**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for 1 of 8 residents (Resident #1) reviewed for accident hazards and supervision.The facility failed to supervise and put measures in place to keep Resident #1 from eloping on 6/13/25.The facility failed to complete Resident #1's quarterly elopement risk assessment due after 12/27/25. Resident #1's elopement risk assessment was not completed until 06/13/25, after she had eloped from the facility.The noncompliance was identified as PNC. The IJ began on 06/13/25 and ended on 06/17/25. The facility had corrected the noncompliance before the survey began. These failures could place the residents at risk for serious injury, serious harm, serious impairment, or death. Findings included:Record review of Resident #1's face sheet, undated, indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses including schizophrenia (is a serious mental health condition that affects how people think, feel and behave), bipolar disorder (is a mental health condition that causes extreme shifts in mood, energy, and activity levels, impacting a person's ability to carry out daily tasks), generalized anxiety disorder (is a mental health condition characterized by excessive, uncontrollable, and often irrational worry about everyday things), intermittent explosive disorder (is a mental health condition characterized by sudden, impulsive, and disproportionate outbursts of anger or violence), autistic disorder (is a condition related to brain development that affects how people see others and socialize with them), tremor, and right ear hearing loss. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was usually understood and usually had the ability to understand others. Resident #1 had adequate hearing, clear speech, and impaired vision with corrective lenses. Resident #1 had a BIMS score of 09 which indicated moderate cognitive impairment. Resident #1 did not display wandering behaviors. Resident #1 used a walker and wheelchair as mobility devices. Resident #1 required supervision to walk 10 feet and 50 feet with two turns. Resident #1 required substantial assistance to walk 150 feet. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was usually understood and usually had the ability to understand others. Resident #1 had adequate hearing, clear speech, and impaired vision with corrective lenses. Resident #1 had a BIMS score of 11 which indicated moderate cognitive impairment. Resident #1 displayed wandering behaviors 1 to 3 days during the assessment period. Resident #1 used a walker and wheelchair as mobility devices. Resident #1 required supervision to walk 10 feet and 50 feet with two turns. Resident #1 required partial assistance to walk 150 feet. Record review of Resident #1's care plan dated 10/20/24, edited on 06/29/25 indicated:*Resident #1 had intermittent explosive disorder, Schizophrenia, bipolar disorder and anxiety which could affect her mood. Interventions included encourage to report any concerns or needs, assess, monitor, and document mood, and reassure and listen to concerns. *Resident #1 had cognitive deficits and mental disability with childlike responses, poor cognition, delayed response, concentration and attention difficulties, Autism, and speech impediment. Resident #1 had hearing loss in her right ear. Resident #1 had risk for communication deficits. Interventions included allow time when speaking to process thoughts and speck directly to resident in a clear voice facing her. Record review of Resident #1's care plan dated 06/13/25, edited on 06/29/25 indicated:*Resident #1 was at risk for elopement as evidenced by attempt to leave the facility on 06/12/25. Interventions included frequent monitoring and checks throughout the night to ensure safety and roam bracelet will be always worn.*Resident #1 was at risk for wandering due to attempt to exit seek. Resident #1 wore a roam alert bracelet. Intervention included an elopement assessment done on admission, as needed, and with significant change of condition and staff will monitor and report change in exit seeking behaviors. Record review of Resident #1's assessment for risk of elopement dated 12/27/24, completed by LVN A, indicated Resident #1 was not at risk for elopement at this time. Record review of Resident #1's medical records did not reflect an assessment for risk for elopement due 90 days or quarterly from the 12/27/24 assessment for risk of elopement. Record review of Resident #1's assessment for risk of elopement dated 6/13/25, completed by ADON G, indicated Resident #1 was likely at risk for elopement due to resident being ambulatory yet cognitively impaired with poor decision-making skills. Resident #1 was at risk for elopement. Resident #1 had the following intervention implemented of Wander guard ( is bracelet with triggering alarms and locking monitored doors to prevent wander-prone residents from leaving unattended) with informed consent of responsible party and updated care plan on 6/13/25. Record review of Resident #1's Event Report dated 06/13/25 at 12:48 a.m., completed by ADON G, indicated Resident #1 attempted exit seeking approximately 12:18 a.m. Resident #1 was found sitting near a road in the ditch. Resident #1 head to toe assessment did not reveal any injuries. Resident #1 exhibited the following behaviors prior to elopement: resisting redirection from staff, verbalizing statements about leaving, and stated she wanted to go to a group home and social service was working on placement prior to incident. Resident #1 had exhibited a change in mental status of new onset of agitation, resistiveness, and restlessness. Resident #1 stated she could do what she wanted to do. Resident #1 had possible contributing diagnoses to the safety event. Resident #1 had experienced absence of personal contact with family/friends. Resident #1 exhibited depressed, sad or anxious mood but was easily altered. Resident #1 had falls and attention seeking behaviors. Resident #1 had a new medication added at night. Resident #1 had door alarm band applied. Record review of Resident #1's Progress Notes dated 6/13/25, completed by LVN D, indicated .patient [Resident #1] had walked outside down to road and sat down on side of road.a woman came and told us that a lady was sitting on side of road, there was a walker and she was concerned.this sn [LVN D] and CNA K went to get patient [Resident #1], she was agitated and refused to get up and said she would do what she wanted to do.she [Resident #1] finally agreed to get up if she could have her vape.patient [Resident #1] finally got up with minimal assistance and walked back in to n/h with walker and nurse [LVN D] and CNA [K] at side.she [Resident #1] return outside to vape on front porch with supervision.head to toe assessment completed, no apparent injuries. Record review of Resident #1's Progress Notes dated 06/13/25 at 1:03 a.m., revised at 1:22 p.m., completed by ADON G, indicated .Resident [#1] was found attempting to elope from the facility shortly after a reported fall.when approached, resident [Resident #1] states she was upset because she wanted to vape and proceeded to exit the building without staff permission.staff made multiple attempts to redirect resident [Resident #1] back inside approximately 10 minutes, during which time the resident was verbally resistant and refused to comply.after continued encouragement and redirection, the resident [Resident #1] agreed to sit on front porch with CNA J sitting with her at this time.this nurse [ADON G] notified resident's responsible party regarding the incident.RP was in agreement for placement of a Wanderguard for safety and care plan updated to reflect elopement risk.Resident [#1] refused to allow wanderguard placement and stated that if I attempted to place it on her that she would rip it off and that I am not gonna put it on her.RP and MD O notified. Record review of CNA K's witness statement dated 6/13/25 indicated, .at approximately 12:15 a.m., a lady came to the facility and said a resident was walking by the stop sign and was worried about her.LVN D and I [CNA K] went out the door and saw [Resident #1] sitting on the ground at the corner.she [Resident #1] refused to get up and said she ‘was leaving' until the nurse agreed to give let her vape.once LVN D agreed, [Resident #1] got up and quickly walked back to the building and sat on the porch.[ ADON G] got here and after [LVN D] had smoked on her vape, she [Resident #1] agreed to come back in the building but stayed in the lobby the rest of the night.this is the first time I've seen [Resident #1] act like that. Record review of CNA J's witness statement dated 6/13/25 indicated, .about 11:00 p.m. [Resident #1] was going to her room to go to bed.at about 12, she [Resident #1] she had her call light on and I [CNA J] went to answer it and observed [Resident #1] on the floor.she [Resident #1] was crying complaining her hip was hurting.I [CNA J] got the nurse [LVN D] who assessed her [Resident #1], we got her up off the floor and we put her back in bed and she was complaining about the head of her bed being up and was being really pouty.a few minutes later she [Resident #1] came to the nurse's station and asked to vape. the nurse [LVN D] told her she couldn't vape right now, that she had just fallen and said she was hurt.the nurse [LVN D] told her that she needed to go back and lay down.[Resident #1] said, ‘I'm not hurt, I'm a grown woman and I want to vape.' LVN D told her again that she needed to go back to her room.Resident #1 said, ‘Do you want me to come get my vape myself?' and the nurse [LVN D] said no, you need to go back and lay down.[Resident #1] said, ‘I'm leaving' and went outside to sit on the porch.Resident #1 had mentioned earlier in the week that she was moving to a group home so that's what I [CNA J] thought she was talking about when she said, ‘I'm leaving.'.[Resident #1] never tried to leave the building and likes to sit outside on the front porch.approximately 15 minutes later a lady came and said a resident was in the road with her walker.[CNA K] and [LVN D] went outside to see who it was.I [CNA J] stayed in the facility with the other residents, and they came back with [Resident #1] about 5-10 minutes later.I [CNA J] then went outside on the porch with {Resident #1] so she could vape.[ADON G] came after that and got [Resident #1] to come inside and sit in the lobby.I've never seen [Resident #1] act like this before. Record review of ADON G, undated statement indicated, .this nurse [ADON G] received a call around 1218 ish from charge nurse [LVN D] that a lady came to facility and reported a lady was sitting in ditch with walker at roadside and almost hit her and was concerned.she [LVN D] and [CNA K] were at roadside attempting to get resident [Resident #1] to come inside facility and was refusing.this nurse [ ADON G] spoke with resident [Resident #1] and she stated that she did not want to go inside and she did not have to.this nurse [ADON G] discussed with the resident [Resident #1] of the safety issues and concerns and told her that I was on my way to the facility.[LVN D] reported back that resident [Resident #1] agreed to go back if she could vape.stated that she [Resident #1] got up without difficulties, took her walker and walked quickly to facility.upon arriving to facility at 1241am the resident [Resident #1] was sitting on front porch with CNA K vaping.she [Resident #1] was agitated and stated that she wanted to go [local city] to group home. Record review of PIR started on 6/13/25, completed on 6/19/25 by the ADM, indicated a missing resident/individual incident occurred on 6/13/25 at 12:30 a.m. The incident occurred in front of the building and involved Resident #1. Resident #1 was noted to be outside on the corner of two local streets with her walker. Resident #1 had no injuries noted. The investigation summary indicated, .Resident #1 reported fall in room at approximately 11:45 p.m. on 6/12/25.no injuries noted at time nut Resident #1 complained of pain.staff encourage resident [Resident #1] to rest in bed.Resident #1 came to nurses station approximately 5 minutes later wanting to vape and became upset when she was advised she could not vape per the smoking schedule, no one available to monitor her and staff concerned due to recent fall.staff encouraged resident [Resident #1] to rest and monitor condition, however, Resident #1 stated she was leaving and proceeded to exit the building to sit on the front porch, which is a permitted area.approximately 5-10 minutes later, a passerby observed Resident #1 walking with her walker near the end of the building on the corner.passerby alerted staff who directed Resident #1 back to facility.Resident #1 had been verbalizing her plans to move to a group home so when she said she was leaving, they thought she was talking about moving to the group home.staff noted she had been sitting on the front porch 5-10 minutes which was typical behavior for her and other residents and had never attempted to wander off.Resident #1 did not have wanderguard at the time based on her elopement assessment and no history of elopement or wandering behavior.unconfirmed. During an observation on 7/14/25 at 9:15 a.m., the facility's front door was locked. Two residents were outside on the porch and instructed the surveyor to ring a bell. A doorbell was located on the wall and a keypad was also noted. The surveyor was admitted entrance by staff at the front desk. Two keypads were noted on the inside of building near the door. During an observation on 7/14/25 starting at 11:22 a.m., Hall 100-600 doors and side door near the kitchen area had red box alarm lights noted on the keypads. All the doors red box alarms were in the on position. A resident with a wanderguard was near the front door and the alarm sounded. Staff responded to the alarm and redirected the resident. During an observation and interview on 7/14/25 at 1:32 p.m., Resident #1 was sitting in a wheelchair with a wanderguard on her left wrist. Resident #1 had a speech impediment but was understood. Resident #1 was hesitant and appeared nervous when asked about the elopement on 6/13/25. She said she did not remember getting out of the facility last month (June 2025). She said she did not know why she had the bracelet on her wrist. She said the ADM put the bracelet on her wrist. She said the ADM did not want her to go by the front door alone. She said someone was coming on the 27th of July to help her get in a group home. On 7/14/25 at 2:06 p.m., attempted to contact LVN D by phone. Contact was unsuccessful and a message left with callback phone number. On 7/14/25 at 2:11 p.m., attempted to contact CNA J by phone. Contact was unsuccessful and a message left with callback phone number. On 7/14/25 at 2:12 p.m., attempted to contact CNA K by phone. Contact was unsuccessful and a message left with callback phone number. During an interview on 7/14/25 at 2:16 p.m., ADON G said it was reported to her that Resident #1 had a fall then wanted to vape. She said LVN D asked Resident #1 to wait to vape and to stay to be assessed from the earlier fall. She said she did not know if Resident #1 had smoked at the last smoke break at 10 pm. She said the front door was not locked on 6/13/25. She said about a week prior to the elopement, Resident #1 had mentioned leaving. She said when Resident #1 was talking about leaving, it was to a group home in [nearby city]. She said the DON was on vacation and unavailable for an interview. During an interview on 7/14/25 at 2:57 p.m., CNA K said prior to the incident, the residents that vaped could smoke anytime. She said the residents could vape even at 12am and 1am. She said she was in the breakroom on 6/13/25 but overheard the conversation between LVN D and Resident #1. She said Resident #1 wanted to vape but LVN D told her to wait because she just had a fall. She said LVN D told Resident #1 to go to her room and put her feet up. She said Resident #1 refused to lay down. She said the front door was locked so she did not know how Resident #1 got out. She said she did not hear any alarms go off when she was in the breakroom. She said 10-15 minutes later, she heard someone knocking on the facility's front door. She said when she got to the door, a lady said she had almost hit someone. She said when they found Resident #1, she was at the [nearest two streets], in the ditch. She said Resident #1 had refused to get up. She said Resident #1 would only get up after they agreed to let her vape. She said Resident #1 got up by herself. She said she had heard from other employees that Resident #1 had threatened to leave, prior to getting out. She said Resident #1 had never told her she wanted to leave the facility. She said Resident #1 had never misbehaved before the incident on 6/13/25. She said after the incident on 6/13/25, she knew not to take the statements of leaving as a joke. She said if a resident