to him. The Director of Food Services stated she was notified by the Assistant Director of Clinic Operations that Resident #1 had choked on a Brussel sprout that had been served whole. The Director of Food Services stated she was aware Resident #1 was on a mechanical soft with ground meat texture diet. The Director of Food Services stated she thought she could serve whole Brussel sprouts because they were cooked to a soft consistency. The Director of Food Services stated the printer in her office had not been printing correctly so she looked over the menu/spreadsheet and noticed it had not printed the full menu for the mechanical soft diets because it was out of ink therefore she cooked and served whole Brussel sprouts to Resident #1. The Director of Food Services stated she notified the Administrator, Director of Clinic Operations, and Dietician and informed them of the incident. The Director of Food Services stated as per Resident #1's meal ticket and dietary orders, Brussel sprouts should have been chopped up and she had not chopped them up. Director of Food Services stated after the incident 10-24-22, she began using the main copier located in the conference room. The Director of Food Services stated she is responsible for ensuring all menu/spreadsheets are accurate and complete. The Director of Food Services stated, the cook/dietary aide are responsible for checking meal tickets and food consistency for accuracy and the cook is responsible for ensuring all meals cooked as ordered by the physician/meal ticket. The Director of Food Services stated, the Dietary aide will serve meals as noted on the meal ticket and ensure texture accuracy before handing the off the tray. During an interview on 12-12-22 at 1:05 PM, the Assistant Director of Clinic Operations stated she was working in the dining room on 10-24-22. The Assistant Director of Clinic Operations stated she had taken Resident #1's lunch tray to the table and placed it in front of him and sat between him and another resident that needed feeding assistance. The Assistant Director of Clinic Operations stated when she turned around to feed Resident #1 she saw him gasping for air and immediately called for assistance. The Physical Therapist and dietary aide stood Resident #1 up and held him while she performed the Heimlich maneuver. The Assistant Director of Clinic Operations stated she continued to perform the Heimlich maneuver until the food item was dislodged. The Assistant Director of Clinic Operations stated she stopped performing the Heimlich maneuver when Resident #1 spit out a whole Brussel sprout. The Assistant Director of Clinic Operations stated she then placed a fork in one of the other Brussel sprouts and it was hard to cut through at which time she notified the Director of Food Services who told her a cooked whole Brussel sprout was considered a mechanically soft diet. The Assistant Director of Clinic Operations stated she was responsible for checking Resident #1's meal ticket against what was being served. The Assistant Director of Clinic Operations stated she did not think the cook would have the not prepared the food according to dietary orders. The Assistant Director of Clinic Operations stated she had spoken to the Dietitian who informed her the dietary spreadsheet shows how resident meals are supposed to be prepared and according to the spreadsheet the brusselBrussel sprouts were cooked and served correctly. During an interview on 12-12-22 at 1:24 PM, the Dietitian stated she was responsible for all reviewing all the menu/spreadsheets. The Dietitian stated she was notified of the incident and reviewed the spreadsheet which was correct and the Brussel sprouts for Resident #1 should have been chopped before serving. The Dietitian stated she had spoken to the Director of Food Services and informed her that the menu/spreadsheet must be followed at all times. The dietitian stated the cook is responsible for ensuring all meals cooked as ordered by the physician During an interview on 12-12-22 at 2:40 PM. The Director of Clinic Operations stated she had been notified by the Assistant Director of Clinic Operations that Resident #1 had choked on a Brussel sprout and the Heimlich maneuver was applied. The Director of Clinic Operations stated Resident #1 is on a mechanical soft diet and his food should have been served per his dietary orders. The Director of Clinic Operations stated Resident #1's tray should have been checked for accuracy before placing it in front of him. During an interview on 12-12-22 at 3:20 PM, the Administrator stated she was notified of the choking incident involving Resident #1. The Administrator stated she was told Resident #1 had choked on a Brussel sprout and the Assistant Director of Clinic Operations performed the Heimlich maneuver until it came out. The Administrator stated she was not aware of any special orders for chopping Brussel sprouts. The Administrator stated the nurse was responsible for checking the meal ticket against what was being served to Resident #1. The Administrator stated the Assistant Director of Clinic Operations was responsible for checking the meal ticket on 10-24-22 against what was being served to Resident #1. Record review for Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7 reflected all had orders for mechanical soft with ground meat texture diets. Observation on 12-12-22 at 4:45 PM revealed the kitchen printer being removed from the kitchen office after notifying the Administrator that it was not working. On 12-12-22 at 5:00 PM, a dinner meal was observed. Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7 had been served a mechanical soft with ground meat texture diet. The meal consisted of chopped pizza, finely chopped Caesar salad, brownie, milk 2%, tea, water. On 12-12-22 at 5:32 PM, the dietary aide stated she was responsible for plating the lunch trays and the cooking dinner meal. The Dietary aide stated the cook is responsible for cooking, chopping and preparing all food before placing it on the warming table. The Dietary aide stated she did not remember the choking incident and does not remember how the Brussel sprouts were cooked and served on 10-24-22. The Dietary aide stated she uses the menu/spreadsheet as a guide on what food to cook, how to prepare the food and how the food should be served. The Dietary aide stated she checked the spreadsheet to verify what meals have to be ground or pureed. The Dietary aide stated she looks at the meal ticket and serves the food according to the meal ticket and hands the plate to an aide. The Dietary aide stated the nurse is responsible for checking the meal tickets against the trays before sending them out to the residents. During an interview on 12-12-22 at 5:45 PM, the Director of Food Services stated Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7 had been served cooked whole Brussel sprouts on 10-24-22. The Director of Food Services stated she did not chop their Brussel sprouts before placing them on the warming table. During an interview on 12-13-22 at 8:46 AM, the Medical Director stated that Resident #1 choking could have caused the following harm: esophageal obstruction (malformation in which the esophagus is interrupted and forms a blind-ending pouch rather than connecting normally to the stomach) due to a foreign body if it had been swallowed, retained secretions that could have come up the esophagus that could have caused aspiration (when something enters your airway or lungs), nausea and vomiting because of the obstruction, possible aspiration of vomitus (matter that has been vomited), Boerhaave's tear (rupture of the esophagus caused by tremendous stress), closed airway or death. The Medical Director stated all staff should be familiar with resident's dietary orders and should follow them. Record review of facility Food and Nutrition Services policy (revised October 2017) reflected, The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. The food and nutrition staff will be available and adequately staffed to assist residents with eating as needed. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. Record review of dietary staff inservice dated 1-20-22 and 4-26-22 given by Director of Food Services reflected the following topics: Following recipes and spread sheets, reading resident tickets daily. Record review of dietary staff inservice dated 9-7-22 given by Director of Food Services reflected the following topics: Everyone held accountable (job description), Reading tickets and knowing residents likes and dislikes, cooking what menu says. The facility took the following actions to correct the non-compliance on 10/24/2022. In an interview on 12-12-22 at 1:05 PM the Assistant Director of Clinic Operations stated that nursing staff had been inserviced on 10-24-22 and the topic was Assessing Resident's Tray During Mealtime. Topics covered in the inservice included: Nurse will assess each tray for accuracy of order and safety. Staff will not pass tray until tray has been assessed by the nurse, nurse to remain in the dining room trough entirety of meal while residents are eating. The Assistant Director of Clinic Operations stated she was responsible for checking Resident #1's meal tray against the meal ticket for accuracy. During an interview on 12-13-22 at 12:40 PM, the Administrator stated all staff had been inserviced 10/24/2022 on dietary expectations after the choking incident. Staff not present were notified via text that the inservice was to be completed prior to working their next shift. She said the Director of Food Services was responsible for reviewing the menu/spreadsheet for accuracy and would ensure all physician orders were followed. She said the Nurse would be responsible for checking all meal trays before serving it to the residents. The Administrator stated she was not aware the printer in the kitchen was not printing and the ink had not been replaced. The Administrator stated that she was not aware that the menu had not been printed correctly. The Administrator stated the kitchen printer would be removed immediately and the Director of Food Services would print all menu/spreadsheet from the main printer located in the conference room. The Administrator stated that she instructed the Director of Food Services to continue using the main printer which was located in the conference room. The Administrator stated the main printer had plenty of ink and it was checked on a daily basis by herself or the Business Office Manager and if out it would be replaced. The Administrator stated when on duty the Assistant Director of Operations was responsible for checking all meal trays before serving it to the residents. The Administrator stated the weekend nurse would be responsible for checking all meal trays before serving the tray to the resident and ensure accuracy. Observation on 12-13-22 at 12:45 PM revealed 10 ink cartridges that will be used to replace the ink in the main printer as needed. During an interview on 12-13-22 at 1:23 PM, the Director of Clinic Operations stated all staff had been retrained 10/24/2022, after the choking incident. She said the Director of Food Services was responsible for ensuring menu/spreadsheets are accurate, the cook and dietary aide checked meal tickets/dietary order, food consistency before passing off the tray, and the nurse was the final person who checked the meal ticket against what was being served before giving it to the residents. The Director of Clinic Operations stated verbal communication was used when there was a change in the resident's dietary order and staff have been informed to review PCC for any changes. The Director of Clinic Operations stated when on duty the Assistant Director of Clinic Operations was responsible for checking all meal trays for accuracy. Record review of nursing and dietary staff inservice dated 10-24-22 given by Director of Clinic Operations reflected, Topic-Assessing Resident's Tray During Mealtime, Nurses will assess each tray for accuracy of order and safety, staff will not pass tray until tray has been assessed by the nurse, staff will be present in the dining room for meal pass promptly before the start of meal, Nurse to remain in dining room through entirety of meal while residents are eating. In-service reflected the names, signature and department of the nursing and CNA staff who attended the in-service.