mentioned leaving, she needed to report it to the charge nurse and act. She said if it was not taken seriously, then a resident could get out. During an interview on 7/14/25 at 3:56 p.m., CNA J said she took the smokers to their smoke break at 10 p.m. She said Resident #1 was one of the residents. She said Resident #1 had smoked a cigarette not vaped. She said during the smoke break, Resident #1 said, I'm leaving, She said she replied, Oh, really. Where are you going? She said Resident #1 said, I'm going to [a nearby city]. She said she did not think much of it and brought the residents back in from the smoke break. She said not too long after coming in from the smoke break, she heard Resident #1 ask LVN D for her vape. She said LVN D told Resident #1 she needed to rest her feet. She said LVN D told Resident #1 someone would take her later. She said Resident #1 was not happy and told LVN D, That's why I'm leaving this place!' She said Resident #1 did not go back to her room but went to the lobby in front of the nurses' station and sat down. She said she started answering call lights after that. She said when she last saw Resident #1 in the lobby, LVN D was at the nurses' station. She said she then heard someone beating on the front door. She said a lady told them she was driving by and almost hit Resident #1. She said no one knew when or how Resident #1 got out of the facility. She said the facility's front door was not locked at that time. She said Resident #1 said she left because she wanted to vape. She said she knew not to assume what a resident meant when they said, I'm leaving. She said she knew to report what the resident said to the charge nurse. She said she knew to monitor the resident and not let them leave the building. She said the resident could get hurt if they left the building. During an interview on 7/14/25 at 4:10 p.m., the ADM said before the incident on 6/13/25, the front door only alarmed when the resident with a wanderguard got too close to the door. She said the front door was not locked before the incident on 6/13/25. She said sometimes the staff locked the door after 10pm to the outside but not the inside. She said Resident #1 could have easily got out on 6/13/25 because she did not have on a wanderguard. She said Resident #1 had mentioned going to a group home earlier in the week. She said Resident #1 had made false abuse allegation on a male resident (6/9/25). She said Resident #1 reported she lied because she wanted to go to a group home. She said the facility informed Resident #1's PASRR representative of her request the next day (6/10/25). She said the facility's last smoke break was at 10 pm. She said before the incident, the night shift staff were letting the few residents that vaped, go out anytime. She said that was why Resident #1 felt like she could ask to vape at 12am. She said the resident's elopement assessment were done quarterly and with a change of condition. She said she expected the nursing staff to do the scheduled risk assessments. She said she wished the staff had taken Resident #1's leaving' statements seriously. She said she wished the staff had not let Resident #1 go outside to sit on the porch. She said a staff member had reported seeing Resident #1 sitting on the porch for 10 minutes on 6/13/25. She said Resident #1 was known to sit on the front porch unsupervised prior to the incident. She said a resident sitting on the front porch, unsupervised at 12 am was not a safe idea. Record review of a facility's Wandering and Elopements policy revised 4/22/2025 reflected, .the facility will ensure that residents who exhibit wandering behaviors and/or at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care.residents will be assessed by the IDT for risk of elopement and unsafe wandering on admission, readmission, quarterly, and/or with a change of condition (e.g., increased agitation, changes in mobility, wandering). Record review of a facility's Change in a Resident's Condition or Status policy revised 4/20/23 and reviewed 6/2025 reflected, .our facility promptly notifies the resident, his or her attending physician, healthcare provider and the resident representative of changes in the resident's medical/mental condition and/or status. Record review of a facility conducted in-service, Wandering and Elopement dated 6/13/25 reflected provider and non-provider staff members were provided education on the topic. Record review of a facility conducted in-service, Emergency Procedure-Missing Residents dated 6/13/25 reflected provider and non-provider staff members were provided education on the topic. Record review of a facility conducted in-service, Abuse, Neglect and Exploitation dated 6/13/25 reflected provider and non-provider staff members were provided education on the topic. Record review of facility conducted in-service, Smoking Policy dated 6/13/25 reflected all smoking residents were provided education on the topic. Record review of a facility conducted in-service, Resident Change in Condition dated 6/17/25 reflected provider and non-provider staff members were provided education on the topic. Record review of a facility's smoking policy dated August 2019 indicated .this facility shall establish and maintain safe resident smoking practices .for the purpose of the policy, smoking and smoking materials included but not limited to; cigarettes, cigars, pipes, chewing tobacco, electronic cigarettes and vaporizers .all residents shall have the direct supervision of a staff member while smoking . The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy on (6/17/25) by:- Conducted observation on 7/14/25 at 9:15 a.m., of door lock project completed on 6/17/25. The facility's front door was locked. A doorbell was located on the wall and a keypad was also noted. Two keypads were noted on the inside of building near the door. - Conducted observation on 7/14/25 starting at 11:22 a.m., of all the facility's Halls (100-600 and side door) door alarms were armed. - Conducted observation on 7/14/25 at 1:32 p.m., of Resident #1 with wanderguard on left wrist.- Reviewed completed facility self-reported incident to HHSC for Resident #1 dated 6/13/25. - Reviewed Resident #1's care plan on 7/14/25 which reflected updated care area of elopement risk and incident on 6/13/25.- Reviewed Resident #1's medical record on 7/14/25 which reflected an elopement risk assessment was completed on 6/13/25. Resident #1 was at risk for elopement with intervention in place. - Reviewed resident roster dated 6/13/25 at 1:00 a.m. with validated head count after incident, completed by ADON G. All residents were accounted for.- Reviewed incident reported dated 6/13/25 reflected Resident #1 did not have injuries noted, MD O and Resident #1's RP were notified of the incident. - Reviewed all (7) residents with wanderguards, progress notes dated 6/13/25 which reflected a function test was completed and wander guard functioning properly. Staff members noted location of wanderguards placement.- Reviewed of a facility's Missing Resident Drill-AM shift in-service and sign-in sheet dated 6/13/25 reflected 23 staff members attended the drill. - Reviewed of a facility's Missing Resident Drill-PM shift in-service and sign-in sheet dated 6/13/25 reflected 7 staff members attended the drill. - Record review of a Record of Drills dated 6/13/25 at 12:15 p.m., for 6am-2pm shift reflected adequate response of personnel for missing residents. All departments responded appropriately. Drill conducted by ADM. - Record review of a Record of Drills dated 6/13/25 at 3:38 p.m., for 2pm-10pm shift reflected adequate response of personnel for missing residents. All departments responded appropriately. Drill conducted by DON. - Record review of a Record of Drills dated 6/13/25 at 10:30 p.m., for 10pm-6am shift reflected adequate response of personnel for missing residents. All departments responded appropriately. Drill conducted by DON. - Record review of an Ad Hoc QAPI- Elopement meeting dated 6/13/25 reflected the MD O attended by phone, ADM, DON, ADON P, and ADON G were in attendance. - Record review of a safe survey on resident who sat on the front porch unsupervised dated 6/16/25-6/17/25 reflected 13 residents understood to never leave the facility grounds. - Reviewed in-service and sign in sheet on Wandering and Elopement for all staff which indicated the following:*dated 6/13/25 reflected 51 employees were provided education on the topic. - Reviewed in-service and sign in sheet on Emergency Procedure-Missing Residents for all staff which indicated the following: *dated 6/13/25 reflected 51 employees were provided education on the topic.- Reviewed in-service and sign in sheet on Abuse, Neglect, and Exploitation for all staff which indicated the following:*dated 6/13/25 reflected 51 employees were provided education on the topic.- Reviewed in-service and sign in sheet on Smoking Policy for all smoking residents which indicated the following:*dated 6/13/25 reflected 13 residents were provided education on the topic.- Reviewed in-service and sign in sheet on Resident Change in Condition for all staff which indicated the following:*dated 6/17/25 reflected 46 employees were provided education on the topic.- Reviewed the facility's Change in a Resident's Condition or Status policy was reviewed on 6/2025. - Reviewed all current residents with wander guards and a random sample of other residents' elopement risk assessments on 7/15/25. All residents reviewed had elopement risk assessments completed on 6/13/25.- Reviewed Elopement Binder for accuracy on 7/15/25. All (8) resident's pictures were current with consents noted. - Reviewed logbook documentation for Door, Locks, Gates, and Alarms dated 6/11/25 and 7/9/25 reflected pass for Hall 1-6 exit doors, dining room exit door, entrance door, and service door exit. - Reviewed of a Record of Drills dated 7/10/25 were completed for all three shifts by ADON G. No issue noted.During an interview conducted on 7/14/25 starting at 11:36 a.m., Resident #2, Resident #3, and Resident #4 verbalized understanding of not leaving the facility property without supervision or authorization. On 7/15/25 at 9:59 a.m., attempted to contact Resident #1' RP by phone. Contact was unsuccessful and a message left with callback phone number. No return call received prior or after exit. During interviews conducted on 7/15/25 starting at 11:33 a.m., CNA N (6a-2p), CNA H (6a-2p & 2p-10p), CNA M (6a-2p), LVN A (6a-6p), LVN E (6a-6p), LVN C (6p-6a), CNA L (10pm-6am), CNA K (10pm-6am), HSK/Laundry Manager, Maintenance Supervisor, CNA F (2p-10p), MA B (6a-2p & 2p-10p), LVN D (6p-6a), ADON G, and CNA J (10p-6a) were provided in-service education on abuse, neglect, and exploitation, emergency procedure-missing resident, wandering and elopement, resident's change in condition, and smoking policy. The staff also participated in missing resident drills. The staff were able to give examples of the different types of abuse to include neglect, identify the abuse coordinator, and verbalize abuse or neglect should be reported immediately. The staff were able to verbalize policy and procedure for elopement and identified residents at risk. The staff were able to verbalize interventions that could be used to prevent elopement for residents at risk. The staff verbalize the front door was to be always locked. The staff verbalize understanding of identifying a resident's change in behavior that could place them at risk for elopement. The staff verbalize the smoking policy rules which included adequate supervision and following the smoking schedule. The staff verbalized honoring the resident's rights as much as while keeping them safe. During an interview on 7/15/25 at 12:36 p.m., LVN A said if a resident started talking about leaving the facility, they needed to be monitored. She said if the resident continued talking about it then a consent for a wander guard needed to be obtained. She said it was important to take what the resident said seriously. She said when a resident became agitated, the staff should try to redirect them. She said if the agitation and exit seeking behavior was new, then it needed to be reported immediately. She said when a resident was not taken seriously, they could exit and harm themselves and others. She said elopement was when a resident left the facility unsupervised or without staff knowledge. She said the elopement risk assessments were done on admission, quarterly, and with a change of condition. She said the nurses were responsible for the assessments. She said the assessments should be done on schedule to keep everything updated. She said the resident's condition changed frequently. She said when the elopement risk assessments were not done, a resident could get out without supervision. She said the resident could hurt themselves and others. During an interview on 7/15/25 at 2:07 p.m., LVN E said an elopement was when a resident left the facility unsupervised or without staff knowledge. She said the elopement risk assessments were done on admission, quarterly, and with a change of condition. She said the nurses were responsible for completing the assessments. She said the assessment needed to be done to identify who was most likely to elope. She said when the assessments were not done it increased the risk of a resident slipping through the cracks and missing who was a wander risk. During an interview on 7/15/25 at 3:45 p.m., MA B said an elopement was when a resident left the facility unsupervised or without staff knowledge. She said if a resident started displaying exit seeking behaviors, she would report it to the charge nurse immediately. She said if a resident started making statements of leaving or wanting to go somewhere, she would also report it. She said the statements may or may not be serious. She said the resident needed to be monitored until it was determined how serious the resident was. She said if the resident was not taken seriously, it could be considered neglect and the resident could elope. She said if the resident eloped, they could get hurt. She said when Resident #1 eloped, Resident #1 said she was going to [a nearby city] to get a vape. During an interview on 7/15/25 at 4:09 p.m., LVN D said Resident #1 had a fall late on 6/12/25. She said the staff had to pick Resident #1 off the floor and she was complaining of pain. She said 10-15 minutes after the fall, Resident #1 walked to the nurses' station wanting to vape. She said she told Resident #1 to lay down and rest awhile since she just had a fall. She said Resident #1 got upset and went to the lobby near the nurses' station. She said she did not know when Resident #1 exited the facility. She said she was going back and forth from the nurses

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide basic life support, including CPR to a resident requiring emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the residents advanced directives for 1 of 4 residents reviewed for emergency care ( Resident #1) The facility failed to assess and immediately initiate CPR when Resident #1, who was a full code, was found unresponsive in the dining room on 08/11/24 at 7:10 a.m. CPR was not initiated until EMS arrived (12 minutes after the resident was found unresponsive). Resident #1 was transported to the hospital, found to have large amounts of solid food in his airway, and pronounced deceased on [DATE] at 9:18 a.m. An Immediate Jeopardy (IJ) was identified on 08/15/24. The IJ template was provided to the facility on [DATE] at 6:10 p.m. While the IJ was removed on 08/16/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for not receiving immediate emergency services (CPR) and death. Findings included: Review of Resident #1's face sheet with undated indicated he was a [AGE] year-old male initially admitted to the facility on [DATE] and his last readmission date was 4/9/24. Some of his diagnoses were stroke, cognitive communication deficit, and seizure disorder. Record review of quarterly MDS dated [DATE] indicated Resident #1's cognitive status was severely impaired with a BIMS score of 5. He required substantial to maximal assist with eating, and oral hygiene. He was dependent for all other ADLs. Record review of Resident #1's care plan dated 7/17/24 indicated the following care areas: *At risk for choking related to seizure disorder requiring medications problem start date of 5/11/23 and last edited on 8/2/24 . The approaches were to monitor the resident frequently throughout the shift following seizure activity. To assess the resident after seizures, the time, length, level of consciousness, activity, and respiratory activity if a seizure occurred. *A mechanical soft diet due to a history of stroke with residual effects and contractors to bilateral hands problem start date of 10/11/22 . The approaches may have clothes protector during meals if desired, ensure a bedside table was provided in the ding area with meals for easy reach. Report problems to charge nurse such as choking or difficulty chewing. Someone to assist with feeding on days he had difficult feeding himself. *An advance directive problem start date of 10/11/22 and last edited 7/10/24. The approach was full code. Record review of Resident #1's computerized physician orders indicated the following: *dated 4/9/24 for Full Code Status. *dated 4/24/24 for regular diet, mechanical soft with thin fluids. Record review of an EMS report dated 8/11/24 indicated at 7:16 a.m. dispatch received a call. The EMS were in route at 7:17 a.m. and arrived on the scene at 7:20 a.m. The report indicated they were at the patient at 7:22 a.m. and departed the scene at 7:30 a.m. The report indicated they were at the hospital at 7:37 a.m. The report indicated the Resident's primary impression was cardiac arrest with a reported-on set of 7:10 a.m. and a duration of 12 minutes. The report indicated on arrival on the scene they asked for directions to the patient, and the nursing staff pointed to a resident sitting in a wheelchair. The nurse who gave report stated he had breakfast at about 6:30 a.m. and when she approached him at 7:10 a.m. he was not responsive. There was no CPR initiated prior to EMS arrival. At 7:22 a.m. initial contact with the resident showed he was unresponsive, pulseless, and warm to touch. Record review of hospital records dated 8/11/24 indicated Resident #1 arrived at 7:38 a.m. with a diagnosis of Cardiac arrest with pulseless electrical activity. Resident #1's airway was assessed per guided scope and found to have large amounts of solid food throughout visible airway. The food products were noted in King airway( a tube used for intubation for advanced airway management) as well. Attempts to clear the airway via mechanical and suction removal. EMS stated the patient was sitting in a wheelchair at the nurse's station unresponsive with no CPR in progress when they arrived. The patent had just eaten breakfast. The exact down time is unknown. We were unable to replace the laryngeal mask airway ( LMA a medical device that keeps a patient's air way open while they are unconscious) due to the amount of food in his trachea. (Windpipe ). The patient was pulseless from the time of arrival to the time the MD pronounced him deceased . Compressions were stopped at 8:45 a.m. and he was pronounced by the physician at 9:18 a.m. as deceased . Record review of Resident #1's nursing note dated 8/11/24 with a time of 7:50 a.m. but was created on 8/11/24 at 3:41 p.m. indicated, Resident #1 was up in his Geri-chair in the dining room for breakfast between 6:30 a.m. and 7:00 a.m. He was sitting up joking with the other residents in his usual manner. He consumed about 90 percent of his meal which consisted of oatmeal, eggs, and a biscuit. Kitchen Stall D, Kitchen Staff E and LVN B remained in the dining area while this nurse (LVN A) assisted another resident to his room. When nurse returned to the dining area Kitchen Staff D was loudly calling Resident #1's name and tapping him. The nurse performed a sternum rub and he did not respond. He had a significant history of seizures, hypoglycemia, and cardiac arrest. The nurse asked Kitchen Staff D to get LVN B and call 911 for help. LVN B called 911 and came to assist this nurse. The nurse proceeded to check the code status( to determine If he was a do not resuscitate or to perform CPR) and gather items needed to assess the resident while LVN B pushed the resident to the nursing station. Resident #1 was a Full Code( indicated the resident wished for the facility to provide every possible effort to save his life in a medical emergency including CPR). The nurse was unable to get vitals or arose the resident per verbal or tactile stimulation. EMS arrived and initiated CPR. The note indicated the responsible party was notified at 7:19 of the transfer to the hospital. and another entity was notified at 7:18 a.m. The note was written by LVN A. Record review of a nursing note dated 8/11/24 at 9:20 a.m. indicated the facility contacted the family for a report on Resident #1 and as informed the resident had expired. Record review of a timeline provided by the facility on 8/15/24 at 3:40 p.m. by the administrator undated indicated on 8/11/24 between 6:30 a.m. and 7:00 a.m. breakfast was served. LVN A was located in the dining room until 6:50 a.m. when she left to walk a resident back to his room and check on another resident. LVN B was in the dining room until approximately 7:00 a.m. and then gathered smokers to take them out to smoke. At 6:50 a.m. Kitchen Staff D and Kitchen Staff Kitchen Staff were eating their breakfast in the dining room. At 7:10 a.m. smokers came back inside, and Resident #1 appeared to be sleeping. Kitchen staff D went to Resident #1 to take him to the lobby and could not get him to respond. Staff loudly called his name, and LVN A overheard Kitchen Staff D talking to Resident #1 and walked into the dining room. At 7: 14 a.m. LVN A told LVN B to call 911. LVN B dial 911 and handed the phone to CNA C. Then LVN B returned to the dining room with LVN A. LVN A went to the nurse's station to verify Resident #1's code status and get things to check Resident #1's vitals. LVN B then pushed Resident #1 to the nurse's station after she was unable to get vital signs and he did not respond to a sternal rub. EMS arrived at approximately 7:20 a.m. and left the facility at approximately 7:28 a.m. with CPR in progress. Verbal statements from the staff indicated CNA C said she was asked by LVN B to speak with 911 between 7:10 a.m. and 7:14 a.m. During interviews Kitchen Staff D and Kitchen Staff E said between 6:30 a.m. and 7:00 a.m. they served breakfast. They said that LVN A was in the dining room sitting with residents. They said that LVN B took the smokers out to smoke between 7:00 a.m. and 7:10 a.m. Kitchen Staff D said she went over to Resident #1 to push him to the lobby to help nurses out like she always did while Kitchen Staff E went back into the kitchen. Kitchen Staff D said she could not arouse Resident #1. She said she called his name loudly and LVN A came in the dining room. LVN A said she asked Kitchen Staff D to get LVN B and to call 911. LVN A said EMS arrived at approximately 7:15 a.m. to 7:20 a.m. Resident #2 said Resident #1 was sitting up and talking and joking like he always did. She said she went out with the smokers at 7:00 a.m. for smoke break. She said when she returned from smoking Resident #1 appeared to be sleeping. She said Kitchen Staff D was standing with him, calling his name, and shaking him and LVN A came into the dining room. There was no signature on the typed note. During an interview on 8/14/24 at 4:50 p.m. a concerned citizen said the facility failed to put life saving measures in place to prevent Resident #1 from dying. They said on 8/11/24 at about 7:30 a.m. EMS arrived, and a full code resident was sitting in a chair, with nurses standing around not performing CPR. They said EMS was informed by a nurse Resident #1 had been unresponsive since 7:10 a.m. They said Resident #1 was still in the chair and facility staff did not perform CPR to try and save the resident's life. During an interview on 8/15/24 at 7:47 a.m. the Dietary Manager said she worked 8/11/24 as a CNA. She said she heard Kitchen Staff D calling for LVN A. She said Kitchen Staff D told her Resident #1's lips were blue when she approached him. The Dietary Manager said the two kitchen aides that worked on 8/11/24 Kitchen Staff D and Kitchen Staff E She said when she walked up front on the morning of 8/11/24 someone had brought Resident #1 up to the front and CNA C was on the phone with 911. She said LVN B had the Resident #1 in the Geri-chair and LVN A was behind the nurse's station. During an interview on 8/15/24 at 7:55 a.m. LVN A said Resident #1 was found in the dining room unconscious. She said she was headed back to the dining room when she heard Kitchen Aide D screaming and calling her name. She said when she went into the dining room Resident #1 was unresponsive, she shook him, did a sternal rub, and did not get a response. LVN A said she asked Kitchen Staff D to get LVN B. She said LVN B called 911. LVN A said she did not notice Resident #1's color or take his pulse. When LVN B arrived, she went to check his code status she did not want to initiate CPR if he was a DNR. She said they did not call for the crash cart. While she was at the nurse's station about 2 minutes, LVN B brought Resident #1 up to the nurse's station. She said just about that time EMS walked in the facility. EMS took Resident #1 out of his chair, put him on the gurney, and initiated CPR. LVN A said Resident #1 was a Full Code. She said Resident #1 did not require assistance with eating, but he had a mechanical soft meat. She said he was sitting at the table by himself with a tray table sit up just for him. She said Breakfast stated about 6:30 a.m. and she left about 6:50 a.m. to go and assist another resident to his room. She said Resident #1 had a history of heart attacks. She said he was in a Geri chair, and she checked the status by looking in her book at the nurse's station. She said the crash cart was located on hall 3, but she never sent for it. She said LVN B checked Resident #1's pulse. LVN A said when EMS arrived it was 4 or 5 EMS workers, and they asked when the last time Resident #1 was responsive. She said she told them it was about 7:10 a.m. She said she was behind the nurse's station when EMS arrived and LVN B handed Resident #1 off to EMS. LVN A said she called the ADON/RN on the way to the nurse's station to let her know what was going on. LVN A said she had been a nurse for less than a year, Resident #1 was her first medical emergency. She said ADON/RN had educated them on doing CPR no matter what. LVN A said she was not sure of the exact time frame because everything appeared to go so fast, but it was at least 5 minutes maybe 10 minutes form the time she saw the resident in the dining room until EMS arrived. During an interview on 8/15/24 at 8:15 a.m. the Administrator said they had completed a timeline regarding Resident #1. They had investigated the incident and taken statements from staff. She said their investigation did not determine any abuse or neglect, so they had not called the incident into the state. She said they had tried to get hospital records but were unable to do so. She said the EMS company was right down the road less than 5 minutes from the facility and they arrived almost immediately after being called. During an interview and observation on 8/15/24 at 8:17 a.m. LVN B said on 8/11/24 most residents had finished eating and had left the dining room or been taken to their rooms. She said LVN A left the dining room to take a resident back to his room. She said around 7:00 a.m. there were only two residents left in the ding room, Resident #1, and Resident #2. LVN B said at about 7:00 a.m. someone wanted her to take them out to smoke. She said when she walked outside Resident #1 was drinking his coffee. She said he had a little food on his plate. LVN B said when she came back inside after about 10 minutes, she did not really look at Resident #1. She said she had one resident to push inside, and she had the cigarette box. She said she was at the nurse's station, and she heard Kitchen Staff D yelling for her. LVN B said as she was on her way, she heard LVN A and heard both say come here. She said LVN A called for her, heard her say call 911. LVN B said she called 911 and had CNA C to hold the phone with EMS. She said when she arrived in the dining room Resident # 1 was laid back in his Geri chair, she did see a blue [NAME] to his lips. She said LVN A went to get blood pressure cup and pulse ox. LVN B said she did a sternal rub, she checked Resident #1's pulse at his wrist and neck, and he did not have a pulse. She said she was probably with the resident about 2 minutes after LVN A left. She said LVN A did not return. She said she did not initiate CPR. LVN B said she took Resident #1 to the nurse's station in his Geri chair. LVN B pointed out where the resident was in the dining room which was close to the exit door for the smokers. Observations and interview indicated it was about 100 feet across the dining room to the door and about 5 to 7 feet from the door to the nurse's station. LVN B said the whole process took 5 to 6 minutes. She said no one got the crash cart and she did not request the cart. She said when she got Resident #1 to the nurse's station EMS arrived. LVN B said EMS pulled Resident #1 out of the chair put on gurney and started doing compression right there in the hallway. She said EMS did not ask her any questions, they asked LVN A for a face sheet. LVN B said at school she was taught you did not start CPR until after you verified code status. She said she had been a nurse since January 2024, and this was her first job. She had done CPR but only on a dummy, and Resident #1 was her first code. LVN B said she was in serviced after the incident on 8/11/24 by ADON/RN who said you start CPR first and then check the code status. During an interview on 8/15/24 at 8:28 a.m. LVN A said she noted Resident #1's color was off, she did not note anything about his lips being discolored. During an interview on 8/15/24 at 8:30 a.m., ADON/RN said she came to the facility on 8/11/24 after the Resident #1 was taken to the hospital. She said she got a call from LVN A on 8/11/24. She said her telephone log indicated that call was received at 7:18 a.m. and she was on the phone about two minutes with LVN A. She said when she arrived at the facility, she did in services on emergency procedures and providing CPR. ADON/ RN said she could not say that anyone did anything wrong she just felt that the staff needed education. During an interview on 8/15/24 at 9:00 a.m. CNA C said she worked at the facility for 20 years, and was at the facility on 8/11/24. She said she was coming the hall brings something to the dining room. She said she heard Kitchen Staff D yell for LVN A to come to the dining room and run. CNA C said when she made it to the nurse's station LVN B was running to nurse station to call 911. She said LVN B gave the phone to her and told her what to tell dispatch. She said LVN B said they had a resident that was unresponsive, and he was in the dining room. CNA C said while she was still on the phone LVN A came to the Nurses station to see if Resident #1 was full code or DNR. She said LVN A looked on the computer. CNA C said LVN A was on her cell phone talking to ADON/RN. She said she did not know how long LVN A was at the nurse's station, she turned her back while still on the phone with EMS dispatch. She said LVN B brought Resident #1 to the nurse's station still in the Geri chair. CNA C said LVN B asked her to take him to his room while she was still on the phone. CNA C said when Resident #1 was brought to the nurse's station she did not see his color, and no one asked her to get the crash cart. She said after calling EMS they arrived about 5 minutes later. CNA C said it might have been 10 minutes form the time of Kitchen Staff D was screaming to EMS got to the facility. CNA C said LVN A was behind the nurse's station at that point. She said when EMS arrived, LVN B pointed to Resident #1 in the Geri chair. CNA C said EMS asked a few questions, they put Resident #1 on the stretcher, and initiated CPR. She said she did not write a statement; she did not see anyone taking vitals. During an interview and observation on 8/15/24 at 11:05 a.m. LVN A revealed a book at the nurse's station. Observation of the book showed a couple of pages dated 8/14/24 with full code residents on the first page and DNR residents on the second page. LVN A said they just updated the list yesterday and that was the book she used to determine if Resident #1 was a full code. She said she did not know how long she remained at the nurse's station after checking but before she could get back to the dining room, LVN B had brought Resident #1 to the nursing station. LVN A said just about that time EMS walked in. She said that she had not taken Resident #1's pulse or checked his mouth to see if there was any food or blockage. During an interview and observation on 8/15/24 at 11:07 a.m. with the ADON/LVN . The crash cart was located on hall 6 in a storage room. The cart had all the required supplies and on the crash cart was a list of Resident and their code status. The ADON/LVN said the list has always been on the crash cart. The ADON said the AED was located on the wall behind the nurse's station. Observation of the AED showed it was on the wall with the pads right beside it. Also, a battery check of the AED showed it was in working order. During an interview on 8/11/24 at 11:25 a.m. Resident #2 said she was in the dining room on the morning of 8/11/24. She said Resident #1 was his usually joking self. She said they went out to smoke about 7:00 a.m. and he asked for another cup of coffee right before they left. Resident #2 said when they came back inside about 10-15 minutes later, Resident #1 was sitting in his chair and appeared to be asleep. Resident #2 said she spoke to Resident #1, but he did not speak back. She said it looked like he ate all his food, and sometimes he chokes when he eats, and he made noises in his throat when he ate. She said Kitchen Staff D went over to him and she could not get him to awaken so she started screaming. She said LVN A and LVN B came running. She heard them say something about code status, and they could not find a pulse. She said after a few minutes they took him out of the dining room. During a telephone interview on 8/11/24 at 11:43 a.m. Kitchen Staff D said that she and Kitchen Staff E were in the kitchen with the door closed. She said around 6:50 a.m. they went out to eat their breakfast in the dining room. She said when they first went into the dining room LVN B was there but had gone to get the smoking box for the residents. Then she took them out to smoke. Resident #1 was sitting at the table, and he looked like he was sleeping. She had gone to take him out of the dining room, she said she normally helped the aides get some of the residents out. She said when she had gone over, she could not get Resident #1 to respond, and his color was off. She called his name several times and she guessed LVN A heard her, she did not remember calling her name. Kitchen Staff D said the nurse came and told her to get LVN B. She said LVN B called 911. She did not know what happened after that she said it was 2 or three minutes and they had him up front and she knew the paramedics came and she went back into the kitchen. During a telephone interview on 8/11/24 at 11:50 a.m. Kitchen Staff E said she and Kitchen Staff D came out of the kitchen around 6:50 a.m. when they arrived in the dining room LVN A got up to take a resident back to their room. She said LVN B went to take the residents out to smoke. She said the whole time they ate their breakfast Resident # 1 appeared asleep. She said she left to go back in the kitchen at about 7:10 a.m. when she finished eating and Kitchen Staff D went to take Resident #1 out of the dining room. Kitchen Staff E said she did not hear any commotion and was only aware of the situation when Kitchen Staff D came back into the kitchen. During an interview on 8/15/24 at 2:22 p.m. the Administrator and ADON/RN were informed of the concerns about the resident choking and no CPR being provided prior to EMS arrival. They said that EMS company was right down the street, and it did not take them long to arrive at the facility, about 5 minutes. The Administrator said staff acted appropriately, they called 911. The staff did what they were supposed to do. During an interview on 8/15/24 at 2:55 p.m. LVN B said she did not look in Resident #1's mouth. She said when they went out to smoke, he had a little food on his plate. She said there was a spoon or two of oatmeal and a small piece of biscuit. She did not look at his plate when they returned, or the plate may have been removed. She said the resident did cough on occasion when he ate but she had never seen him choke. During an interview on 8/15/24 at 3:00 p.m. CNA C said Resident #1 coughed a lot it did not matter if he was eating or not. Sometimes he did cough when he was eating and cleared his throat quite a bit. She said he had done that for a long time, and it was nothing new. During an interview on 8/15/24 at 3:05 p.m. p.m. CNA F said Resident #1 had a deep cough that would startle you. She said he did cough when he ate occasionally. During an interview on 8/15/24 at 3:10 p.m. LVN A said she did not look in Resident #1's mouth on the morning of 8/11/24. She had gone to get the supplies to complete his vitals. She had told EMS he had been unresponsive 5 to 10 minutes before they arrived. During a telephone interview on 8/15/24 at 3:15 p.m. with the DON and ADON/RN, LVN A and the Administrator was present. The DON said the nurses saw Resident #1 unresponsive and tried to arise him. She said LVN A went to the nurse's station to get supplies. She said the resident had a history of seizures and she likely thought he had a seizure. The DON said she stood behind her staff, the resident was unresponsive, and they called 911. She said that was what they were supposed to do, EMS arrived in about 5 minutes, and they did not have time to initiate CPR. The DON asked LVN A what she thought might have happened with Resident #1. LVN A said she did not know what she thought. LVN A said she was going back to the dining room to check Resident #1's blood sugars because she had not had time to do so prior to breakfast. She said when she found Resident #1 unresponsive, she did not check his blood sugar either. LVN A said it was her first code ever, and her first emergency. She said Resident #1 did have a change in the tone of his skin. She said his skin was usually a light brown but was more of a whiter tone. During an interview on 8/15/24 at 3:40 p.m. the DON and the Administrator said Resident #1 could have had a seizure. The Administrator said they called 911 and EMS at the facility within 6 minutes. The DON said the nurse did a sternal rub, and that was the first part of an assessment, and then they called 911. The Administrator said their timeline correlated with EMS. During an interview on 8/15/24 at 4:45 p.m. the ADON/RN said the book that contacted the codes had always been at the nurse's station with code status and the code status were always on the crash cart. They update them every Monday and put them in the book and on the cart. During an interview on 8/1524 at 5:31 p.m. ADON/RN said regarding care plan Resident #1 wanted to be more independent and they allowed him to do so by feeding himself. When he first came to the facility he could hardly move or do anything for himself, but he gotten better. She said he did have days when he required assistance with eating. During a telephone interview on 8/19/24 at 4:05 p.m. an EMS worker said they were notified by dispatch on the morning of 8/11/24 there was a resident at the facility in cardiac arrest. The worker said the dispatch said Resident #1 was in the dining room. The EMS worker said when they arrived it was four of them that entered the facility at 7:22 a.m. and were directed to a resident sitting beside the nurse's station in a laid-back chair. They were told this was the resident in distress. The EMS worker said an assessment of Resident #1 showed him to be pulseless and they removed him from the chair and began CPR. He said the nurse told him at 7:10 a.m. Resident #1 was unresponsive. The EMS worker said there had never been a time when they had gone to a facility and nurses were just standing around not providing CPR to a resident in need. The worker said there were at least two people behind the nurse's station and one holding on to Resident #1's chair. The EMS worker said it was over 10 minutes and no CPR was being performed. The EMS worker said when they got the resident to the hospital, they found food in his airway. The facility staff said he had just eaten breakfast but gave no indication he could have choked. Record review of in service dated 8/11/24 was provided to the investigator on 8/15/24 at 8:30 a.m. indicated staff were educated on Emergency Procedure policy. Record review of facility emergency procedure/cardiopulmonary resuscitation policy last revised, June 2019. [The policy statement indicated personnel have completed training on the initiation of CPR and basic life support, including defibrillation, for victims of sudden cardiac arrest. The chances of surviving a sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. The delivery of shock with the defibrillator plus CPR within 3 to 5 minutes of collapse can further increase chances of survival. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or physicians order not to administer CPR. Emergency procedures indicated if an individual is found unresponsive, briefly check for abnormal or absence of breathing. If sudden cardiac arrest is likely begin CPR. Staff member to activate the emergency response system code and dial 911. Instructed staff member to retrieve the automatic external defibrillator. Verify or instruct the staff member to verify the DNR or code status of the individual. Initiate the basic life support sequence of events, continuous CPR and basic life support until emergency medical personnel arrive.] The Administrator and were notified on 08/15/24 at 6:10 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 08/15/24 at 6:10 p.m. and a Plan of Removal was requested. The facility's Plan of Removal was accepted on 08/16/24 at 12:40 p.m. and included: [Plan of Removal: 678: Cardio-Pulmonary Resuscitation (CPR) The facility failed to fully monitor the Resident #1 while he was eating to prevent possible choking. The resident was found unresponsive by a dietary staff. The facility failed to immediately assess the resident or check for a pulse, when finding him unresponsive. They failed to initiate CPR within the first 6 to 16 minutes of finding Resident #1 unresponsive. They failed to follow the facility policy on CPR. 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #1 was noted as unresponsive in the dining room, 911 called, EMTs initiated CPR (not the facility), resident left the home with EMTs in the same condition as noted in the dining room (unresponsive). Resident #1 was later pronounced as deceased outside the nursing home. Person(s) Responsible: Charge Nurse Date: 8/11/2024 2. How the Facility Identified Other Possibly Effected Residents: Action: Completed a DNR and Full Code audit: Reviewed Physician orders, vs the face sheet, vs the care plan, vs the Out of Hospital DNR (if applicable) to ensure all are matching and correct. Person(s) Responsible: Director of Clinical Operations, Clinical Resource Nurse, and/or Designee Date: 8/15/2024 Action: Audit staff CPR cards to ensure proper number of certified employees present each shift. Person(s) Responsible: Human Resources, Administrator, and/or Designee Date: 8/15/2024 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Ensured the crash cart has an updated list of full code and DNR residents. Person(s) Responsible: Administrator and/or Designee Date: 8/15/2024 Action: The facility will be updating their CPR policy to take out: If the resident's DNR status is unclear, CPR will be initiated per the below procedure until it is determined that there is a DNR or a physician's order not to administer CPR. The facility will be updating their CPR policy to now reflect: If the staff assigned to check the resident's code status is unable to verify if the resident is a Full Code or DNR, CPR will be initiated, per the procedure lined out below, until it is determined that there is a DNR in place, a physician's order to stop CPR, and/or the Emergency Medical Technician/Paramedics take control of the event. Person(s) Responsible: Chief Nursing Officer Date: 8/16/2024 Action: Administrator and Director of Nursing educated regarding the Emergency Management Code Procedure Policy and meal supervision expectations by the Director of Regulatory Compliance and meal service supervision (training the trainer). All Nurses educated regarding Emergency Management Code Procedure Policy (Updated on 8/16/2024) to include the following, in which would be the response in an emergency situation for a full code resident requiring CPR: 1. If an individual is found unresponsive, the nurse to first arrive to the resident will briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: The first responding nurse will- Instruct a staff member to activate the emergency response system (code) and call 911. The first responding nurse will- Instruct a staff member to retrieve the automatic external defibrillator. The first responding nurse will- Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). 3. Chest compressions: Following initial assessment, begin CPR with chest compressions. Push[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 10 residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to prevent LVN A, on 12/10/23, from verbally and physically abusing Resident #1 when she used foul language and threw ice at Resident #1. The facility failed to prevent LVN A, on or about 12/10/23, from verbally and physically abusing Resident #2 when she used foul language and threw an object at Resident #2. The noncompliance was identified as PNC. The IJ began on 12/10/2023 and ended on 12/15/2023. The facility had corrected the noncompliance before the survey began. These failures could place resident at risk for emotional distress, fear, decreased quality of life and further abuse. Findings included: 1.Record review of Resident #1's face sheet, dated 07/08/24, indicated Resident #1 was a [AGE] year-old, male admitted to the facility on [DATE] and discharged on 02/21/24 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), mood affective disorder (is any of a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature), and mild cognitive impairment (is the stage between the expected decline in memory and thinking that happens with age and the more serious decline of dementia). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was sometimes understood and sometimes had the ability to understand others. Resident #1 had minimal difficult hearing, clear speech, and adequate vision. Resident #1 had a BIMS score of 03 which indicated severe cognitive impairment. Resident #1 required supervision for ADL assistance except for shower/bathe self which required maximal assistance. Record review of Resident #1's care plan dated 04/19/23 indicated Resident #1 was at risk for altered psychosocial well-being related to dementia. Intervention included listen carefully and be non-judgmental. Record review of a PIR for Resident #1, dated 12/11/23, indicated .on 12/10/23 at 3:00 p.m .LVN A used foul language and threw ice at a resident .LVN A denied .Cook B and Dietary Aide C reported to me [ADM], that they were standing at the nurses station and witnessed resident [Resident #1] come up to the nurses station and LVN A told him to 'stop fucking looking at me and go on' and threw a piece of ice at him .MA D stated that she heard LVN A say 'stop fucking looking at me and go on' but she did not see her throw ice at him [Resident #1] .LVN A was questioned about it, she denied saying anything to him but stated she and Resident #1 were playing and throwing ice at each other .the administrator visited Resident #1 who did not remember any incident .staff interviews indicated that many staff have witnessed LVN A speak rudely or harshly to the residents and often curse or speaks inappropriately to the staff .Resident safe surveys did not indicate any concerns with LVN A .physician and RP for Resident #1 notified of the incident .investigation findings: unconfirmed .Provider action taken post-investigation: staff reeducated on Abuse and Neglect Prevention and reporting, Professionalism, and Resident Rights .5 random staff interviews and resident safe surveys will be conducted monthly and results will be reviewed by QAPI committee monthly for 3 months . 2. Record review of Resident #2's face sheet, dated 07/08/24, indicated Resident #2 was a [AGE] year-old, male admitted on [DATE] and discharge 06/19/24 with diagnoses including anxiety disorder (persistent and excessive worry that interferes with daily activities), Type 2 diabetes (s a chronic condition that happens when you have persistently high blood sugar levels), nicotine dependence, schizoaffective disorder, bipolar type (is a chronic mental health condition characterized primarily by symptoms of schizophrenia (is a serious mental health condition that affects how people think, feel and behave), such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), and restlessness and agitation. Record review of Resident #2's annual MDS assessment dated [DATE], indicated Resident #2 was usually understood and usually understood others. Resident #2 had moderate difficulty hearing, clear speech, and impaired vision with use of corrective lenses. Resident #2 had a BIMS of 09, which indicated moderate cognitive impairment. Resident #2 required set up assistance for eating, dressing, and personal hygiene, supervision assistance for oral and toilet hygiene and partial assistance for shower/bathe self. Record review of Resident #2's care plan dated 06/12/23, indicated: *Resident #2 was at risk for altered psychosocial well-being related to schizoaffective disorder. Intervention included listen carefully and be non-judgmental. *Resident #2 was at risk for altered mood state related to schizoaffective disorder. Resident #2 pace the halls frequently, visit multiple staff members, frequently in/out of office. Resident #2 am easily agitated, yell loudly, make threatening statements to staff and/or residents. Intervention included be reassuring and listen to concerns. During an interview on 07/09/24 at 9:29 a.m., CNA E said she had worked at the facility for 20 years. She said she had witnessed LVN A being loud and heard LVN A used inappropriate language at residents. She said LVN A would escalate situations with Resident #2. She said she heard LVN A had cussed at Resident #1 and Resident #2. She said she did not work the day of LVN A and Resident #1 incident. She said cussing and throwing things at resident was abuse. She said LVN A talked ugly, and, in a way, she would not want her family members spoken to. She said after LVN A and Resident #2 would get into, Resident #2 would talk aloud to himself and stated he did not like LVN A. During an interview on 07/09/24 at 10:52 a.m., MA D said she worked for the facility for 2 years. She said she worked the day LVN A cussed at Resident #1. She said Resident #1 said or did something at the nursing station where LVN A was sitting. She said LVN A threw ice at Resident #1 and used the F word towards him. She said Resident #1 liked to touch people and grab drinks so maybe he did something to set her off. She said Resident #1 was walking away from LVN A and she threw ice at him. She said LVN behavior was abusive and inappropriate. She said Resident #2 was at the nursing station and was asking LVN A to take him out to smoke. She said LVN A and Resident #2 exchanged words because she did not take him out. She said LVN A had made a sign on a posted note that said, get the fuck away or go away, leave me alone and would put it up when Resident #2 came to the nurses' station. She said about the second time Resident #2 came to the nurses' station, LVN A cussed at him and threw the posted note at him. She said Resident #2 walked away and was upset. She said another staff member took him out to smoke. She said this incident happened around the same time of Resident #1's incident. She said LVN A escalate situation especially with Resident #2. She said using foul language at resident was abusive. During an interview on 07/09/24 at 11:15 a.m., the ADM said the incident with LVN A and Resident #1 happened on a Sunday. She said on Monday, [NAME] B and DA C told her Resident #1 walked up to the nurses' station and LVN A cussed at him and threw something at him. She said LVN A may have also called him a wierdo. She said [NAME] B and DA C said the situation bothered them, so they reported it, the next day. She said LVN A denied the event happened. She said she believed the incident with LVN A and Resident #2 happened the same day as Resident #1's incident with LVN A. She said she recalled being told LVN A held up a sign at Resident #2 but did not remember anything else about foul language being used between them. On 07/09/24 at 1:10 p.m., called LVN A and left message. LVN A did not return call before or after exit. During an interview on 07/09/24 at 1:45 p.m., [NAME] B said Resident #1 was at the nurses' station and LVN A told Resident #1 go the fuck away and threw ice at him. She said Resident #1 did say anything because he was not very verbal, but he was visibly upset by his facial expression. She said Resident #1 walked away from the nurses' station away from LVN A. She said she considered what LVN A did to Resident #1 was verbal abuse. During an interview on 07/09/24 at 4:15 p.m., DA C said LVN A threw ice and said get the fuck away from me to Resident #1. She said Resident #1 looked upset like anyone else would if they got ice thrown at them. During an interview on 07/10/24 at 11:50 a.m., the ADM said she recalled MA D telling her LVN A was on a roll that day and LVN A had a sign telling Resident #2 to go away. She said LVN A egged Resident #2 on all the time. She said if LVN A threw something at Resident #2, she was surprised Resident #2 did not attack LVN A. She said maybe she misinterpreted the situation when MA D told her about LVN A and Resident #2. She said maybe she thought MA D was talking about LVN A and Resident #1's incident. She said she was the abuse coordinator, and it was her responsibility to investigate and report allegations of abuse to the State. Record review of LVN A's annual training dated 06/01/23 indicated training on subjects of resident rights and abuse and neglect. Record review of a facility conducted in-service, Abuse Prevention Program dated 12/11/23 reflected all employees were provided education of the topic. Record review of a facility conducted in-service, Reporting Allegations of Abuse, Neglect, and Exploitation dated 12/11/23 reflected all employees were provided education of the topic. Record review of a facility conducted in-service, Resident Rights dated 12/11/23 reflected all employees were provided education of the topic. Record review of 13 resident safe surveys dated 12/12/23-12/14/23 indicated no resident had a staff member curse at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. Record review of 29 staff interviews dated 12/12/23-12/14/23 indicated some staff members witnessed LVN A said or did something inappropriate to a resident, they did know what the resident rights were, knew who was considered a mandated reporter, knew who to report abuse to, and was comfortable reporting abuse. Record review of LVN A's Employee Corrective Action Form dated 12/15/23, indicated .type of action: termination .Category I Offense, inappropriate conduct towards a resident .Code of Conduct, Attitude, and Behavior- Policy Violation .Employees are expected and required to be kind, and considerate of residents, visitors, and other facility personnel. Any behavior that is deemed offensive or unsafe. Using profanity, abusive, or suggestive language, or gestures .date of violation 12/10/23 .incident: on, December 11, 2023, it was reported that LVN A used abusive language towards a resident, in which, led to the throwing of a solid object towards the resident .after speaking with all parties involved, we have confirmed these actions .LVN A has received several in-services regarding abuse and neglect among residents, in which, LVN A understands the appropriate conduct when managing residents .consequences: due to category I offense, LVN A will be subjective to immediate termination of employment .employee's comments: the ADM and DON attempted to call LVN A multiple times on 12/15/23 and left message to return call. LVN A texted and stated, 'if I'm fired just let me know so I can find another job'. This ADM responded with 'after we concluded the investigation and spoke to HR, we've decided to terminate your employment.' LVN A did not respond .DON 12/15/23 .ADM 12/15/23 . Record review of LVN A's Notice of Termination dated 12/18/23, indicated .LVN A .termination date 12/18/23 .reason of termination: abusive language toward resident .is employee eligible for rehire: No . Record review of LVN A's personnel file indicated hire date of 10/18/22. The facility had performed background check and employee misconduct search. No concerns were identified. Record review of a facility's Abuse Prevention policy revised 01/09/23 indicated .our residents have the right to be free from abuse, neglect .this includes but is not limited to .verbal, mental, sexual, or physical abuse . The administrator was notified of PNC IJ on 07/09/2024 at 4:40 p.m. due to the above failures. The administrator was provided with the IJ template on 07/09/2024 at 4:45 p.m. The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy on (12/15/23) by: - Reviewed completed facility self-reported incident to HHSC for Resident #1 which indicated the following: * dated 12/11/23, indicated .on 12/10/23 at 3:00 p.m .LVN A used foul language and threw ice at a resident .LVN A denied .Cook B and Dietary Aide C reported to me [ADM], that they were standing at the nurses station and witnessed resident [Resident #1] come up to the nurses station and LVN A told him to 'stop fucking looking at me and go on' and threw a piece of ice at him .MA D stated that she heard LVN A say 'stop fucking looking at me and go on' but she did not see her throw ice at him [Resident #1] .LVN A was questioned about it, she denied saying anything to him but stated she and Resident #1 were playing and throwing ice at each other .the administrator visited Resident #1 who did not remember any incident .staff interviews indicated that many staff have witnessed LVN A speak rudely or harshly to the residents and often curse or speaks inappropriately to the staff . - Reviewed paperwork indicating LVN A was suspended until completion of investigation which indicated the following: * dated 12/15/23, indicated .type of action: termination .Category I Offense, inappropriate conduct towards a resident .Code of Conduct, Attitude, and Behavior- Policy Violation .Employees are expected and required to be kind, and considerate of residents, visitors, and other facility personnel. Any behavior that is deemed offensive or unsafe. Using profanity, abusive, or suggestive language, or gestures .date of violation 12/10/23 .incident: on, December 11, 2023, it was reported that LVN A used abusive language towards a resident, in which, led to the throwing of a solid object towards the resident .after speaking with all parties involved, we have confirmed these actions .LVN A has received several in-services regarding abuse and neglect among residents, in which, LVN A understands the appropriate conduct when managing residents .consequences: due to category I offense, LVN A will be subjective to immediate termination of employment .employee's comments: the ADM and DON attempted to call LVN A multiple times on 12/15/23 and left message to return call. LVN A texted and stated, 'if I'm fired just let me know so I can find another job'. This ADM responded with 'after we concluded the investigation and spoke to HR, we've decided to terminate your employment.' LVN A did not respond .DON 12/15/23 .ADM 12/15/23 . - Reviewed termination paperwork for LVN A which indicated the following: *dated 12/18/23, indicated .LVN A .termination date 12/18/23 .reason of termination: abusive language toward resident .is employee eligible for rehire: No . - Reviewed LVN A's time sheet to verify last day worked which indicated the following: * dated 12/01/23-12/31/23, indicated LVN A last day worked was 12/10/23 - Reviewed employee corrective action form for [NAME] B, DA C and MA D which indicated the following: *dated 12/11/23, indicated .Employee Corrective Action Form for [NAME] B C .verbal coaching .facility policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur .Cook B .ADM . * dated 12/11/23, indicated .Employee Corrective Action Form for DA C .verbal coaching .facility policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur .DA C .ADM . * dated 12/11/23, indicated .Employee Corrective Action Form for MA D .verbal coaching .facility policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur . - Reviewed in-service and sign in sheet on Abuse Prevention for all staff which indicated the following: * dated 12/11/23 reflected all employees were provided education of the topic. - Reviewed in-service and sign in sheet on Reporting Abuse Allegation for all staff which indicated the following: *dated 12/11/23 reflected all employees were provided education of the topic. - Reviewed in-service and sign in sheet on Resident Rights for all staff which indicated the following: * dated 12/11/23 reflected all employees were provided education of the topic. - Reviewed completion of notification of RP which indicated the following: *dated 12/15/23, the PIR, reflected responsible party for Resident #1 was notified of incident - Reviewed completion of notifying physician of incident which indicated the following: * dated 12/11/23, the PIR, reflected the physician was notified of the incident involving Resident #1. - Reviewed staff surveys results concerning LVN A which indicated the following: * dated 12/12/23-12/14/23 indicated some staff members witnessed LVN A said or did something inappropriate to a resident, they did know what the resident rights were, knew who was considered a mandated reporter, knew who to report abuse to, and was comfortable reporting abuse. - Reviewed resident safe surveys conducted after incident which indicated the following: * dated 12/12/23-12/14/23 indicated no resident had a staff member curse at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. - Reviewed 5 random staff and resident safe surveys conducted monthly x 3 months for QAPI which indicted the following: dated 01/23/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. One resident revealed LVN A had cursed at him or another resident. All other resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. * dated 02/22/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. All five resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. * dated 03/25/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. All five resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. The noncompliance was identified as PNC. The IJ began on 12/10/2023 and ended on 12/15/2023. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 2 of 10 residents (Resident #1 and Resident #2) reviewed for abuse. 1. The facility failed to ensure [NAME] B, DA C, and MA D immediately reported witnessed abuse towards Resident #1 to the abuse coordinator. 2. The facility failed to ensure Resident #1, and Resident #2 was free from abuse per the policy. 3. The facility failed to ensure the abuse coordinator obtained in writing or electronic format witness statements from [NAME] B, DA C, and MA D. 4. The facility failed to ensure, per their policy, to report alleged allegation of abuse towards Resident #2 to HHSC. The noncompliance was identified as PNC. The IJ began on 12/10/2023 and ended on 12/15/2023. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for physical harm, psychosocial harm, unsafe environment, and further abuse. Findings included: Record review of a facility's Abuse Prevention Program policy, revised 01/09/23, indicated .the administrator is responsible for the overall coordination and implementation of our Center's abuse prevention program policies and procedures .our residents have the right to be free from abuse, neglect .our center will not condone any form of resident abuse or neglect .to aide in abuse prevention, all personnel are to report any signs and symptoms of abuse/neglect to their supervisor and to the Abuse Prevention Coordinator immediately .all reports of resident abuse .shall be promptly reported to local, state and federal agencies (as defined by current allegations) and thoroughly investigated by Center management .as part of the resident abuse prevention program, the administration will .develop and implement policies and procedures to aid our Center in preventing abuse, neglect, or mistreatment of our residents .identify and assess all possible incidents of abuse .implement measures to address factors that may lead to abusive situations .investigate and report any abuse within timeframes as required by federal requirements .the administrator will ensure that any further potential abuse, neglect, exploitation or mistreatment is prevented .witness reports will be obtained in writing or in electronic format .the investigator will obtain a statement . Record review of a facility's Reporting Allegations of Abuse, neglect, and Exploitation policy revised 10/2023 indicated .it is the policy of the facility to report to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within all prescribed timeframes all allegations of abuse/neglect/exploitation or mistreatment .the facility will develop and operationalize policies and procedures for screening and training of employees on the topics of protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment .prevention .the facility will identify, correct, and intervene in situations in which abuse, neglect .the facility will identify events, occurrences, patterns, and trends that may constitute .abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can included staff to resident abuse .instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish .it includes verbal abuse, sexual abuse, physical abuse, and mental abuse .verbal abuse means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .mistreatment: inappropriate treatment or exploitation of a resident .alleged violation: a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified , could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse .investigation .the facility will investigate all allegation and type of incidents .reporting/response: the facility will report all alleged violations and all substantiated incidents to the state agency .any owner, operator, manager, agent, or contracture of the facility can report an allegation of abuse/neglect .when suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the following procedure will be initiated .the licensed nurse will .remove the accused employee from resident care areas .notify the Administrator or designee .the Administrator or designee will .notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after discovery of the incident .obtain statements from direct care staff . 1. Record review of Resident #1's face sheet, dated 07/08/24, indicated Resident #1 was a [AGE] year-old, male admitted to the facility on [DATE] and discharged on 02/21/24 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), mood affective disorder (is any of a group of conditions of mental and behavioral disorder where a disturbance in the person's mood is the main underlying feature), and mild cognitive impairment (is the stage between the expected decline in memory and thinking that happens with age and the more serious decline of dementia). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was sometimes understood and sometimes had the ability to understand others. Resident #1 had minimal difficult hearing, clear speech, and adequate vision. Resident #1 had a BIMS score of 03 which indicated severe cognitive impairment. Resident #1 required supervision for ADL assistance except for shower/bathe self which required maximal assistance. Record review of Resident #1's care plan dated 04/19/23 indicated Resident #1 was at risk for altered psychosocial well-being related to dementia. Intervention included listen carefully and be non-judgmental. Record review of a PIR for Resident #1, dated 12/11/23, indicated .on 12/10/23 at 3:00 p.m.LVN A used foul language and threw ice at a resident .LVN A denied .Cook B and Dietary Aide C reported to me [ADM], that they were standing at the nurses station and witnessed resident [Resident #1] come up to the nurses station and LVN A told him to 'stop fucking looking at me and go on' and threw a piece of ice at him .MA D stated that she heard LVN A say 'stop fucking looking at me and go on' but she did not see her throw ice at him [Resident #1] .LVN A was questioned about it, she denied saying anything to him but stated she and Resident #1 were playing and throwing ice at each other .the administrator visited Resident #1 who did not remember any incident .staff interviews indicated that many staff have witnessed LVN A speak rudely or harshly to the residents and often curse or speaks inappropriately to the staff .Resident safe surveys did not indicate any concerns with LVN A .physician and RP for Resident #1 notified of the incident .investigation findings: unconfirmed .Provider action taken post-investigation: staff reeducated on Abuse and Neglect Prevention and reporting, Professionalism, and Resident Rights .5 random staff interviews and resident safe surveys will be conducted monthly and results will be reviewed by QAPI committee monthly for 3 months . The PIR did not indicate an incident between LVN A and Resident #2. 2. Record review of Resident #2's face sheet, dated 07/08/24, indicated Resident #2 was a [AGE] year-old, male admitted on [DATE] and discharge 06/19/24 with diagnoses including anxiety disorder (persistent and excessive worry that interferes with daily activities), Type 2 diabetes (s a chronic condition that happens when you have persistently high blood sugar levels), nicotine dependence, schizoaffective disorder, bipolar type (is a chronic mental health condition characterized primarily by symptoms of schizophrenia (is a serious mental health condition that affects how people think, feel and behave), such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), and restlessness and agitation. Record review of Resident #2's annual MDS assessment dated [DATE], indicated Resident #2 was usually understood and usually understood others. Resident #2 had moderate difficulty hearing, clear speech, and impaired vision with use of corrective lenses. Resident #2 had a BIMS of 09, which indicated moderate cognitive impairment. Resident #2 required set up assistance for eating, dressing, and personal hygiene, supervision assistance for oral and toilet hygiene and partial assistance for shower/bathe self. Record review of Resident #2's care plan dated 06/12/23, indicated: *Resident #2 was at risk for altered psychosocial well-being related to schizoaffective disorder. Intervention included listen carefully and be non-judgmental. *Resident #2 was at risk for altered mood state related to schizoaffective disorder. Resident #2 pace the halls frequently, visit multiple staff members, frequently in/out of office. Resident #2 am easily agitated, yell loudly, make threatening statements to staff and/or residents. Intervention included be reassuring and listen to concerns. During an interview on 07/09/24 at 9:29 a.m., CNA E said she had worked at the facility for 20 years. She said she had witnessed LVN A being loud to resident but had only heard about LVN A using inappropriate language at residents. She said LVN A would escalate situations with Resident #2. She said she heard LVN A had cussed at Resident #1 and Resident #2. She said cussing and throwing things at resident was abuse. She said LVN A talked ugly, and, in a way, she would not want her family members spoken to. She said after LVN A and Resident #2 would get into, Resident #2 would talk aloud to himself and stated he did not like LVN A. She said she thought LVN A had been coached about her conduct with staff and resident before Resident #1's incident. She said if she witnessed or heard abuse toward a resident, she would report it to the ADM immediately. She said she received quarterly abuse prevention training. She said it was important to report abuse to the abuse coordinator immediately so the issue could be taken care of. She said reporting also stopped the abuse from happening. She said not reporting abuse allegations placed resident at risk to getting hurt or harmed. During an interview on 07/09/24 at 10:52 a.m., MA D said she worked for the facility for 2 years. She said she worked the day LVN A cussed at Resident #1. She said Resident #1 said or did something at the nursing station where LVN A was sitting. She said LVN A threw ice at Resident #1 and used the F word towards him. She said Resident #1 liked to touch people and grab drinks so maybe he did something to set her off. She said Resident #1 was walking away from LVN A and she threw ice at him. She said LVN behavior was abusive and inappropriate. She said she did not report the incident between Resident #1 and LVN A. She said she did not have the ADM phone number in her phone, but her number was posted in the sign in book. She said the next day after the incident, the ADM questioned her. She said it was important to report abuse immediately to the ADM so she could report it the state. She said if abuse was not reported immediately, resident could get hurt and situations could escalate. She said Resident #2 was at the nursing station and was asking LVN A to take him out to smoke. She said LVN A and Resident #2 exchanged words because she did not take him out. She said LVN A had made a sign on a posted note that said, get the fuck away or go away, leave me alone and would put it up when Resident #2 came to the nurses' station. She said about the second time Resident #2 came to the nurses' station, LVN A cussed at him and threw the posted note at him. She said Resident #2 walked away and was upset. She said another staff member took him out to smoke. She said this incident happened around the same time of Resident #1's incident. She said LVN A escalate situation especially with Resident #2. She said using foul language at a resident was abusive. She said she immediately reported the incident with Resident #2 and LVN A. She said the situation was getting out of control between LVN A and Resident #2. She said she called the ADM on her phone and told her what was going on. She said the ADM eventually showed up at the facility to handle the situation. During an interview on 07/09/24 at 11:15 a.m., the ADM said LVN A and Resident #1 incident happened on a Sunday. She said on Monday, [NAME] B and DA C told her Resident #1 walked up to the nurses' station and LVN A cussed at him and threw something at him. She said LVN A may have also called him a wierdo. She said [NAME] B and DA C said the situation bothered them, so they reported it. She said LVN A denied the event happened. She said LVN A was suspended pending investigation. She said she interviewed staff and resident about LVN A. She said the staff interviews revealed some concerns about LVN A. She said LVN A was terminated 3-4 days later after completion of the investigation. She said she believed the incident with LVN A and Resident #2 happened the same day as Resident #1's incident with LVN A. She said she recalled being told LVN A held up a sign at Resident #2 but did not remember anything else about foul language being used between them. She said in December 2023, she did not believe it was stated in the facility's policy to obtain witness statements. She said in March 2024, the corporation provided reeducation on self-reports and recommended obtaining witness statements. She said it was important to obtain witness statements to get accurate information. She said witness statements were part of the investigation and made it more thorough. She said witness statements were not obtained stories could change. She said not obtaining witness statements could make the investigation not thorough. She said the incident between LVN A and Resident #1 was the first incident involving LVN A and a resident. She said LVN A had a history bullying staff members but not residents. She said general in-services on professionalism and conduct was provided to LVN A. She said LVN A did have one on one counseling for complaint from staff on her attitude and bullying. She said she expected her staff to report allegation of abuse immediately. She said her information to contact her was posted in the posting cabinet, in the hallway, and at the nurses' station. She said the facility had provided in-person training on abuse prevention and reporting to staff. She said not reporting abuse risked the abuse continuing. During an interview on 07/09/24 at 1:45 p.m., [NAME] B said Resident #1 was at the nurses' station and LVN A told Resident #1 go the fuck away and threw ice at him. She said Resident #1 did say anything because he was not very verbal, but he was visibly upset by his facial expression. She said Resident #1 walked away from the nurses' station away from LVN A. She said she considered what LVN A did to Resident #1 was verbal abuse. She said she did not report the incident between LVN A and Resident #1 until the next day. She said she got busy the day of the incident because she had to do her job and forgot. She said she should have reported the incident between LVN A and Resident #1 immediately and received a verbal coaching for not reporting. She said it was important to report to the ADM immediately, so she could deal with it right then. She said if abuse was not reported, it could keep happening. During an interview on 07/09/24 at 4:15 p.m., DA C said LVN threw ice and said get the fuck away from me to Resident #1. She said Resident #1 looked upset like anyone else would if they got ice thrown at them. She said she did not have the ADM phone number the day of the incident which was why she did not report it immediately. She said she did not know the ADM phone number was at the nurses' station in the sign in book. She said she knew the incident should have been reported to the ADM immediately. She said she did get a verbal corrective coaching for not reporting. During an interview on 07/10/24 at 9:02 a.m., the Housekeeping/Laundry Supervisor F said she had witnessed, on one occasion, LVN A being rude to Resident #2 at the nurses' station. She said LVN was just rude but did not use foul language towards him. She said Resident #2 was mad after the incident and went into his room. She said when she heard how she was talking to Resident #2, she told her to stop being rude. She said she did not tell the DON or ADM about the incident. She said she felt the incident was inappropriate but not abuse. She said she knew to report abuse to the ADM as soon as possible. She said it should be reported because the abuse should not be happening. She said she would not want to be treated the LVN A treated Resident #2. She said abuse could keep happening if not immediately reported. She said she had received training on abuse, neglect, and exploitation. During an interview on 07/10/24 at 11:50 a.m., the ADM said she was the abuse coordinator, and it was her responsibility to investigate and report allegations of abuse to the State. She said she had to report abuse allegation within 2 hours. She said reporting and investigating protected the resident. She said not reporting placed resident at risk for abuse. Record review of LVN A's annual training dated 06/01/23 indicated training on subjects of resident rights and abuse and neglect. Record review of a facility conducted in-service, Abuse Prevention Program dated 12/11/23 reflected all employees were provided education of the topic. Record review of a facility conducted in-service, Reporting Allegations of Abuse, Neglect, and Exploitation dated 12/11/23 reflected all employees were provided education of the topic. Record review of a facility conducted in-service, Resident Rights dated 12/11/23 reflected all employees were provided education of the topic. Record review of 13 resident safe surveys dated 12/12/23-12/14/23 indicated no resident had a staff member curse at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. Record review of 29 staff interviews dated 12/12/23-12/14/23 indicated some staff members witnessed LVN A said or did something inappropriate to a resident, they did know what the resident rights were, knew who was considered a mandated reporter, knew who to report abuse to, and was comfortable reporting abuse. Record review of LVN A's Employee Corrective Action Form dated 12/15/23, indicated .type of action: termination .Category I Offense, inappropriate conduct towards a resident .Code of Conduct, Attitude, and Behavior- Policy Violation .Employees are expected and required to be kind, and considerate of residents, visitors, and other facility personnel. Any behavior that is deemed offensive or unsafe. Using profanity, abusive, or suggestive language, or gestures .date of violation 12/10/23 .incident: on, December 11, 2023, it was reported that LVN A used abusive language towards a resident, in which, led to the throwing of a solid object towards the resident .after speaking with all parties involved, we have confirmed these actions .LVN A has received several in-services regarding abuse and neglect among residents, in which, LVN A understands the appropriate conduct when managing residents .consequences: due to category I offense, LVN A will be subjective to immediate termination of employment .employee's comments: the ADM and DON attempted to call LVN A multiple times on 12/15/23 and left message to return call. LVN A texted and stated, 'if I'm fired just let me know so I can find another job'. This ADM responded with 'after we concluded the investigation and spoke to HR, we've decided to terminate your employment.' LVN A did not respond .DON 12/15/23 .ADM 12/15/23 . Record review of LVN A's Notice of Termination dated 12/18/23, indicated .LVN A .termination date 12/18/23 .reason of termination: abusive language toward resident .is employee eligible for rehire: No . Record review of LVN A's personnel file on 07/09/24 indicated hire date of 10/18/22. The facility had performed background check and employee misconduct search. No concerns were identified. Record review of a facility's Abuse Prevention policy revised 01/09/23 indicated .our residents have the right to be free from abuse, neglect .this includes but is not limited to .verbal, mental, sexual, or physical abuse . Record review of 5 Random Interviews of Staff and Residents, dated 01/23/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. One resident revealed LVN A had cursed at him or another resident. All other resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. Record review of 5 Random Interviews of Staff and Residents, dated 02/22/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. All five resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. Record review of 5 Random Interviews of Staff and Residents, dated 03/25/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. All five resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. The administrator was notified of IJ PNC on 07/09/2024 at 4:40 p.m. due to the above failures. The administrator was provided with the IJ template on 07/09/2024 at 4:45 p.m. The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy on 12/15/23 by: - Reviewed completed facility self-reported incident to HHSC for Resident #1 which indicated the following: * dated 12/11/23, indicated .on 12/10/23 at 3:00 p.m .LVN A used foul language and threw ice at a resident .LVN A denied .Cook B and Dietary Aide C reported to me [ADM], that they were standing at the nurses station and witnessed resident [Resident #1] come up to the nurses station and LVN A told him to 'stop fucking looking at me and go on' and threw a piece of ice at him .MA D stated that she heard LVN A say 'stop fucking looking at me and go on' but she did not see her throw ice at him [Resident #1] .LVN A was questioned about it, she denied saying anything to him but stated she and Resident #1 were playing and throwing ice at each other .the administrator visited Resident #1 who did not remember any incident .staff interviews indicated that many staff have witnessed LVN A speak rudely or harshly to the residents and often curse or speaks inappropriately to the staff . - Reviewed paperwork indicating LVN A was suspended until completion of investigation which indicated the following: * dated 12/15/23, indicated .type of action: termination .Category I Offense, inappropriate conduct towards a resident .Code of Conduct, Attitude, and Behavior- Policy Violation .Employees are expected and required to be kind, and considerate of residents, visitors, and other facility personnel. Any behavior that is deemed offensive or unsafe. Using profanity, abusive, or suggestive language, or gestures .date of violation 12/10/23 .incident: on, December 11, 2023, it was reported that LVN A used abusive language towards a resident, in which, led to the throwing of a solid object towards the resident .after speaking with all parties involved, we have confirmed these actions .LVN A has received several in-services regarding abuse and neglect among residents, in which, LVN A understands the appropriate conduct when managing residents .consequences: due to category I offense, LVN A will be subjective to immediate termination of employment .employee's comments: the ADM and DON attempted to call LVN A multiple times on 12/15/23 and left message to return call. LVN A texted and stated, 'if I'm fired just let me know so I can find another job'. This ADM responded with 'after we concluded the investigation and spoke to HR, we've decided to terminate your employment.' LVN A did not respond .DON 12/15/23 .ADM 12/15/23 . - Reviewed termination paperwork for LVN A which indicated the following: *dated 12/18/23, indicated .LVN A .termination date 12/18/23 .reason of termination: abusive language toward resident .is employee eligible for rehire: No . - Reviewed LVN A's time sheet to verify last day worked which indicated the following: * dated 12/01/23-12/31/23, indicated LVN A last day worked was 12/10/23 - Reviewed employee corrective action form for [NAME] B, DA C and MA D which indicated the following: *dated 12/11/23, indicated .Employee Corrective Action Form for [NAME] B C .verbal coaching .facility policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur .Cook B .ADM . * dated 12/11/23, indicated .Employee Corrective Action Form for DA C .verbal coaching .facility policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur .DA C .ADM . * dated 12/11/23, indicated .Employee Corrective Action Form for MA D .verbal coaching .facility policy-Abuse and Neglect Reporting .date of violation: 12/11/23 .employee witnessed situation that could be considered Abuse to a resident and did not report to Administrator until the next day .employee was educated 1:1 on reporting of abuse to administrator immediately so the proper investigation process could occur .further disciplinary action could occur . - Reviewed in-service and sign in sheet on Abuse Prevention for all staff which indicated the following: * dated 12/11/23 reflected all employees were provided education of the topic. - Reviewed in-service and sign in sheet on Reporting Abuse Allegation for all staff which indicated the following: *dated 12/11/23 reflected all employees were provided education of the topic. - Reviewed in-service and sign in sheet on Resident Rights for all staff which indicated the following: * dated 12/11/23 reflected all employees were provided education of the topic. - Reviewed completion of notification of RP which indicated the following: *dated 12/15/23, the PIR, reflected responsible party for Resident #1 was notified of incident - Reviewed completion of notifying physician of incident which indicated the following: * dated 12/11/23, the PIR, reflected the physician was notified of the incident involving Resident #1. - Reviewed staff surveys results concerning LVN A which indicated the following: * dated 12/12/23-12/14/23 indicated some staff members witnessed LVN A said or did something inappropriate to a resident, they did know what the resident rights were, knew who was considered a mandated reporter, knew who to report abuse to, and was comfortable reporting abuse. - Reviewed resident safe surveys conducted after incident which indicated the following: * dated 12/12/23-12/14/23 indicated no resident had a staff member curse at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. - Reviewed 5 random staff and resident safe surveys conducted monthly x 3 months for QAPI which indicted the following: dated 01/23/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. One resident revealed LVN A had cursed at him or another resident. All other resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. * dated 02/22/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. All five resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. * dated 03/25/24, indicated no staff members had witnessed a staff member mistreat a resident, knew the resident's rights, and knew who to report abuse to. All five resident indicated no staff member cursed at them or another resident, knew their rights and who to report abuse to, felt comfortable reporting abuse, and felt safe in the facility. The noncompliance was identified as PNC. The IJ began on 12/10/2023 and ended on 12/15/2023. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 of 5 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for smoking. The facility failed to ensure Resident #1 was not provided with smoking paraphernalia by Resident #2. Resident #1 had a history of attempting to smoke while in room. On 02/27/2023, Resident #1 was given a cigarette and lighter by Resident #2 and lit the cigarette in her room and set the lit cigarette on the over bed table causing a napkin to catch fire, and minutes later lit a brief on fire catching the residents blanket on fire. On 4/09/2023 Resident #1 was provided with smoking paraphernalia by Resident #2 again. The facility failed to ensure Resident #4 was monitored during a trial of unsupervised smoking. Resident #4 was observed outside smoking unsupervised on 04/11/23. Resident #4 was observed practicing unsafe smoking behaviors. The facility failed to ensure Resident #3 was monitored for safe smoking behaviors. Resident #3 was observed outside in the smoking area on 04/11/23 lighting her pipe while it was resting on her right breast. An Immediate Jeopardy (IJ) was identified on 04/11/2023 at 5:25 PM. While the IJ was removed on 04/12/2023 at 4:35 PM, the facility remained out of compliance at a scope of pattern and severity of no actual harm with a potential for more than minimal harm because the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of harm, severe injury, and possible death to residents who are deemed unsafe smokers. The findings included: 1. Record review of Resident #1's face sheet, dated 04/12/2023, indicated Resident #1 was a [AGE] year-old female, who admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (occurs when disease of the heart or lungs leads to failure to maintain adequate blood oxygen levels), cognitive communication deficit (difficulty with thinking and how someone uses language), mild cognitive impairment (decline in memory and thinking), and major depressive disorder (persistent feeling of sadness and loss of interest). Record review of Resident #1's comprehensive MDS assessment, dated 10/02/22, indicated that Resident #1 did not have current tobacco use. Record review of the comprehensive care plan, initiated on 11/04/2022, indicated Resident #1 I am a smoker. The interventions included Perform smoking assessment according to facility policy, remind resident frequently that smoking is not allowed in room, use smoking vest when appropriate, keep my smoking materials in a safe and secure place. Provide them to me as per smoking schedule. Record review of Resident #1's quarterly MDS assessment, dated 01/16/2023, did not address current tobacco usage. It indicated Resident #1's BIMS=11, which indicated moderate cognitive impairment. Record review of the smoking risk (acuity), assessment dated [DATE], indicated Resident #1 had a score of 14 which deemed the resident to be an unsafe smoker and to follow facility policy. The care plan indicated Resident #1 had severe problems with smoking in unauthorized areas, she had a severe problem with being careless with smoking materials, and she had a severe problem with the capability to follow the facility's safe smoking policy. Record review of Resident #1's nursing progress note dated 02/27/2023 at 12:45 PM, written by LVN A, indicated CNA reported to this nurse that the resident was smoking in her bedroom. On the way to the resident's room the fire alarm was activated. This nurse observed the resident lighting toilet paper and smoking a cigarette. This nurse removed the cigarette and the lighter in use. This nurse reiterated the smoking policy to the resident, she was upset and used foul language directed at this nurse. The nurse left the room, the fire alarm was again activated. The nurse and CNA again entered the room to find the resident had started a fire. A blanket and a brief were on fire. This nurse put out the fire and educated the resident on fire safety and prohibited items. Record review of the incident report, dated 02/27/2023 at 12:45 PM, indicated Resident #1 was given a cigarette and lighter by Resident #2. Resident #1 then lit the cigarette in her room and was smoking. The report indicated Resident #1 then laid the cigarette down on the over the bed table next to a napkin and the napkin caught fire. The fire alarm activated and LVN A was able to put the fire out and removed the cigarette and lighter in use. LVN A and CNA C returned to the nurse's station when the fire alarm activated a second time. LVN A and CNA C returned to the room and a brief and blanket were on fire. LVN A was able to put the fire out and then searched room and removed 2 additional lighters from Resident #1's room. 2.Record review of Resident #2's face sheet, dated 04/12/2023, indicated Resident #2 was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (occurs when disease of the heart or lungs leads to failure to maintain adequate blood oxygen levels), cognitive communication deficit (difficulty with thinking and how someone uses language), and schizoaffective disorder, bipolar type (mental illness that can affect your thoughts, mood and behavior). Record review of the smoking risk (acuity), assessment dated [DATE], indicated Resident #2 had a score of 05 which deemed resident to be a safe smoker. The assessment indicated Resident #2 had a history of borrowing a lighter, he had a minimal problem with smoking in unauthorized areas, he had a minimal problem with smoking cigarettes/cigar butts from ash trays, and he had a severe problem with general behavior and interpersonal interactions. Record Review of incident report dated 4/09/2023 indicated that Resident #2 was observed by staff giving Resident #1 a cigarette and lighter. Facility staff confiscated the smoking paraphernalia and educated Resident #2 on the smoking policy. During an observation and interview on 4/11/2023 at 9:15 AM, Resident #2 reached into the right pocket of his shorts and retrieved a yellow lighter. He said he did not remember an incident when he gave Resident #1 a cigarette and lighter. Resident #2 said he kept his cigarettes and lighter in his pocket because the administrator said he could, but he was out of cigarettes. Resident #2 said he was going to ask the administrator to get him some more cigarettes. During an interview on 4/11/2023 at 12:45 PM, Resident #1 said she remembered Resident #2 giving her a cigarette and taking her out to smoke a few days ago, but she did not remember if any staff members were with her at the time. Resident #1 said she did not have any smoking materials with her currently because the nurse took it and locked it up. During an interview on 04/12/2023 at 11:06 AM, CNA C said smoking used to always be supervised and then she heard by word of mouth but can not remember who told her, it changed about 4-5 months ago. She said now some residents could go smoke anytime they wanted, and those residents were allowed to keep their smoking materials. CNA C said there were still some residents who must be monitored when smoking and the nurse kept their smoking materials. CNA C said there were 5 residents who were unsupervised smokers and 4 residents who were supervised. CNA C said Resident #2 was an unsupervised smoker and was allowed to keep his smoking materials, she said Resident #2 is a supervised smoker. CNA C said the day in February Resident #1 lit the cigarette in her room, she went to pick up the resident's lunch tray and the resident had a cigarette laying on the table that caught a napkin on fire. CNA C said LVN A came to the resident's room and found the cigarette and a lighter. CNA C said 20-25 minutes later, she went to check on Resident #1 and the resident had a blanket on the bed and a brief on the floor. She said the brief was on fire and had caused the blanket on the bed to catch fire. CNA C said LVN A came down and searched the resident's room again and found 2 more lighters. CNA C said she did not know how Resident #1 had the cigarettes and lighters. CNA C said she was not aware Resident #2 had given Resident #1 a cigarette on 04/09/23. During an interview on 04/11/2023 at 2:28 PM, LVN A said the residents were able to take themselves out to the smoking area and smoke if they were able to smoke unsupervised. LVN A said there were currently no designated smoking times in place and residents could go out whenever. LVN A said the residents were able to keep their cigarettes and lighters. LVN A said there were a few residents who had to be supervised and a list of those residents was kept at the nurse's station. LVN A said supervised smokers were determined by their smoking assessment, but she was not sure who completed that assessment. LVN A said there were 5 unsupervised smokers and 4 supervised smokers. LVN A said Resident #2 was an unsupervised smoker and was allowed to keep his smoking materials. LVN A said Resident #1 lit a cigarette in her room on 02/27/23. LVN A said Resident #1 had laid the cigarette on the over the bed table and caught a napkin on fire. LVN A said she was able to put the fire out and took the cigarette and lighter that was in use. LVN A said a few minutes later the fire alarm activated a second time. LVN A said she returned to the room and Resident #1 had lit a brief on the floor on fire that had caught the blanket on fire. LVN A said she was able to put the fire out and searched the room and found 2 more lighters. During an interview and observation on 04/11/2023 at 12:22 PM, LVN B said some residents were allowed to smoke unsupervised and there was a list of residents who had to be supervised. LVN B said the list was taped to the nurse's station. LVN B provided the initial list titled Monitored Smokers then took the list and added a resident's name at the bottom and returned the updated list. Record Review of Monitored Smokers on 4/11/2023 at 12:22 PM provided by LVN B initially contained 5 residents listed as monitored smokers. LVN B provided the monitored smokers list again and it now contains 6 residents listed as monitored smokers. During an interview on 04/11/2023 at 9:40 AM, the BOM said Attachment K of the Smoking Policy statement (dated 2/22/2022) was provided to residents and families in the admission agreement. Record Review of the facility's Attachment K Smoking policy statement dated 2/22/2022 indicated the facility would supervise all resident smoking for the safety of all residents and employees, and all resident smoking paraphernalia must be checked in with the nurse. Attachment K did not address unsupervised smoking. During an interview on 4/11/2023 at 12:32 PM, the MA said the smoking policy was in the glass case across from the nurse's station. The MA said there was a time to go smoke designated for each hall. She said there were some residents who required to be supervised, but there were some residents who could come and go as they wanted and keep their smoking materials. Record Review of HCC Smoking Policy from the glass case was undated and indicated: In order to protect the lives and safety of all residents, we require that resident smoking be conducted with direct supervision from staff or family/RP at all times. Residents are not allowed to smoke unsupervised. All smoking materials are to be kept by facility staff in a designated secure area. Family members or responsible parties must alert nursing staff when they are accompanying their resident to smoke area during a non-scheduled smoking time. Designated smoking areas: The designated smoking areas are located outside the patio exit int the main dining room; for inclement weather, the covered walkway outside of Hall 4 and Laundry exit; and secured unit residents, outside the end door of Hall 2 or the center court. Smoking is prohibited in all other areas of the facility and the grounds. Designated smoking times: Designated times for staff-supervised smoking for residents are: 8:30am 10:30am 1:00pm 2:30pm 4:30pm 6:30pm 8:30pm designated times for staff-supervised smoking for residents on the secured unit area: 8:00am 11:00am 1:00pm 4:00pm 7:00pm. Record review of the Smoking Policy Independent Smokers In-service, initiated on 02/27/2023, indicated staff were in-serviced on the smoking policy signed by 40 employees with only the sign in sheet provided with no education attached. Record review of Resident #4's face sheet dated 04/11/23 revealed, Resident #4 was admitted on [DATE] with diagnosis of dementia (memory impairment), hemiplegia following cerebral infarction (stroke affecting the left side), and bipolar disorder (affecting mood). Record review of Resident #4's quarterly MDS dated [DATE] revealed, Resident #4 needs extensive assistance with transfers, bed mobility, toilet use, personal hygiene and dressing. Resident #4 also requires supervision with locomotion and eating. Resident #4's BIMS=12 which indicated moderate cognitive impairment. Record review of Resident #4's care plan initiated on 05/16/22, revealed Resident #4 is a smoker. Resident #4's interventions include: I may wear a smoking apron upon my request, I will keep my smoking material in a safe and secure place. Staff will provide smoking materials to me as requested, monitor as needed when smoking so that if something should happen, I have someone to assist and help me at assure my safety. Record review of Resident #4's smoking risk (acuity) assessment dated [DATE] revealed a score of 4, which indicated Resident #4 is a safe smoker. During an interview outside in the smoking area 04/11/2023 at 9:30 AM, Resident #4 said she used to have to have staff take her out to smoke, but she asked the DON to be unsupervised and was granted a trial of being an unsupervised smoker. Resident #4 said when she was ready to smoke, she stopped by the nurse's station and the nurse would give her 2 cigarettes and a lighter. She said she propelled herself outside to smoke unsupervised. Resident #4 said when she went back inside the facility, she would give the lighter back to the nurse. Record review of Resident #3's face sheet dated 04/11/23 revealed, Resident #3 was originally admitted on [DATE] with the most recent admission on [DATE]. Resident #3's diagnosis includes dementia (memory problem), seizures (stiffness, twitching, or limpness), and schizoaffective disorder (mental health problem where you experience psychosis as well as mood problems). Record review of Resident #3's quarterly MDS dated [DATE] revealed, Resident #3 requires extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. Resident #3's BIMS=12 which indicated moderate cognitive impairment. Record review of Resident #3's care plan initiated on 07/23/2019 and revised on 04/11/23 revealed, Resident #3 is a smoker. Care plan interventions include I may use smoking apron upon my request, remind to not share cigarettes with others, report observations of resident having smoking materials in possession at times other than during smoking break and remind to keep in lock box when not smoking, resident may participate independently for smoke break as requested. Record review of Resident #3's smoking risk (acuity) assessment dated [DATE] revealed, Resident #3 score was 1 which indicated resident is a safe smoker. During an interview and observation outside in the smoking area on 04/11/2023 at 9:35 AM, Resident #3 said the residents raised enough ruckus about smoking that the administrator gave in and decided they could smoke anytime they wanted and keep their smoking materials. Resident #3 said Resident #2 came out to the smoking area frequently wanting to borrow cigarettes from other residents. Resident #3 does not have use of her left arm due to hemiplegia following a cerebral infarction affecting the left side. Resident #3 was smoking a pipe. Resident #3 took the pipe and dipped it into a pouch of loose tobacco, put the pipe in her mouth and rested the bottom of the pipe on her right breast, she then took a blue Bic lighter turned it upside down and lit the tobacco in the bottom of the pipe and began to smoke the pipe. After smoking, Resident #3 emptied the contents of the pipe into the ashtray and repeated the process multiple times. During an observation on 04/11/2023 at 10:15 AM, Resident #2 was observed putting in the code to the smoking door and came out to the smoking area. Resident #2 asked Resident #3 if she could pay him back his cigarettes. Resident #3 told Resident #2 that she did not have any money and he would have to wait until she got some. Resident #2 then put the code into the number pad and went back inside the facility. During a continuous observation on 04/11/2023 at 9:30 AM to 10:49 AM, four residents (Resident's #2, #3, #4 and #5) were outside in the smoking courtyard. Residents #2, #3, #4 and #5 had their own cigarettes and lighters and were unsupervised. Resident #4 was wearing a smoking apron that covered the front of her clothing and was not secured in the back. Observed no interaction with staff and smoking residents from 9:30 AM until 10:49 AM. At 10:49 AM, LVN A came to the smoking door and told Resident #4 she needed to come inside. During an interview on 4/11/2023 at 12:05 PM, CNA E said smoking used to always be supervised and then it changed, but she did not know when. CNA E said now some residents could go smoke anytime they wanted, and those residents were allowed to keep their smoking materials. CNA E said there were still some residents who must be monitored when smoking and the nurse kept their smoking materials. CNA E said there were 2 residents who were supervised. CNA E said Resident #2 was an unsupervised smoker and was allowed to keep his smoking materials. During an observation on 4/11/2023 at 12:51pm, two residents (Resident's #2 and #5) were outside in the smoking courtyard. Residents #2 and #5 had their own cigarettes and lighters and were unsupervised. During an interview outside in the smoking area on 04/11/2023 at 12:51 PM, Resident #5 said the staff used to bring him out to smoke, but that had not happened in a while. He said his family member provided his cigarettes, and he had his cigarettes and lighter in his jacket pocket. During an interview on 4/12/2023 at 10:17 AM, CNA D said smoking used to always be supervised and then it was changed but did not know when. CNA D said now some residents can go smoke anytime they want, and those residents are allowed to keep their smoking materials. CNA D said there are still some residents who had to be monitored when smoking and the nurse kept their smoking materials. CNA D said there were 6 residents who were unsupervised smokers and 3 residents who were supervised. CNA D said Resident #2 is an unsupervised smoker and was allowed to keep his smoking materials. CNA D said Resident #1 is a supervised smoker. During an interview on 4/12/2023 at 3:32 PM, CNA E Said that there are 3 residents that must be supervised to smoke, they can't share cigarettes, they must wear their aprons, and they get one every 2 hours. During an interview on 04/11/2023 at 3:23 PM with the Administrator, she said let's go talk to the DON about who completes the smoking risk (acuity) assessments. Upon entering the DON's office, the Administrator left the office. During an interview on 04/11/2023 at 3:25 PM, the DON said they use the smoking assessment in Matrix as a tool for determining what residents are considered safe or unsafe smokers. She said they also will assess the resident for any changes in condition that could cause the resident to become unsafe. Said Resident #4 has come and asked that she be made an unsupervised smoker, she said they are now doing a trial run with the resident to see if she does ok with unsupervised smoking. She Said she is aware Resident #2 gave Resident #1 cigarettes and a lighter on more than one occasion because he is a giver and when he is sweet on someone, he will give that person anything he has. She said he is sweet on Resident #1. The DON said the facility educated Resident #2 on the smoking policy of not giving cigarettes and lighter to a supervised smoker. The DON said Resident #2 is still allowed to keep his smoking paraphernalia and they have no way to ensure that Resident #2 will not do it again. The Administrator was notified on 04/11/2023 at 5:25 PM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy Template on 04/11/2023 at 5:25 PM. The Administrator provided a third smoking policy on 4/11/2023 at 5:30pm, titled, Smoking Policy-Residents 2001 med-pass, INC. (Revised December 2019) and included the following: This facility shall establish and maintain safe resident smoking practices. Policy interpretation and Implementation. 1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Otherwise, smoking is not allowed inside the facility under any circumstances. 3. Oxygen use is prohibited in smoking areas. 4. Metal containers, with self-closing cover devices, are available in smoking areas. 5. Ashtrays are emptied only into designated receptacles. 6. The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker, the evaluation will include A. current level of tobacco consumption; b. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipes, etc.); c. Desire to quit smoking, if a current smoker; and d. Ability to smoke safely with or without supervision (per a completed smoke risk (Acuity). 7. The staff shall consult with the attending physician and the director of nursing services to determine if safety restrictions need to be placed on a resident's smoking privileges based on the safe smoking evaluation. 8. A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive) and as determined by the staff. 9. Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. 11. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession, only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. 13. Residents are not permitted to give smoking articles to other residents. 14. Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision. 15. Staff members and volunteer workers are not permitted to purchase and or provide any smoking articles for residents. 16. This facility maintains the right to confiscate smoking articles found in violation of our smoking policies. 17. Confiscated resident property will be itemized and ultimately returned to the resident, or his or her legal representative. When the property is returned will be determined during a meeting with the resident or representative regarding the circumstances that led to the confiscation. The facility's plan of removal was accepted on 04/12/2023 at 4:35 PM and included the following: The facility's nursing administration will complete smoking acuity assessments on all residents in the facility. The facility's administration will communicate with staff the residents will be deemed to be safe to smoke independently according to our smoking acuity assessment and residents that will be deemed not safe to smoke independently according to our smoking acuity assessment by completing a list and updating the care plans, so staff are aware. The Facility's administration will update the monitored smoking schedule and will ensure residents that will be deemed not safe to smoke independently according to out smoking acuity assessment are monitored while smoking. Nursing administration, Social Services, Administrator, and/or designee will educate all smoking residents regarding having smoking paraphernalia on person, sharing cigarettes and lighters, and ensuring they understand not everyone is capable of self-smoking. Residents will sign or verbally agree with two witnesses to the above educational information (if unable to sign). Violation of this policy will result in supervised smoking. Smoking policy has been reviewed and updated. Ask residents for their smoking paraphernalia while respecting their rights and ensuring residents that will be deemed not safe to smoke independently according to out smoking acuity assessment will not have paraphernalia. The facility will keep residents that will be deemed not safe to smoke independently according to out smoking acuity assessment smoking paraphernalia in a secure location where only staff have access and can distribute as necessary. Resident #2's smoking paraphernalia will be secured where only staff has access and can distribute as necessary. Administrator, Director of Nurses, and /or designee, will in-service all staff on current smoking policy, ensure they understand residents will be deemed to be safe to smoke independently according to our smoking acuity assessment. Vs. residents that will be deemed not safe to smoke independently according to our smoking acuity assessment (those residents will be identified through a list created by nursing administration-post smoking acuity assessment- and can be additionally identified through the residents' care plans). All staff will be trained prior to working their next shift. Administrator, Director of Nurses, and/or designee, will speak with family members of Resident #1 to assist with ensuring that resident does not have smoking paraphernalia and document in medical record. Room search will be conducted as needed. Ad-Hoc QAPI performed with Medical Director, Administrator, and Director of Nursing. The facility smoking policy was revised April 2023 and at that time the DON began in-servicing facility staff on the policy changes. All staff currently on duty were in-serviced on the revised smoking policy 4/12/23 at 3:30 PM. Any staff members not available for in-service will be in-serviced prior to returning to shift. Policy related to supervision during smoking times has been implemented and is in place. The smoking policy implementation explanation started 4/11/23 with all residents who smoke. The smoking policy implementation was completed on 4/12/2023 for all residents who smoke. On 04/12/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation 4/12/2023 at 1:00pm, Resident #2 was observed turning in his lighter to the nurse at the nurse's station. During an observation on 04/03/2023 at 2:25 PM, 4 residents were outside smoking supervised by Administrator in training. During resident interviews on 04/12/2023 between 3:45 PM - 4:15 PM, Resident's #1, #2, #3, #4, #5, #6, #7, #8, and #9 were able to verbalize understanding of the smoking policy, which included supervised smoking for supervised residents and designated smoking times, and verified all cigarettes and lighters were turned into the facility staff. Record review of the comprehensive care plan for Resident's #1, #2, #3, #4, #5, #6, #7, #8, and #9 indicated they had been reviewed and revised as necessary. Record review of the smoking assessments for Resident's #1 #2, #3, #4, #5, #6, #7, #8, and #9 indicated they had been reviewed and revised as necessary. Record review of the smoking policy in-service provided to staff, dated 04/11/2023, indicated 40 staff members had signed and dated the read and understood the smoking policy, which included Resident #2 is required to keep smoking paraphernalia at the nurse's station, supervised smoking residents were required to keep their cigarettes and lighters at the nurse's station, and designated smoking times and supervision. During interview on 04/12/2023 between 3:30 PM and 4:30 PM, the following staff members, 3 charge nurses, 1 CMA, 6 CNA's, 1 housekeeping staff member, and the ADON were interviewed and verbalized understanding that supervised smoking residents were required to keep their cigarettes and lighters at the nurse's station, and Resident #2 must keep his cigarettes and lighter at the nurse's station, and the new digitated smoking times and supervision. On 04/12/2023 at 4:35 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of pattern and severity of no actual harm with a potential for more than minimal harm because to the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems.