**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure a resident in the facility was free from sexual, and physical abuse for 1 (Resident #1) of 3 residents reviewed for abuse. The facility failed to protect Resident #1 from abuse when: RN A failed to report to the Administrator (at that time), or the DON when Resident #1 reported significant bruising of unknown origin to the upper thigh, inner thigh, buttocks, groin area, and to the knee on the right leg on 03/08/23. On 07/13/23 Resident #1 provided video to RN A that she had been sexually assaulted by the Dialysis RN. It was determined a past non-compliance Immediate Jeopardy existed from 03/08/23 to 07/17/23. The Immediate Jeopardy was determined to have been removed on 07/17/23 due to the facility's implemented actions that corrected the non-compliance. These failures could place all residents at risk for abuse and could lead to serious injury, serious harm, serious impairment, pain, mental anguish, or death. Findings Included: Review of Resident #1's EHR reflected she was a [AGE] year-old female admitted to the facility on [DATE], discharge home on [DATE]. Her diagnoses included: Encephalopathy (disease to the brain), Diabetes, (increase sugar), and end stage renal disease (kidneys not working). Review of Resident #1's annual MDS dated [DATE] reflected she had a BIMS score of 15 and indicated she was cognitively intact. Resident #1 required minimal to no assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Resident #1's care plan dated 07/19/23 reflected she required hemodialysis ( procedure to cleanse the blood) three times a week on Tuesday, Thursday, and Saturday. She required assistance with supervision as needed with activities of daily living due to impaired balance. Further review reflected Resident #1 had, a psychosocial well-being problems (actual sexual assault by dialysis staff) anger, feeling betrayed. Her care plan did not contain any interventions regarding bruising. Review of the nursing progress note dated 03/08/23 documented by RN A, reflected Resident #1 reported to RN A bruising to her right leg. RN A assessed Resident #1, documented large purple/red bruises from the right buttocks down to her right knee. RN A informed the physician and the family of the bruising. Resident #1 denied falling, to RN A, and when asked by RN A how the bruising happened Resident #1 told RN A, she did not know. Review of the dialysis schedule revealed that the Dialysis RN was working at the facility during the month of March and had provided dialysis on 03/08/23 to Resident #1, the day that the bruising was reported to RN A. Record review of the incident accident log dated 03/23 reflected no reports of bruising by Resident #1 on 03/08/23. In an interview with RN A on 09/20/23 at 3:00 p.m. revealed he did not recall Resident #1 reporting any bruising on her body to him. RN A stated, the policy for reporting was when a resident had an incident the nurse was to assess the injury and call the family, doctor, and follow orders, if it was something the resident could not tell them how it happened they were to report to the Administrator and the DON immediately. RN A stated he did not recall reporting anything to Administrator D (at that time) or the DON concerning Resident #1 in March (2023). Attempts were made to contact on 09/20/23 at 1:00 p.m., and 09/21/23 at 12:30 p.m. for Administrator D with no return calls. In an interview on 09/20/23 at 3:35 p.m. with Administrator E revealed that since he had been the Administrator at the facility (mid-June 2023) he had in-services with all staff informing them to report immediately to him and the DON any unusual injuries, to include bruising without a cause, and unwitnessed falls with injuries. The Administrator stated I had no reports concerning Resident #1, except the sexual assault that had occurred in July (2023). Administrator E stated I was working the day of the assault and RN A had brought him the video on Resident #1's phone, Administrator E stated I immediately called the police, the family, the dialysis company, and the physician. I immediately went and spoke to Resident #1 the police came, I took the police officers to the resident and asked her permission to speak to the police. The police viewed the video and called additional police and a crime scene was set up in the dialysis room. The police brought in crime scene investigators and investigated, taking a lot of items from the room. Administrator E stated I meet with the family and Resident #1 went to the hospital. Administrator E stated I did complete an investigation including in-servicing and training on abuse/neglect with all staff, had safe surveys conducted and spoke to the residents himself. Administrator E stated I spoke with his cooperation informed, of the sexual assault and requested cameras installed, a special lock for the door, and contacted the dialysis company informed, I wanted no male dialysis RNs provided to the facility from 07/14/23 date forward. Record review of the in-service trainings reflected all staff for all shifts and all disciplines in the facility were in-serviced on 06/26/23 and 06/27/23 given by Administrator E on the following topics: abuse and neglect, reporting injuries of unknown origin and injuries to the Administrator and DON immediately. A copy of the abuse and neglect policy was provided, and testing was completed by the staff that had attended. In a follow-up interview with RN A on 09/20/23 at 4:00 p.m. revealed he recalled the in-service from the new Administrator E, and he knew that he was supposed to report to the Administrator and DON immediately. RN A stated he did not know why he did not follow policy in March and he guessed he was busy that day. In an interview on 09/20/23 at 4:15 p.m. with the DON revealed the charge nurses were supposed to assess and inform the physician, the family, and the Administrator and herself when an incident occurred. The Administrator wanted to be told about all incidents, then they discussed them in the morning meeting. The charge nurse was supposed to fill out and document an incident/accident form, so the occurrence could be followed-up on. The DON stated she was unaware of any bruising reported by Resident #1 in March (2023). The DON stated had she been made aware she would have investigated and reported the incident. The DON stated that did concern her RN A had failed to report the bruising of unknown origin, after what had happened to Resident #1 July (2023), and stated, I could have found something out maybe in March, but now I will never know. Review of the Provider Investigation Report dated 07/13/23 reflected a timely investigation, following RN A provided the video to the facility Administrator immediately. Further review reflected the referral of the dialysis nurse, police report, communication, and in-service for all staff dated: 07/14/23 through 07/19/23 concerning reporting abuse and neglect, to include injuries of unknown origin, suspicious injures, or unusual behavior by the resident, no male nurses were provided to the facility by contract dialysis center after 07/13/23, cameras were placed in the dialysis room in the facility, monitored by the Administrator E with his back up monitoring by the DON. The cameras could be monitored on his phone from anywhere in the world anytime of the day. Administrator E had logs of the monitoring dated 07/17/23 (when the camera was installed) until the time of the visit 09/21/23. The facility placed a key code lock on the dialysis room, that only a select number of staff had, not including the dialysis nurses. The dialysis room door was to always remain open when in use. Safe surveys with all residents, including the dialysis resident at that time, with follow-up each week with the dialysis resident and other residents to check for any concerns the resident had. Psychological and psychiatric services were proved to Resident #1. Record review of the her nursing progress notes reflected on 07/13/23 that Resident #1 provided to RN A video that she had been sexual assaulted by her assigned dialysis nurse. RN A reported to Administrator E immediately, the family, police and the physician were notified. Resident #1 was sent to the hospital for further evaluation. RN A had documented Resident #1 had been assessed head to toe with no physical evidence of trauma. In an interview on 09/20/23 at 11:00 a.m. with RN B Director of the SANE (Sexual Assault Nurse Examiner) unit at the hospital revealed Resident #1 had been assigned to another RN working the unit. RN B said that she had not seen the video but could provide all the testing results from the SANE exam. RN B stated that the resident had remained calm throughout the process and was returned to the facility after her evaluation at the hospital. In an attempt to interview on 09/20/23 At 11: 45 a.m. with RN C SANE nurse, that retuned the call on 09/25/23 at 2:00 p.m. reflected that she had processed Resident #1 when she arrived at the emergency room on [DATE]. She did review the video and stated it was disturbing. RN C stated she had been involved in [NAME] assessing for 15 years and the video was very disturbing. RN C stated the sexual assault on Resident #1 from the dialysis RN was very disturbing. RN C stated one of the most disturbing things for her was at the end of eh sexual assault from Dialysis RN , he leans into the face of Resident #1 who is obviously unable to respond and says so you feel better now. Resident #1 was quietly speaking and was very tired and was alert and oriented and able to answer questions at the time of her assessment. Record Review of the SANE Documentation dated 07/14/23 reflected that RN C had processed Resident #1 for sexual assault to include review of the video provided by Resident #1. The summary of the video reflected dialysis RN inserting gloved and ungloved hands in the vagina of [Resident #1], [dialysis RN] inserting his penis no condom used, multiple times in the vagina of [Resident #1], while holding her legs straight up in the air. During the exam Resident #1 reported to RN C that she had rectal pressure and a rectal exam revealed redness and tenderness with a clear discharge and soft stool surrounding the anal opening. Resident #1 had 2cm X 2cm purple bruising on her right breast, that was tender (Resident #1 stated dialysis RN had grabbed her breast) and a 2cm scratch on her right shoulder. RN C documented Resident #1 had reported to her that she had discussed that she felt something was wrong with her family, but they did not believe her, so she made her mind up to get her own evidence, by ordering a Spy Cam and videoing him. She said she could not get the Spy Cam to work so she used her cell phone. Attempt was made to contact the Dialysis RN on 09/21/23 at 2:00 p.m.; the phone had been disconnected. Review of the facility's policy titled, Abuse, and Neglect, revised dated 03/2018, reflected the following: The resident has the right to be free from abuse, neglect, and exploitation . residents should not be subjected to abuse by anyone, including, but not limited to facility staff other residents, consultants, or volunteers, staff of other agencies serving the resident . The facility will provide and ensure the promotion and protection of resident rights . It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or . abuse and situations that may constitute abuse or neglect to any resident in the facility . Definitions: . 4. Sexual Abuse: non-consensual sexual contact of any type with a resident 12. Injury of unknown Source any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident: and The injury is suspicious because of the extent of the injury or the location of the injury . Prevention .3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility . Investigations will be reviewed by the facility Administrator and /or Abuse Prevention within 24 hours of complaint. Appropriate notification to state and home office will be responsibility of the administrator .4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising or residents . that may constitute abuse . Repairing .3. Facility employees must report all allegations of abuse, neglect, exploitation .or injuries of unknown source to the facility administrator Monitoring of the facility's implemented actions that corrected the non-compliance prior to entry included: Observation and interview on 09/19/23 9:30 a.m.it was observed that room to the dialysis room was locked with a special coded lock, the nurse in charge of the area, RN A was ask if he knew the code and how did the dialysis nurses get in, he said he knew the code and he had to let them in they did not have the code. When he opened the room there was a bed and a chair in the room, with the cameras that had been placed to monitor, the RN left the door open as he said if anyone was in the room the door had to remain open who when the staff went by, they could look into the room. RN A stated all of this occurred after the sexual assault occurred with Resident #1. These are interventions put in place, we have only women that come from the dialysis center to dialyze our residents. RN A was asked if he followed-up on the dialysis residents: follow-up was assessing the site as we would on any dialysis resident checking the shunt, checking the site of the port. RN A stated if he notices anything different on the resident or if the resident was acting differently or mentioned something he would immediately report it to the Administrator and the DON. RN A stated he had been in-serviced after the sexual assault had occurred and before that he had been in-serviced by the new administrator, concerning his expectations concerning abuse and neglect. Record review of the all staff in-services dated: 07/14/23 through 07/19/23 concerning reporting abuse and neglect, to include injuries of unknown origin, suspicious injures, or unusual behavior by the resident. Further review reflected in-services given by the Administrator dated 06/26/23 and 06/27/23 for abuse, and neglect, to include reporting bruising, injury of unknown origin, and his expectations that he is to be informed by any staff member of anything they considered usual or abuse. Record Review of the geriatric psychological services revealed the psychologist visited with Resident #1 on 07/20/23/ after her return from hospital, further review reflected the psychologist continued weekly visit with Resident #1 until discharge. Review of the psychiatric progress note dated 07/20/23 reflected a review of the medications that resident was taking after the return form the hospital, no changes were made at the time. In an observation on 09/19/23 at 1:00 p.m. there was an unknown male resident in the dialysis room with a female RN receiving dialysis. The resident appeared comfortable. The resident stated he had to [NAME] a consent since there were cameras in the room, indicating where the cameras were located. 09/21/23 at 2:00 p.m. the Administrator revealed the monitoring logs that he had dated 07/17/23 (when cameras were placed) until current. In an observation on 09/19/23 at 1:00 p.m. with the Administrator revealed a large television in the administrator's office that revealed the entire facility inside and out, as well as the dialysis room. Further observation was shown to the investigator by the Administrator on the his phone. In an observation on 09/21/23 at 2:00 p.m. revealed the Administrator showed the monitoring logs dated 07/17/23 (after cameras were installed) until the current visit. There was no attempt to contact the Resident #1 as she had moved out of the state. Interviews were conducted on 09/21/23 from 10:29 a.m. to 10:42 a.m., 09/21/23 at 2:40 p.m. and from 4:40 p.m. to 4:50 p.m. with licensed nursing staff RN A, LVN F, LVN G, and LVN H. The nursing staff were able to accurately summarize the facility's reporting policy and procedure related to abuse/neglect to include unknown bruising or injures of unknown origin, reporting and documenting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse and for reporting injuries of unknown origin for 1 (Resident #1) of 3 residents reviewed for abuse. The facility failed to implement their internal policies when: RN A failed to report to the Administrator (at that time), or the DON when Resident #1 reported significant bruising of unknown origin to the upper thigh, inner thigh, buttocks, groin area, and to the knee on the right leg on 03/08/23. On 07/13/23 Resident #1 provided video to RN A that she had been sexually assaulted by the Dialysis RN. It was determined a past non-compliance Immediate Jeopardy existed from 03/08/23 to 07/17/23. The Immediate Jeopardy was determined to have been removed on 07/17/23 due to the facility's implemented actions that corrected the non-compliance. This failure could place residents at risk of abuse, neglect, exploitation, or mistreatment. Findings included: Review of the facility's policy titled, Abuse, and Neglect, revised dated 03/2018, reflected the following: The resident has the right to be free from abuse, neglect, and exploitation . residents should not be subjected o abuse by anyone, including, but not limited to facility staff other residents, consultants, or volunteers, staff of other agencies serving the resident . The facility will provide and ensure the promotion and protection of resident rights . It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or . abuse and situations that may constitute abuse or neglect to any resident in the facility . Definitions: . 4. Sexual Abuse: non-consensual sexual contact of any type with a resident 12. Injury of unknown Source any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident: and The injury is suspicious because of the extent of the injury or the location of the injury . Prevention .3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility . Investigations will be reviewed by the facility Administrator and /or Abuse Prevention within 24 hours of complaint. Appropriate notification to state and home office will be responsibility of the administrator .4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising or residents . that may constitute abuse . Repairing .3. Facility employees must report all allegations of abuse, neglect, exploitation .or injuries of unknown source to the facility administrator Review of Resident #1's EHR reflected she was a [AGE] year-old female admitted to the facility on [DATE], discharge home on [DATE]. Her diagnoses included: Encephalopathy (disease to the brain), Diabetes, (increase sugar), and end stage renal disease (kidneys not working). Review of Resident #1's annual MDS dated [DATE] reflected she had a BIMS score of 15 and indicated she was cognitively intact. Resident #1 required minimal to no assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Resident #1's care plan dated 07/19/23 reflected she required hemodialysis ( procedure to cleanse the blood) three times a week on Tuesday, Thursday, and Saturday. She required assistance with supervision as needed with activities of daily living due to impaired balance. Further review reflected Resident #1 had, a psychosocial well-being problems (actual sexual assault by dialysis staff) anger, feeling betrayed. Her care plan did not contain any interventions regarding bruising. Review of the nursing progress note dated 03/08/23 documented by RN A, reflected Resident #1 reported to RN A bruising to her right leg. RN A assessed Resident #1, documented large purple/red bruises from the right buttocks down to her right knee. RN A informed the physician and the family of the bruising. Resident #1 denied falling, to RN A, and when asked by RN A how the bruising happened Resident #1 told RN A, she did not know. Review of the dialysis schedule revealed that the Dialysis RN was working at the facility during the month of March and had provided dialysis on 03/08/23 to Resident #1, the day that the bruising was reported to RN A. Record review of the incident accident log dated 03/23 reflected no reports of bruising by Resident #1 on 03/08/23. In an interview with RN A on 09/20/23 at 3:00 p.m. revealed he did not recall Resident #1 reporting any bruising on her body to him. RN A stated, the policy for reporting was when a resident had an incident the nurse was to assess the injury and call the family, doctor, and follow orders, if it was something the resident could not tell them how it happened they were to report to the Administrator and the DON immediately. RN A stated he did not recall reporting anything to Administrator D (at that time) or the DON concerning Resident #1 in March (2023). Attempts were made to contact on 09/20/23 at 1:00 p.m., and 09/21/23 at 12:30 p.m. for Administrator D with no return calls. In an interview on 09/20/23 at 3:35 p.m. with Administrator E revealed that since he had been the Administrator at the facility (mid-June 2023) he had in-services with all staff informing them to report immediately to him and the DON any unusual injuries, to include bruising without a cause, and unwitnessed falls with injuries. The Administrator stated I had no reports concerning Resident #1, except the sexual assault that had occurred in July (2023). Administrator E stated I was working the day of the assault and RN A had brought him the video on Resident #1's phone, Administrator E stated I immediately called the police, the family, the dialysis company, and the physician. I immediately went and spoke to Resident #1 the police came, I took the police officers to the resident and asked her permission to speak to the police. The police viewed the video and called additional police and a crime scene was set up in the dialysis room. The police brought in crime scene investigators and investigated, taking a lot of items from the room. Administrator E stated I meet with the family and Resident #1 went to the hospital. Administrator E stated I did complete an investigation including in-servicing and training on abuse/neglect with all staff, had safe surveys conducted and spoke to the residents himself. Administrator E stated I spoke with his cooperation informed, of the sexual assault and requested cameras installed, a special lock for the door, and contacted the dialysis company informed, I wanted no male dialysis RNs provided to the facility from 07/14/23 date forward. Record review of the in-service trainings reflected all staff for all shifts and all disciplines in the facility were in-serviced on 06/26/23 and 06/27/23 given by Administrator E on the following topics: abuse and neglect, reporting injuries of unknown origin and injuries to the Administrator and DON immediately. A copy of the abuse and neglect policy was provided, and testing was completed by the staff that had attended. In a follow-up interview with RN A on 09/20/23 at 4:00 p.m. revealed he recalled the in-service from the new Administrator E, and he knew that he was supposed to report to the Administrator and DON immediately. RN A stated he did not know why he did not follow policy in March and he guessed he was busy that day. In an interview on 09/20/23 at 4:15 p.m. with the DON revealed the charge nurses were supposed to assess and inform the physician, the family, and the Administrator and herself when an incident occurred. The Administrator wanted to be told about all incidents, then they discussed them in the morning meeting. The charge nurse was supposed to fill out and document an incident/accident form, so the occurrence could be followed-up on. The DON stated she was unaware of any bruising reported by Resident #1 in March (2023). The DON stated had she been made aware she would have investigated and reported the incident. The DON stated that did concern her RN A had failed to report the bruising of unknown origin, after what had happened to Resident #1 July (2023), and stated, I could have found something out maybe in March, but now I will never know. Review of the Provider Investigation Report dated 07/13/23 reflected a timely investigation, following RN A provided the video to the facility Administrator immediately. Further review reflected the referral of the dialysis nurse, police report, communication, and in-service for all staff dated: 07/14/23 through 07/19/23 concerning reporting abuse and neglect, to include injuries of unknown origin, suspicious injures, or unusual behavior by the resident, no male nurses were provided to the facility by contract dialysis center after 07/13/23, cameras were placed in the dialysis room in the facility, monitored by the Administrator E with his back up monitoring by the DON. The cameras could be monitored on his phone from anywhere in the world anytime of the day. Administrator E had logs of the monitoring dated 07/17/23 (when the camera was installed) until the time of the visit 09/21/23. The facility placed a key code lock on the dialysis room, that only a select number of staff had, not including the dialysis nurses. The dialysis room door was to always remain open when in use. Safe surveys with all residents, including the dialysis resident at that time, with follow-up each week with the dialysis resident and other residents to check for any concerns the resident had. Psychological and psychiatric services were proved to Resident #1. Record review of the her nursing progress notes reflected on 07/13/23 that Resident #1 provided to RN A video that she had been sexual assaulted by her assigned dialysis nurse. RN A reported to Administrator E immediately, the family, police and the physician were notified. Resident #1 was sent to the hospital for further evaluation. RN A had documented Resident #1 had been assessed head to toe with no physical evidence of trauma. In an interview on 09/20/23 at 11:00 a.m. with RN B Director of the SANE (Sexual Assault Nurse Examiner) unit at the hospital revealed Resident #1 had been assigned to another RN working the unit. RN B said that she had not seen the video but could provide all the testing results from the SANE exam. RN B stated that the resident had remained calm throughout the process and was returned to the facility after her evaluation at the hospital. In an attempt to interview on 09/20/23 At 11: 45 a.m. with RN C SANE nurse, that retuned the call on 09/25/23 at 2:00 p.m. reflected that she had processed Resident #1 when she arrived at the emergency room on [DATE]. She did review the video and stated it was disturbing. RN C stated she had been involved in SANE assessing for 15 years and the video was very disturbing. RN C stated the sexual assault on Resident #1 from the dialysis RN was very disturbing. RN C stated one of the most disturbing things for her was at the end of eh sexual assault from Dialysis RN , he leans into the face of Resident #1 who is obviously unable to respond and says so you feel better now. Resident #1 was quietly speaking and was very tired and was alert and oriented and able to answer questions at the time of her assessment. Record Review of the SANE Documentation dated 07/14/23 reflected that RN C had processed Resident #1 for sexual assault to include review of the video provided by Resident #1. The summary of the video reflected dialysis RN inserting gloved and ungloved hands in the vagina of [Resident #1], [dialysis RN] inserting his penis no condom used, multiple times in the vagina of [Resident #1], while holding her legs straight up in the air. During the exam Resident #1 reported to RN C that she had rectal pressure and a rectal exam revealed redness and tenderness with a clear discharge and soft stool surrounding the anal opening. Resident #1 had 2cm X 2cm purple bruising on her right breast, that was tender (Resident #1 stated dialysis RN had grabbed her breast) and a 2cm scratch on her right shoulder. RN C documented Resident #1 had reported to her that she had discussed that she felt something was wrong with her family, but they did not believe her, so she made her mind up to get her own evidence, by ordering a Spy Cam and videoing him. She said she could not get the Spy Cam to work so she used her cell phone. Attempt was made to contact the Dialysis RN on 09/21/23 at 2:00 p.m.; the phone had been disconnected. Monitoring of the facility's implemented actions that corrected the non-compliance prior to entry included: Observation and interview on 09/19/23 9:30 a.m.it was observed that room to the dialysis room was locked with a special coded lock, the nurse in charge of the area, RN A was ask if he knew the code and how did the dialysis nurses get in, he said he knew the code and he had to let them in they did not have the code. When he opened the room there was a bed and a chair in the room, with the cameras that had been placed to monitor, the RN left the door open as he said if anyone was in the room the door had to remain open who when the staff went by, they could look into the room. RN A stated all of this occurred after the sexual assault occurred with Resident #1. These are interventions put in place, we have only women that come from the dialysis center to dialyze our residents. RN A was asked if he followed-up on the dialysis residents: follow-up was assessing the site as we would on any dialysis resident checking the shunt, checking the site of the port. RN A stated if he notices anything different on the resident or if the resident was acting differently or mentioned something he would immediately report it to the Administrator and the DON. RN A stated he had been in-serviced after the sexual assault had occurred and before that he had been in-serviced by the new administrator, concerning his expectations concerning abuse and neglect. Record review of the all staff in-services dated: 07/14/23 through 07/19/23 concerning reporting abuse and neglect, to include injuries of unknown origin, suspicious injures, or unusual behavior by the resident. Further review reflected in-services given by the Administrator dated 06/26/23 and 06/27/23 for abuse, and neglect, to include reporting bruising, injury of unknown origin, and his expectations that he is to be informed by any staff member of anything they considered usual or abuse. Record Review of the geriatric psychological services revealed the psychologist visited with Resident #1 on 07/20/23/ after her return from hospital, further review reflected the psychologist continued weekly visit with Resident #1 until discharge. Review of the psychiatric progress note dated 07/20/23 reflected a review of the medications that resident was taking after the return form the hospital, no changes were made at the time. In an observation on 09/19/23 at 1:00 p.m. there was an unknown male resident in the dialysis room with a female Rn receiving dialysis. The resident appeared comfortable. The resident stated he had to [NAME] a consent since there were cameras in the room, indicating where the cameras were located. 09/21/23 at 2:00 p.m. the Administrator revealed the monitoring logs that he had dated 07/17/23 (when cameras were placed) until current. In an observation on 09/19/23 at 1:00 p.m. with the Administrator revealed a large television in the administrator's office that revealed the entire facility inside and out, as well as the dialysis room. Further observation was shown to the investigator by the Administrator on the his phone. In an observation on 09/21/23 at 2:00 p.m. revealed the Administrator showed the monitoring logs dated 07/17/23 (after cameras were installed) until the current visit. There was no attempt to contact the Resident #1 as she had moved out of the state. Interviews were conducted on 09/21/23 from 10:29 a.m. to 10:42 a.m., 09/21/23 at 2:40 p.m. and from 4:40 p.m. to 4:50 p.m. with licensed nursing staff RN A, LVN F, LVN G, and LVN H. The nursing staff were able to accurately summarize the facility's reporting policy and procedure related to abuse/neglect to include unknown bruising or injures of unknown origin, reporting and documenting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse and for reporting injuries of unknown origin for 1 (Resident #1) of 3 residents reviewed for abuse. The facility failed to implement their internal policies when: RN A failed to report to the Administrator (at that time), or the DON when Resident #1 reported significant bruising of unknown origin to the upper thigh, inner thigh, buttocks, groin area, and to the knee on the right leg on 03/08/23. On 07/13/23 Resident #1 provided video to RN A that she had been sexually assaulted by the Dialysis RN. It was determined a past non-compliance Immediate Jeopardy existed from 03/08/23 to 07/17/23. The Immediate Jeopardy was determined to have been removed on 07/17/23 due to the facility's implemented actions that corrected the non-compliance. This failure could place residents at risk of abuse, neglect, exploitation, or mistreatment. Findings included: Review of the facility's policy titled, Abuse, and Neglect, revised dated 03/2018, reflected the following: The resident has the right to be free from abuse, neglect, and exploitation . residents should not be subjected o abuse by anyone, including, but not limited to facility staff other residents, consultants, or volunteers, staff of other agencies serving the resident . The facility will provide and ensure the promotion and protection of resident rights . It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or . abuse and situations that may constitute abuse or neglect to any resident in the facility . Definitions: . 4. Sexual Abuse: non-consensual sexual contact of any type with a resident 12. Injury of unknown Source any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident: and The injury is suspicious because of the extent of the injury or the location of the injury . Prevention .3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility . Investigations will be reviewed by the facility Administrator and /or Abuse Prevention within 24 hours of complaint. Appropriate notification to state and home office will be responsibility of the administrator .4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising or residents . that may constitute abuse . Repairing .3. Facility employees must report all allegations of abuse, neglect, exploitation .or injuries of unknown source to the facility administrator Review of Resident #1's EHR reflected she was a [AGE] year-old female admitted to the facility on [DATE], discharge home on [DATE]. Her diagnoses included: Encephalopathy (disease to the brain), Diabetes, (increase sugar), and end stage renal disease (kidneys not working). Review of Resident #1's annual MDS dated [DATE] reflected she had a BIMS score of 15 and indicated she was cognitively intact. Resident #1 required minimal to no assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of Resident #1's care plan dated 07/19/23 reflected she required hemodialysis ( procedure to cleanse the blood) three times a week on Tuesday, Thursday, and Saturday. She required assistance with supervision as needed with activities of daily living due to impaired balance. Further review reflected Resident #1 had, a psychosocial well-being problems (actual sexual assault by dialysis staff) anger, feeling betrayed. Her care plan did not contain any interventions regarding bruising. Review of the nursing progress note dated 03/08/23 documented by RN A, reflected Resident #1 reported to RN A bruising to her right leg. RN A assessed Resident #1, documented large purple/red bruises from the right buttocks down to her right knee. RN A informed the physician and the family of the bruising. Resident #1 denied falling, to RN A, and when asked by RN A how the bruising happened Resident #1 told RN A, she did not know. Review of the dialysis schedule revealed that the Dialysis RN was working at the facility during the month of March and had provided dialysis on 03/08/23 to Resident #1, the day that the bruising was reported to RN A. Record review of the incident accident log dated 03/23 reflected no reports of bruising by Resident #1 on 03/08/23. In an interview with RN A on 09/20/23 at 3:00 p.m. revealed he did not recall Resident #1 reporting any bruising on her body to him. RN A stated, the policy for reporting was when a resident had an incident the nurse was to assess the injury and call the family, doctor, and follow orders, if it was something the resident could not tell them how it happened they were to report to the Administrator and the DON immediately. RN A stated he did not recall reporting anything to Administrator D (at that time) or the DON concerning Resident #1 in March (2023). Attempts were made to contact on 09/20/23 at 1:00 p.m., and 09/21/23 at 12:30 p.m. for Administrator D with no return calls. In an interview on 09/20/23 at 3:35 p.m. with Administrator E revealed that since he had been the Administrator at the facility (mid-June 2023) he had in-services with all staff informing them to report immediately to him and the DON any unusual injuries, to include bruising without a cause, and unwitnessed falls with injuries. The Administrator stated I had no reports concerning Resident #1, except the sexual assault that had occurred in July (2023). Administrator E stated I was working the day of the assault and RN A had brought him the video on Resident #1's phone, Administrator E stated I immediately called the police, the family, the dialysis company, and the physician. I immediately went and spoke to Resident #1 the police came, I took the police officers to the resident and asked her permission to speak to the police. The police viewed the video and called additional police and a crime scene was set up in the dialysis room. The police brought in crime scene investigators and investigated, taking a lot of items from the room. Administrator E stated I meet with the family and Resident #1 went to the hospital. Administrator E stated I did complete an investigation including in-servicing and training on abuse/neglect with all staff, had safe surveys conducted and spoke to the residents himself. Administrator E stated I spoke with his cooperation informed, of the sexual assault and requested cameras installed, a special lock for the door, and contacted the dialysis company informed, I wanted no male dialysis RNs provided to the facility from 07/14/23 date forward. Record review of the in-service trainings reflected all staff for all shifts and all disciplines in the facility were in-serviced on 06/26/23 and 06/27/23 given by Administrator E on the following topics: abuse and neglect, reporting injuries of unknown origin and injuries to the Administrator and DON immediately. A copy of the abuse and neglect policy was provided, and testing was completed by the staff that had attended. In a follow-up interview with RN A on 09/20/23 at 4:00 p.m. revealed he recalled the in-service from the new Administrator E, and he knew that he was supposed to report to the Administrator and DON immediately. RN A stated he did not know why he did not follow policy in March and he guessed he was busy that day. In an interview on 09/20/23 at 4:15 p.m. with the DON revealed the charge nurses were supposed to assess and inform the physician, the family, and the Administrator and herself when an incident occurred. The Administrator wanted to be told about all incidents, then they discussed them in the morning meeting. The charge nurse was supposed to fill out and document an incident/accident form, so the occurrence could be followed-up on. The DON stated she was unaware of any bruising reported by Resident #1 in March (2023). The DON stated had she been made aware she would have investigated and reported the incident. The DON stated that did concern her RN A had failed to report the bruising of unknown origin, after what had happened to Resident #1 July (2023), and stated, I could have found something out maybe in March, but now I will never know. Review of the Provider Investigation Report dated 07/13/23 reflected a timely investigation, following RN A provided the video to the facility Administrator immediately. Further review reflected the referral of the dialysis nurse, police report, communication, and in-service for all staff dated: 07/14/23 through 07/19/23 concerning reporting abuse and neglect, to include injuries of unknown origin, suspicious injures, or unusual behavior by the resident, no male nurses were provided to the facility by contract dialysis center after 07/13/23, cameras were placed in the dialysis room in the facility, monitored by the Administrator E with his back up monitoring by the DON. The cameras could be monitored on his phone from anywhere in the world anytime of the day. Administrator E had logs of the monitoring dated 07/17/23 (when the camera was installed) until the time of the visit 09/21/23. The facility placed a key code lock on the dialysis room, that only a select number of staff had, not including the dialysis nurses. The dialysis room door was to always remain open when in use. Safe surveys with all residents, including the dialysis resident at that time, with follow-up each week with the dialysis resident and other residents to check for any concerns the resident had. Psychological and psychiatric services were proved to Resident #1. Record review of the her nursing progress notes reflected on 07/13/23 that Resident #1 provided to RN A video that she had been sexual assaulted by her assigned dialysis nurse. RN A reported to Administrator E immediately, the family, police and the physician were notified. Resident #1 was sent to the hospital for further evaluation. RN A had documented Resident #1 had been assessed head to toe with no physical evidence of trauma. In an interview on 09/20/23 at 11:00 a.m. with RN B Director of the SANE (Sexual Assault Nurse Examiner) unit at the hospital revealed Resident #1 had been assigned to another RN working the unit. RN B said that she had not seen the video but could provide all the testing results from the SANE exam. RN B stated that the resident had remained calm throughout the process and was returned to the facility after her evaluation at the hospital. In an attempt to interview on 09/20/23 At 11: 45 a.m. with RN C SANE nurse, that retuned the call on 09/25/23 at 2:00 p.m. reflected that she had processed Resident #1 when she arrived at the emergency room on [DATE]. She did review the video and stated it was disturbing. RN C stated she had been involved in SANE assessing for 15 years and the video was very disturbing. RN C stated the sexual assault on Resident #1 from the dialysis RN was very disturbing. RN C stated one of the most disturbing things for her was at the end of eh sexual assault from Dialysis RN , he leans into the face of Resident #1 who is obviously unable to respond and says so you feel better now. Resident #1 was quietly speaking and was very tired and was alert and oriented and able to answer questions at the time of her assessment. Record Review of the SANE Documentation dated 07/14/23 reflected that RN C had processed Resident #1 for sexual assault to include review of the video provided by Resident #1. The summary of the video reflected dialysis RN inserting gloved and ungloved hands in the vagina of [Resident #1], [dialysis RN] inserting his penis no condom used, multiple times in the vagina of [Resident #1], while holding her legs straight up in the air. During the exam Resident #1 reported to RN C that she had rectal pressure and a rectal exam revealed redness and tenderness with a clear discharge and soft stool surrounding the anal opening. Resident #1 had 2cm X 2cm purple bruising on her right breast, that was tender (Resident #1 stated dialysis RN had grabbed her breast) and a 2cm scratch on her right shoulder. RN C documented Resident #1 had reported to her that she had discussed that she felt something was wrong with her family, but they did not believe her, so she made her mind up to get her own evidence, by ordering a Spy Cam and videoing him. She said she could not get the Spy Cam to work so she used her cell phone. Attempt was made to contact the Dialysis RN on 09/21/23 at 2:00 p.m.; the phone had been disconnected. Monitoring of the facility's implemented actions that corrected the non-compliance prior to entry included: Observation and interview on 09/19/23 9:30 a.m.it was observed that room to the dialysis room was locked with a special coded lock, the nurse in charge of the area, RN A was ask if he knew the code and how did the dialysis nurses get in, he said he knew the code and he had to let them in they did not have the code. When he opened the room there was a bed and a chair in the room, with the cameras that had been placed to monitor, the RN left the door open as he said if anyone was in the room the door had to remain open who when the staff went by, they could look into the room. RN A stated all of this occurred after the sexual assault occurred with Resident #1. These are interventions put in place, we have only women that come from the dialysis center to dialyze our residents. RN A was asked if he followed-up on the dialysis residents: follow-up was assessing the site as we would on any dialysis resident checking the shunt, checking the site of the port. RN A stated if he notices anything different on the resident or if the resident was acting differently or mentioned something he would immediately report it to the Administrator and the DON. RN A stated he had been in-serviced after the sexual assault had occurred and before that he had been in-serviced by the new administrator, concerning his expectations concerning abuse and neglect. Record review of the all staff in-services dated: 07/14/23 through 07/19/23 concerning reporting abuse and neglect, to include injuries of unknown origin, suspicious injures, or unusual behavior by the resident. Further review reflected in-services given by the Administrator dated 06/26/23 and 06/27/23 for abuse, and neglect, to include reporting bruising, injury of unknown origin, and his expectations that he is to be informed by any staff member of anything they considered usual or abuse. Record Review of the geriatric psychological services revealed the psychologist visited with Resident #1 on 07/20/23/ after her return from hospital, further review reflected the psychologist continued weekly visit with Resident #1 until discharge. Review of the psychiatric progress note dated 07/20/23 reflected a review of the medications that resident was taking after the return form the hospital, no changes were made at the time. In an observation on 09/19/23 at 1:00 p.m. there was an unknown male resident in the dialysis room with a female Rn receiving dialysis. The resident appeared comfortable. The resident stated he had to [NAME] a consent since there were cameras in the room, indicating where the cameras were located. 09/21/23 at 2:00 p.m. the Administrator revealed the monitoring logs that he had dated 07/17/23 (when cameras were placed) until current. In an observation on 09/19/23 at 1:00 p.m. with the Administrator revealed a large television in the administrator's office that revealed the entire facility inside and out, as well as the dialysis room. Further observation was shown to the investigator by the Administrator on the his phone. In an observation on 09/21/23 at 2:00 p.m. revealed the Administrator showed the monitoring logs dated 07/17/23 (after cameras were installed) until the current visit. There was no attempt to contact the Resident #1 as she had moved out of the state. Interviews were conducted on 09/21/23 from 10:29 a.m. to 10:42 a.m., 09/21/23 at 2:40 p.m. and from 4:40 p.m. to 4:50 p.m. with licensed nursing staff RN A, LVN F, LVN G, and LVN H. The nursing staff were able to accurately summarize the facility's reporting policy and procedure related to abuse/neglect to include unknown bruising or injures of unknown origin, reporting and documenting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to provide an environment that was free from accident hazards over which the facility has control and failed to provide supervision and assistive devices to each resident to prevent avoidable accidents for 1 (Resident #1) reviewed for accidents free of hazards. The facility failed to ensure Resident #1 did not elope from the facility on 05/04/2023. An IJ was identified on 05/23/23. The IJ template was provided to the facility on [DATE] at 5:17 PM. While the IJ was removed on 05/25/2023, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of accidents, hazards and improper supervision. Findings Included: Record review of Resident #1's Face Sheet, dated 05/04/23, revealed she was an 83 -year-old female admitted on [DATE]. Relevant diagnoses included Alzheimer's Disease (memory decline) and Cognitive Communication Deficit (difficulty speaking). Record review of Resident #1's Minimum Data Set (MDS) on dated 11/29/21 revealed she had a Brief Interview for Mental Status (BIMS) score of 00 (mentally impaired). For Wandering, Resident #1 had a 0 score. Interview with Administrator on 05/23/23 at 10:00 AM revealed Resident #1 had eloped from the facility on 05/04/23 at 10:00 AM. She stated a resident that resided in the [NAME] Independent Living had come to Treemont to visit his spouse, who resided at the facility. She stated while the visitor was taking his spouse back over to the [NAME] with him, and Resident #1 must had walked behind them and exited the facility. She stated the resident was small and petite, which made it very challenging to see her. She advised that the receptionist admitted to seeing the couple but did not see the resident behind them. She stated the resident had followed the couple to the [NAME] through the connecting courtyard. She stated the resident then walked into the [NAME] and the Receptionist at the [NAME] had observed the resident walking around the facility and she appeared confused. She stated the Receptionist at [NAME] contacted them and they sent someone over to bring her back to the facility. She stated she reviewed the security tape at the [NAME] and observed how the resident had walked closely behind the couple to go unnoticed. She stated the resident had left the facility at 10:00 Am, and they were contacted by the [NAME] at 10:15 am. She stated she spoke with the Receptionist and advised her the importance of being more observant. She stated she wanted to ensure the resident was in the Elopement book that was kept at the front desk and she verified that she was. She stated she practiced elopement drills with staff and in-serviced staff on elopement procedures. She stated the DON is overall responsible for ensuring staff is properly trained on elopement protocols. She stated the charge nurse on duty must complete an elopement assessment on every resident that is admitted to the facility. She stated that if it is a weekend, the resident will be placed on 72 hours monitoring until a proper assessment is completed and if the resident is deemed an elopement risk, they must be placed on 1 on 1 monitoring until a proper placement is found for the resident. She stated staff must check on residents at least every two hours and they complete a census at every shift change. She stated she had increased her front desk hours of operation to run from 6:00 AM to 1:00 AM, and she is also increasing her own works hours at the facility to ensure more coverage. She stated she had completed a head-to-toe assessment once Resident #1 returned, and no concerns were observed. She advised they notified the family and physician. She stated the long-term plan for the resident was to speak with the family about transferring her to a secured unit. She stated the risk of the resident eloping could result in her being harmed or struck by a vehicle. Interview with Receptionist on 05/23/23 at 10:53 AM revealed she was at the front desk on 05/04/23 when Resident #1 had eloped. She stated that morning, she saw a couple exiting the elevator, but she did not see Resident #1 walking behind them when she unlocked the front door to allow them to leave. She stated she must had put her head down once she saw the couple, because she was unaware that Resident #1 had exited the facility behind the couple, until she had received a call from [NAME] Independent Living where the resident wandered to. She stated she had an elopement book at the front desk to verify any elopement resident, and she stated she should had been more alert. She stated the risk of the resident eloping could had resulted in her wandering into the streets and getting hurt. She stated the day of the incident she was provided in-service on Elopement protocol, being alert at the front desk, how to use the elopement book to check for any residents at risk, and if there are any doubts, ask the resident if they signed out. Observation of Resident #1 on 05/23/23 at 11:00 AM revealed Resident #1 was lying on her bed but when any staff engaged her, she was observed following staff towards the elevator, and she had to be redirected towards the nurse's station . Interview with Licensed Vocational Nurse (LVN) C on 05/23/23 at 11:05 AM advised that Resident #1 was a smoker and any time staff engaged her, she thought it was time to smoke, so she follows them out to the smoking area, which is located on the first floor. She stated the resident had to be frequently redirected throughout the day. She stated the risk of the resident eloping could result in her getting harmed walking on public streets. She stated the DON is overall responsible for ensuring staff is properly trained on elopement protocols. She stated she was trained by the DON and ADON on elopement protocols during the final week in April, but she did not know the date. She stated staff is required to check in on residents at least every two hours and they also conducted a census at every shift change. She stated if a resident is an elopement risk, they must place the resident on one-on-one monitoring until a proper placement is found for the resident. Record Review of the facility Elopement Book on 05/23/23 revealed Resident 1's photo and face sheet in the book as an elopement risk. Interview with Receptionist at [NAME] Independent Living on 05/23/23 at 11:30 AM revealed she was at the front desk on 05/04/23 when she observed Resident #1 walking around the courtyard and inside the facility appearing confused. She stated she engaged Resident #1 and Resident #1 advised her that she was trying to return to her room. The [NAME] Receptionist stated she assumed the resident was residing at the Treemont facility because they often have visitors from that facility, so she contacted the Treemont and they sent someone to pick up the resident to take her back to the Treemont facility. Observation on 05/23/23 at 11:35 AM of facility outside area revealed it was unsecured upon exiting the facility's front door. The front door led to a courtyard connected to the [NAME] and it also led to the facility's parking lots and to major public roads. Review of facility policy on Accident/Hazards/Supervision policy, revised 11/28/16, revealed The Resident has the right to safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. An Immediate Jeopardy (IJ) was identified on 05/23/23. The IJ template was provided to the facility on [DATE] at 5:17 PM. While the IJ was removed on 05/25/23, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/25/23 at 09:31 AM and reflected the following: Resident #1 placed on `1:1 monitoring as of 5/23/23. Care giver assigned for that shift to the resident will sign monitoring tool. Complete 5/23/23 at 3:45pm, resident discharged to secure unit. Transfer referral sent to sister facility with a secure unit on 5/23/23. Resident #1 will remain on 1:1 monitoring until transfer to secure unit is complete. A posting will be placed at every visitor entrance and exit to be mindful of residents exiting the facility. If a resident is noted to leave the facility, notify charge nurse immediately. Charge nurse will notify administrator and DON immediately. Administrator will give further direction to staff. (Systemic Change) All new admission referrals will be pre-screened by DON/Designee for elopement potential risk prior to acceptance to facility. (Systemic Change) Elopement Risk Assessments were completed in Point Click Care (PCC) on 5/23/2023 for all residents in the building by the Director of Nursing, Assistant Director of Nursing, and Treatment Nurse. No other high-risk residents were identified. The Charge Nurse on admitting shift will be responsible for completing the admission elopement risk assessment at the time of admission for all new residents. Start date 5/23/23 and ongoing. DON/Designee to monitor for completion in daily stand-up meeting. DON/Designee will immediately assess resident for elopement risk if not completed upon admission. The charge nurse will complete a quarterly elopement assessment for all residents in PCC. Start date 5/23/23 and ongoing. Head to toe assessment completed and skin assessment with no abnormal findings on 5/23/23 by Charge Nurse. All exit doors in the facility were checked by the Compliance Nurse and Administrator for proper alarming and functioning. No issues were identified. Completed 5/23/23. Compliance Nurse in-serviced Administrator and Director of Nursing on the following: Resident #1 will remain on 1:1 monitoring for safety until transferred to secure unit at sister facility. in-serviced completed on 5/23/23. DON in-serviced the receptionist on 5/23/23 to be aware and monitor for residents leaving the facility with visitors. 2 Courtyard doors in common smoking area have been secured and repaired 5/25/23. In-services All in-services were initiated by Administrator and Director of Nursing on 5/23/23 and ongoing. All staff not present will be in-serviced prior to start of shift. The Administrator and DON will monitor for compliance and ensure all staff have been in-serviced. A printed roster of all staff who have been in-serviced have been maintained by the DON/Administrator Compliance Nurse in-serviced Administrator and Director of Nursing on the following: Resident #1 will remain on 1:1 monitoring for safety until transferred to secure unit at sister facility. in-serviced completed on 5/23/23. Monitored in morning stand-up meeting, completed 5/24/23 at 3:45pm due to resident discharge to secure unit. DON in-serviced the receptionist on 5/23/23 to be aware and monitor for residents leaving the facility with visitors. All staff in-serviced regarding resident elopement facility protocols were initiated on 5-23-23 by Administrator and DON. Moving forward, in-service on elopement will be assigned to all new hires in the SNF Clinic before new hires take their assignments. The Director of Nursing initiated an in-service on any resident that attempts to elope from the facility must be placed on 1:1 supervision immediately until transferred to secure unit at sister facility. The Administrator and Director of Nursing will be notified immediately. In-service initiated on 5/23/23. Charge Nurses were in-serviced by the Director of Nursing on 5/23/23 that all residents must have elopement risk assessment completed upon admission, quarterly, and as needed. Monitoring Administrator and DON will monitor daily that the resident #1 remains on 1:1 monitoring until transferred to sister facility with a secure unit. Monitoring will continue daily indefinitely. It was verified that the resident was transferred to Downtown Health and Rehabilitation in Fort Worth, TX on 05/24/23. Elopement Risk Assessments will be reviewed and monitored for completion in PCC (Point Click Care) by the Administrator and DON weekly. Monitoring will continue for a minimum of 6 weeks and then re-evaluate. Resident records were reviewed on 05/25/23 and all residents had completed an Elopement Risk assessment. The Maintenance Director/designee will check all exit doors for proper alarming and functioning daily. Monitoring will continue for a minimum of 6 weeks and then re-evaluate. (Systemic Change) Involvement of Medical Director The Medical Director was notified of immediate jeopardy on 5/23/23 Involvement of Quality Assurance (QA) On 5/23/23 an Ad Hoc Quality Assurance & Performance Improvement (QAPI) meeting was held with the Medical Director, Facility Administrator, Director of Nursing, and Social Services Director to review the plan of removal. Who is responsible for the implementation of the process? The Director of Nursing and Administrator will be responsible for the implementation of the New Process. The New Process/ system was started on 05/23/23. Who is responsible for monitoring the process? The Facility Administrator will be responsible for monitoring the implementation of this new process. Monitoring of Plan of Removal on completed on 05/25/2023 and started at 09:30 AM and completed at 12:30 PM on 05/25/23 Interview with Medical Records Nurse on 5/25/23 at 09:47 AM and revealed she attended Elopement In-service on 05/24/23 in the morning and addressed the following: Don and ADM monitoring. Code for elopement drill is orange Door signs communicating locking Every nursing station has a sign out book. First floor allowed for vending. Times door has person: 8a-5p last person leaves at 1 am. Nursing staff reliver the person to maintain or department heads. Staff stop wanders and redirect, check with the patient and see where they are going. Interview on 05/25/23 at 9:55 AM with Staff Coordinator revealed she attended Elopement In-service on 05/24/23 in the morning and addressed the following: DON and ADM monitoring. Code for elopement drill is orange Door signs communicating locking Every nursing station has a sign out book. First floor allowed for vending. Times door has person: 8a-5p last person leaves at 1 am. Nursing staff reliver the person to maintain or department heads. Staff stop wanderers and redirect, check with the patient and see where they are going. Interview on 05/25/23 at 10;05 AM with MDS Coordinator revealed she attended Elopement In-service on 05/24/23 in the morning and addressed the following: Admissions process and Elopement Assessment upon admission Steps to take if resident elopes from building Redirect resident if found wandering near exits and elevators? Code Orange if Resident is missing Taking Resident census during shift change and monitoring Q2 hours. Interview on 05/25/23 at 10:07 am with Assistance Maintenance Director revealed he attended Elopement In-service on 05/24/23 and addressed the following: Areas to search if resident eloped from building If resident was found wandering near exits and elevators, ask where they are going, some are not suppose to be on the first floor, ask where they are going take them back upstairs tell the nurse. If Resident is outside question first, where, who, what? Call the nurse, call administrator Check all doors several times a day to make sure the doors are locked. Some contractors will leave the doors cracked and need to be closed. What does code orange mean? Resident missing start searching the facility rooms, showers, closets. Check stairway doors. Interview on 05/25/23 at 10:10 AM with ADON T revealed she attended an Elopement in-service on 05/24/23 and she covered the following: Elopement Assessment upon admission, if high, put the resident on 1 to 1 monitoring until the resident is moved to a secure placement. Notify the DON, ADM, What do you do when a resident goes missing? Notify charge nurse of status then proceed to search outside and announce a code orange. How frequently do you check on residents monitor every 2 hours and shift change process for elopes. Interview on 05/25/23 at 10:47 AM with CNA F revealed she attended an Elopement in-service on 05/24/23 and she covered the following: Resident exit seeking? Notify the nurse an direct the resident. Code orange, notify the nurse, check the elopement book, check the rooms and halls. Rounds? Every hour. Doors? Look back put in code, come in make sure no one following, then close door look. Interview on 05/25/23 at 10:50 AM with CNA S revealed she attended an Elopement in-service on 05/24/23 and she covered the following: Exit seeking- Redirect the resident and notify a nurse. census-every 15 minutes Code Orange? Room to room check for residents' closets, bathroom, outside around the facility, notify the administrator and DON. Ensure doors are closed and locked as well as the stair way. Interview with DON on 05/25/23 at 12:15 AM revealed an elopement assessment would be completed by the charge nurse on duty upon the resident being admitted to the facility. Once completed, if the resident was considered to be a high risk for elopement, the resident would be placed on 1 on 1 monitoring for 72 hours and DON and Administrator would be notified so a more secure facility placement could be found for transfer. The DON advised Code orange means there is a missing resident. She would instruct staff on the search inside and outside the building and contact the police if they are unable to locate the resident. Staff was trained to make sure the doors are closed and locked when exiting and entering and check behind themselves to assure there are no residents behind them. She advised they will ensure elopement education is completed with all new hires and ensure they know the process for elopement. She advised of monitoring the nurse's staff for wandering, exit seeking, and changes in condition for elopement. She advised of completing daily stand-up meetings and reminding of Elopement prevention and she will speak with all nursing staff to make sure they understood the process. This will continue to occur for 6 weeks. She stated her role is also to report immediately and intervene if any elopement concerns occur. Interview with the Administrator on 05/25/23 at 12:25 PM revealed her role in the Plan of Removal (POR) was to ensure the POR was followed. She stated that since they are not equipped for residents that were an elopement risk, they will no longer allow the resident to reside at the facility. She advised Resident #1 was transferred on 05/25/23 to a secured sister facility. She stated that moving forward, an elopement assessment will be completed on all new admissions by the charge nurse on duty and if a resident possess as an elopement risk, they will be placed on one-on-one monitoring until a more appropriate placement is found for the resident. The administrator stated she would facilitate the daily Champion rounds and observe for any elopement risks. She advised of staff being aware of resident displaying exit seeking behaviors, Meeting with corporate every morning to discuss and elopement concerns, and monitoring for changes in condition that would create an elopement risk. She stated she will have a rotating schedule for leadership to monitor weekend staff implementation of the POR. An Immediate Jeopardy (IJ) was identified on 05/23/23. The IJ template was provided to the facility on [DATE] at 5:17 PM. While the IJ was removed on 05/25/23, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. eloped from the facility

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received adequate monitoring and supervision to prevent elopement for 2 of 7 residents reviewed for accidents hazards/supervision. (Resident #1 and Resident #3). The facility failed to implement procedures, monitoring and interventions to prevent Resident #1 (who was cognitively impaired and confused) from eloping from the building unsupervised on 02/12/23 at 1:30 PM. The facility failed to implement procedures and interventions to maintain Resident #3's (who was cognitively impaired and confused )safety and prevention from eloping from the building unsupervised on 03/23/23 at 3:30 PM Had the facility conducted Elopement Risk Assessments upon admission, it might have been discovered that Resident #1,and Resident #3 were high risk of elopement and interventions could have been implemented to prevent the elopements of Residents #1 and #3. These failures could place residents at risk of further increased cognitive impairment and confusion, injuries, and community hazards. An Immediate Jeopardy (IJ) was identified to have existed from 02/13/23 to 03/23/23 . The IJ was determined to be at past non-compliance as the facility had implemented actions that corrected the noncompliance prior to the being of the survey. Findings Included: Review of Resident #1's face sheet dated 04/12/2023 revealed he was a 70 year male admitted on [DATE] with diagnosis: chronic obstructive pulmonary disease (chronic inflamed lung disease), elevated blood-pressure reading, without diagnosis of hypertension (high blood pressure), essential, generalized anxiety disorder (fear or worry), major depressive disorder, recurrent, mild (sadness), unspecified dementia (decline in cognitive function, unspecified severity, with agitation (tension and restlessness.), constipation, unspecified, bipolar disorder (mood disorder). Resident #1 was discharged to a behavior unit on 02/1/23 Review of Resident #1's MDS dated [DATE] reflected a BIMS score of 03 showing he was severely impaired cognitively. He did not have any symptoms of delirium. His mood interview reflected the following symptoms: feeling down, depressed, hopeless, poor appetite, poor concentration, wandering, and moods. Resident #1's behavior section revealed he had behavioral symptoms of wandering excessively. Resident #1 required supervision for ADLs. Review of Resident #1's care plan dated 02/11/2023 reflected the resident had a psychosocial wellbeing problem (actual or potential) r/t anxiety. interventions include allow the resident time to answer questions and to verbalize feelings perceptions, and fears. encourage participation from resident who depends on others to make own decisions. provide opportunities for the resident and family to participate in care. Resident #1 has MI and was PASRR positive with interventions to have specialized services recommended by the local PASSR team. Resident #1 has a diagnosis of bipolar: disorder and affects his thought process. His interventions include demonstrating and encouraging adaptive coping skills to assist with interaction and willingness to participate with others x 90 days be honest and keep all promises. encourage resident to verbalize feelings. psych evaluation as ordered by MD. administered medication as ordered by the MD. Review of Resident #1's physician orders dated 02/11/23 revealed behavior monitoring for: medications (Oxcarbazepine for Bipolar and Risperdal for agitation) documentation to support the # of times the resident exhibited the above behavior during shift by using intervention codes: 0) none; 1)1 on 1; 2) activity; 3) adjust room temperature; 4) backrub; 5) change position; 6)give fluids; 7) give food; 8) redirect; 9) remove resident from environment; 10) return to room. Review of Resident #1's progress note dated 02/12/23 at 1:30 PM by ADON revealed Text: resident eloped from property; Resident #1 was found by police officer and escorted back to facility; resident states he was looking for his pickup truck to go home. resident assessed for injuries; no injures observed at this time. resident currently sitting in dining room currently. His RR was contacted and notified of the incident of elopement, along with MD, DON, and ADM. The DON contacted the psych Dr. who visited the resident 02/12/23 and warranted an increase in his Risperdal from 0.5 mg to 1 mg by mouth every morning for the DX of Bipolar Disorder and Ativan 1 mg by mouth every 4 hours as needed for 14 days was to address his DX of agitation. Noted by LVN D. Review of Resident #1's elopement assessment after the incident dated 2/12/23 at 1:52 PM revealed the resident was exit seeking, experiencing increased wandering, and requesting to leave or go elsewhere .physician orders for |Ativan 0.5 mg every 6 hours PRN for increased anxiety .monitoring every 15 minutes. Review of Resident #1's elopement assessment dated [DATE] 01:06 PM revealed he has increased anxiety, asking to leave he was placed on 15 minutes monitoring, new physician order for Ativan. Observation and interview with Resident #1 were not conducted as he was no longer a resident at the facility. Further investigation determined that the resident was returned to the behavior hospital for further evaluation of placement based on his PASSR positive evaluation. Review of facility provider incident report dated 02/15/23 revealed actions taken by the facility after the resident was returned included the following; Family MD notified of the event and resident was immediately assessed by the charge nurse Resident placed on 1 on 1 monitoring .Resident's medications reviewed, Contractors educated on the need for the facility's alarm system to remain activated at all times .Psych evaluation completed 02/13/23 and plan of care updated .Facility staff retrained/Inservice on resident abuse and elopement prevention Elopement assessments completed on all residents and no other residents were identified. Resident #3 Review of Resident #3's face sheet dated 04/12/23 revealed he was [AGE] year-old male admitted to the facility 03/14/23. His diagnoses included mild cognitive impairment, cerebral infarction (stroke), and left-sided paralysis. Review of Resident #3's MDS dated [DATE], reflected a BIMS score of 0 indicating severe cognitive impairment. Further review of the MDS revealed Resident #3 was independent in functioning with all ADLs, needing extensive assistance with personal hygiene, and dressing, with limited assistance with toileting, due to his diagnosis of dementia. The active diagnosis on Section I of his MDS revealed bipolar disorder and Psych Disorder. There was no information indicating delirium, wandering, behaviors or mood. Review of Resident #3's physician note dated 03/21/23 reflected Pt was seen and examined at the bedside Care plan and medications were reviewed and discussed with nursing staff. Resident #3 will continue PT/OT as requested. Staff will watch for s/s of infections. Continue current POC. Monitor for Pain management and fall precautions PT will work on strengthening, endurance training, neuromotor training, gait training, balance training and stair climbing as appropriate. OT will work on ADL and functional mobility training .Overall remains the same; Continue to monitor. Fall precautions .meds reviewed .continue with current treatment .Monitor recurrent infections, aspiration precautions .pt. and skilled rehab to continue .continue POC .discussed with team .Orders signed . MD-P. A review of Resident #3's Medication review dated 03/21/23 reflected Cyclobenzaprine HCl Oral Tablet 5 MG (Cyclobenzaprine HCl), Give 1 tablet by mouth every 8 hours as needed for Muscle spasm, Mesylate Oral Tablet 2 MG (Doxazosin Mesylate) .Give 1 tablet by mouth at bedtime for HTN .There is a potential drug interaction with another medication . Oral Tablet 40 MG (Furosemide) # Debility and Decline Oral Tablet 40 MG (Furosemide) # Debility and Decline . Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) .Give 1 tablet by mouth every 24 hours as needed for pain. Risperdal Oral Tablet 0.5 MG (Risperidone) .Give 1 tablet by mouth every 12 hours as needed for Psychosis related to unspecified psychosis not due to a substance or known physiological condition. Review of Resident #3's care plan revealed dated 03/15/23 revealed The resident receives antipsychotic medication r/t psychosis Risperdal 0.5 mg routinely The resident has impaired cognitive function/dementia or impaired thought processes Dementia .The resident will maintain current level of cognitive function through the review date. Communicate with the resident/family/caregivers) regarding residents' capabilities and needs. Communication: Use the residents preferred name. Identify yourself at each interaction. Provide the resident with necessary cues- stop and return if agitated. Discuss concerns about confusion, disease process, Engage the resident in simple, structured activities that avoid overly demanding Resident has delirium or an acute confusion episode r/t Bipolar.The resident will be free of s/sx of delirium (changes in behavior, mood, cognitive function, communication, level of consciousness, restlessness) through the review date. Actual elopement or elopement attempt Resident was confused and wandered outside the facility unattended Actual 3/23/23 .Date Initiated: 03/23/2023 .Revision on: 03/30/2023 o Will remain safe in the facility, with no further elopements or elopement attempts, unless accompanied by staff or other authorized person through review Date Initiated: 03/23/2023 Revision on: 03/30/2023 Target Date: 04/02/2023 o Contact emergency room departments at county hospitals for possible admission .Date Initiated: 03/23/2023 Revision on: 03/30/2023 o Contact the local authorities to make aware of eloped resident .Date Initiated: 03/23/2023 o Instructed hospital to discharge resident to a specific secured unit o Assess/record/report to MD risk factors for potential elopement such as: Resident's elopement or attempted elopement, Wandering, Repeated requests to leave facility, statements such as I'm leaving I'm going home, attempts to leave facility, elopement attempts from previous facility, home, or hospital Observation and interview with Resident #3 were not conducted as he was no longer a resident at the facility. Further investigation determined that the resident was placed at a sister facility better able to meet his needs related the diagnosis of Dementia. In an interview with CNA-W on 4/12/23 at 9:40 am, said Resident #3's behaviors were wandering down the hall, and he was easily re-directed. She was not on duty the day Resident #3 eloped. She did not work with Resident #1 She attended in-service non elopement, abuse and neglect and supervision, In an interview on 04/12/23 at 10:35 AM, with the ADM revealed that the incident involving Resident #1's elopement occurred under the previous ADM leadership. The ADM was notified of the elopement of Resident #3 by the DON, on 03/23/2023 at 3:00 PM . An action plan for search due to elopement was activated. The staff searched for the resident on site and in the community. She advised the AD to contact local hospitals and morgues in an attempt to locate the resident and notify his family. The DON notified he MD and ADM called law enforcement. Resident #3 was located at a local hospital, that he was brought in by EMS Fire. The resident was being assessed by the hospital staff when he was located. The ADM stated the investigation revealed that Resident #3 may have exited out the front door. The ADM stated that the front door was locked at all times. She expected the staff to monitor and supervise staff, conduct routine census of residents in the building during rounds and shift. The ADM said she expected residents to be assessed upon admissions for elopement to provide the appropriate care while residing at the facility to maintain safety and prevent incidents of neglect. She stated the staff were immediately in-serviced on Neglect, Elopement, and supervision. All Residents were assessed for wanders, census checks were conducted throughout each shift of residents and the coded on all doors were changed. Family and MD were notified that the resident was missing. The ADM contacted law enforcement and submitted a report. ADM and DON will be conducting Inservice training with nursing to address the importance of Care Plans being thorough and timely this week to prevent accidents of this nature from occurring, In an interview with the Admissions Director on 04/12/23 at 11:30 A.M. revealed that neither Resident #1 or #3 had a history of elopement behaviors at the time of admissions. She does not know if nursing conducts elopement assessments upon admissions. She reported Resident #1 was a bit confused, and admitted from a behavior hospital, so the focus was on his mental health. She said Resident #3 was observed missing and the administrator called a code orange, meaning elopement, and they proceeded to check every room, bathrooms, kitchens, parking lot, community called hospitals and was found. She said they were not sure if he fell off the bike, but reports were that he was found on the ground in the community behind us with an abrasion to his head next to a bike. She said once confirming his location, the hospital said they were assessing him. She advised them not to release him as he had eloped and was demented. She provided contact information and additional numbers and names of the POA, receiving facility and current facility once assessments were completed and ready for discharge. She did not hear from the hospital she was directed to call the hospital the next morning to find out if he was still a patient. She was told by the hospital staff that the was admitted and discharged as there was nothing else, they could do for him. She said he was released independent. The Admissions Director advised the nurse to make a missing persons report, as the documentation of the next step was provided by hospital staff and faxed over. She called the family to see if they picked the resident up, and they did not. She called the receiving facility to see if he was admitted , and he was not. It was determined that Resident #1 was at the hospital after being located near the hospital on a nearby tollway. it was her understanding that pedestrians observed him wandering appearing confused and called 911. EMT assessed resident again and other than confusion he was not in distressed and returned to the hospital. Resident #3 had his hospital bracelet on and she went to the hospital and remained with the resident until transfer. She said the resident was confused and did not remember a bike. She said that the resident said he went to church, ate shrimp, and staff knew where he was as they know everything. He was not in distress, sad, or communicated anything else. He was placed at sister facility with a locked memory unit. In an interview on 04/12/23 at 10:40 AM and 04/13/2023 at 1:30 PM with the DON, revealed that once she was notified of the elopement a plan to alert all staff and search for the resident was conducted. she was not at work the day of the incident (03/23/23,) however she was notified by the weekend nurse that Resident #3 was missing and last seen at approximately 3:00 PM. The DON instructed the RN to contact law enforcement, conduct an alert of code Orange, indicating elopement of resident. She and staff were instructed to search the perimeter of the facility. Admissions Coordinator contacted local nearby hospitals and located the resident. The hospital was notified that Resident #3 had eloped from the facility and he has a diagnosis of dementia and impaired cognition. She stated Resident #3's MD, family, ADM, DON, and ADON were all notified by the charge nurse. The DON and ADON said educated staff on supervision, neglect, and monitoring, and the importance of documentation and census count during shifts. The staff participated in elopement drills, and prevention. Resident #1 was also assessed for elopement. In an interview on 04/13/23023 at 12:15 PM, ADON revealed she was working and notified of Residents elopement, but she wasn't working the day of Resident #2's elopement. She does not know who was working. She said it was important for correct assessments and communication through documentation was completed to know the residents needs and implement them to prevent accidents and hazards from occurring. She said Resident #1 told her he was outside looking for his pickup truck to go home. The ADON said that residents #1 and #3 were supervised by nursing staff on the second floor, by conducting routine rounds every 2 hours and redirecting behaviors of wandering. Every shift a census was conducted to confirm the number of residents in the building. ADON said Resident #1 was assessed for injuries, and none was observed. She said after assessing resident she then notified the MD, DON, ADM, and family of the incident at once. He as placed on 1 on 1 supervised monitoring. Interview with the on 4/13/23 at 1:00 PM with R.N. unit manager that works 8-4:30 p.m. he supervised the west side. He expects the staff to monitor and report resident behaviors of wandering to charge staff or nurse managers immediately. He attended Inservice on supervision, admission assessment including elopement, shift census, and documentation for residents. He was not working when the incident occurred with Resident #1 and #3. He was including on the trainings. He said it was the charge staff and nurse manager responsibility to monitor resident behaviors and report to address with leadership so interventions can be reviewed and adjusted as this was the key component to nursing plan of care for residents. Interview with RN 04/16/23 @1:55 PM who was working with Resident #1 He said while conducting round he received a call from the receptionist that Resident #1 was just returned by law enforcement. He reported this to the ADON, who summons him for assistance downstairs. He does not know how the resident left the second floor and exited the building. He was told that the resident exited the contractor's door on the 1st floor. Census rounds were completed and the ADON assessed resident. All other residents were found to be in the building. He does not remember much about Resident #3. He said resident was placed on one-on-one supervision until being placed at the behavior host additional precautions were implemented by changing the code and check the doors when entering a new placement. He does not recall an elopement assessment on resident prior to admissions, but all residents were assessed after this incident with training on elopement drills, and census residents every shifts. Interview with LVN N, 04/16/2023 @ 2: 25 PM who was working the Resident #1. When he did his rounds he was called by ADON reporting a resident was discovered outside by law enforcement. He was brought back immediately. MD, ombudsman, Administrator were notified. Additional precautions were implemented by changing the code on all doors, being conscience of residents when leaving the building to assure that they are not trailing. Training and actions included elopement assessments, elopement drills, and residents census every shift under the supervision of nurse manager and chare nurses. Aides should be reporting to nurses any wandering behaviors for immediate assessments and education as well as reporting to MD for safety. He did not work with Resident #3. A review of provider report revealed Resident an interview with receptionist that was no longer employed at the facility upon conducting the investigation. The interview revealed DPD Resident #1 on 2/12/2023, asking he was a resident at the facility, as he was found outside walking around in his socks looking. He said the socks were an indication to him the resident was a possible resident at the facility. Resident was returned. ADON was notified. A review wo the facility in-services dated 02/15/2023 and 03/24/23 reflected all staff education on abuse and neglect, elopement, supervision, monitoring and documentation, and elopement drills were performed. Resident #3's provider report revealed resident was reported missing by an aide then charge nurse. A search was conduced on an off the premises including staff driving around the community while others called in a missing persons report and local hospitals. Once found , the hospital staff were told to not release the resident and call before discharging, as he would be going to a memory unit. On 3/24/23 the hospital had not called, so administrator instructed staff to call, it was reported the resident was no longer at the hospital after speaking with several staff it was determined he was discharged to his own recognizance and was to the same hospital being found wandering on a nearby tollway after a 911 call was made by unknown local individuals who reported him wandering and confused. A staff was asked to go to the hospital and remain with the resident until he was transported to the memory unit. Actions included: Elopement drill with all staff and every shift, elopement assessments on all residents, updated care plans, were intiated on 03/23/23. The facility also initiatated a new admission protocol for new residents including elopement assessments, supervision, reporting behaviors, and shift census verification prior to entrance. A record review note from health coordinator revealed on 02/12/23 revealed a call from the receptionist that resident #1 was returned by local PD after being found in the parking lot. She said she last saw him early that morning. He was returned upstairs and assessed by nursing staff. It was unclear how the resident eloped the building. The health coordinator was not available for an interview. Resident #1's incident occurred under a new administrator who was not available for an interview. Facility elopement and abuse policy was requested on 04/13/23 from ADM and DON, and it was not provided a prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide basic life support, including CPR (Cardiopulmonary Resuscitation), to a resident who required such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 5 residents (Resident #1) reviewed for CPR. Nursing staff failed to provide CPR for Resident #1, who had a full code status and was found unresponsive with no pulse. CPR was not provided for approximately six minutes until EMS arrived and started CPR. Resident #1 expired at the facility on 02/21/23. This failure placed residents who had a full code status at risk of not receiving necessary life-saving measures, which could result in death. An Immediate Jeopardy (IJ) situation was identified on 02/27/23 at 3:46 PM. While the IJ was removed on 02/28/23 at 3:55 PM, the facility remained out of compliance at a scope of isolated and with actual harm that is not immediate, due to the facility's need to evaluate the effectiveness of the corrective systems . Findings Include: A record review of Resident #1's electronic face sheet, dated 02/24/23, revealed Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included frontal lobe and executive function deficit following cerebral infraction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), gastroparesis (a disorder that slows or stops the movement of food from your stomach to your small intestine), type 2 diabetes mellitus ( a group of diseases that affect how the body uses blood sugar) with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes), bipolar disorder, anxiety disorder, chronic pain syndrome, psychoactive substance abuse and essential primary hypertension. The face sheet revealed Resident #1's code status as Full Code (full code allows for all interventions needed to restore breathing or heart functioning, including chest compressions, CPR , a defibrillator, and a breathing tube.). A record review of Resident #1's Comprehensive MDS, dated [DATE], revealed she had a BIMS of 12, which indicated her cognition was moderately impaired. A record review of Resident #1's Care Plan, dated 02/16/23, revealed Resident #1 had shortness of breath pain with the following interventions: Assist resident/family/ caregiver in learning signs of respiratory compromise. Refer significant other/caregiver to participate in basic life support class for CPR, as appropriate. Maintain a clear airway by encouraging resident to clear own secretions with effective coughing. If secretions cannot be cleared, suction as needed to clear secretions. Further review of the Care Plan revealed Resident #1 was a Full Code, and the interventions included the following: Request for CPR to be initiated will be followed. Notify the charge nurse immediately if the resident is not breathing or does not have a heartbeat. CNA consult with nursing staff on changes in health. A record review of Resident #1's Progress Notes, dated 02/21/23, revealed LVN A documented 1:25 Resident was in her usual state of health feeding herself in the dinning area, seen 5 minutes earlier. CNA called this nurse attention to notify her that Resident eating in dinning place was not responsive to calls and was moved to her room by the help of the unit manager. Activity Director was met along the way with the same message. This nurse went to the resident room noted resident in bed, with shallow breathing (shorter inhaling and exhaling than normal breathing but with an equal cadence) , lethargic, thready/faint pulse of 60, Rr (respiration rate)12cpm (cycles per minutes), temp. (temperature) 97.2, BS (blood sugar) 373, O2 (oxygen) sat . (saturation) 66%, BP unrecordable, O2 was applied at 10 LPM (liters per minute) O2 level rise to 86%, Code blue was called along with CPR initiation Resident is full code. 13:30 Resident still unresponsive, unable to locate pulse, 13:32 911 called 13:40 EMS took over CPR. 13:45 [family member] called waiting on call back. 14:10 911 call off CPR, and resident pronounced dead. 14:25 [family member] called back and updated on resident state of condition. Dallas medical examiner office called spoke with [family members]. Case #23-03702 was given. Family member in attendance, unit manager and facility social around for needed support. Family given information and case number for further arrangement. Awaiting remove of Body. A record review of EMS incident report, dated 02/21/23, revealed Narrative: [Paramedic] arrived on scene to find an unconscious 40 y/o female at a rehabilitation center. Staff called in a unwitnessed cardiac arrest and pt (patient) was not touched for 6 minutes prior to [EMS] arrival. [EMS] began CPR, BVM (bag-valve-mask) with oxygen and attached their AED to the pt. Upon [EMS] arrival, pt was transferred from the AED to the Lifepack (a multi-parameter device that combines semi-automated and manual defibrillation with capnography, external pacing, 12-lead electrocardiography and other monitoring functions) Pt rhythm was in asystole (a type of cardiac arrest, which is when your heart stops beating entirely and have no pulse). [Paramedic] took over CPR and asystole protocols were followed. IO (Intraosseous lines) was established. Capno (carbon dioxide) was applied but due to poor reading pt airway was suctioned and king tube was placed. BVM with oxygen was continued. First epi (epinephrine injection) was pushed. 782 arrived on scene and got on the phone with biotel. CPR protocols were followed. CPR was discontinued by Biotel at 14:08 per [physician]. Further review of the EMS incident report revealed Resident #1's Initial rhythm: Asystole and CPR Prior to EMS: No. A record review of the medical examiner report, dated 02/21/23 at 4:46 PM, revealed Investigation Narrative: On 2/21/23 @ 1434 hours, this office was notified of the apparent natural death of a 40 (age)/NA (Native American)/F (female), [Resident #1]. Per [facility staff RN B], The deceased (decd) had a hx (history) of CVA (stroke), ESRD (end-stage renal disease), HTN (hypertension), DM (diabetes), and gastroparesis and was admitted on [DATE]. The decd was witnessed to go unresponsive by staff who called 911. [EMS] responded and pronounced the death at 1415 hours. No trauma or history of Trauma was reported. [Facility Physician] will sign death certificate with the above diagnoses as the cause of death. MDI (Medicolegal Death Investigation) confirmed the above information with [Resident #1's family member]. He denied hx of trauma and EtOH (ethyl alcohol), tobacco, and illicit drug use. In an interview on 02/23/23 at 4:30 PM, Resident #1's family member, they stated they were told by RN B, who identified himself as the Unit Manager, that Resident #1 had become unresponsive, and the facility did not perform CPR. Resident #1's family member stated they told RN B Resident #1 had a full code status and asked why the facility did not perform CPR. Resident #1's family member stated RN B mumbled something low that they could not understand because RN B had a heavy accent. Resident #1's family member stated they did not ask RN B to repeat what he stated because at that point they were just really upset the facility had not performed CPR. In an initial interview on 02/24/23 at 12:05 PM, LVN A stated on 02/21/23 she was the nurse for Resident #1. LVN A stated CNA C called her and RN B to the dining area because Resident #1 was unresponsive. She stated she was just in the dining room about 5 minutes before and Resident #1 had asked her for more tea, and she refilled her tea. LVN A stated Resident #1 was talking and acting like her normal self, so she was shocked when Resident #1 became unresponsive. LVN A stated when Resident #1 became unresponsive, and she was unable to get a pulse via the wrist but there was a slight pulse on the neck. She stated she called a code blue, which meant the resident was in distress and needed emergency help. LVN A stated they moved Resident #1 to her room. She stated Resident #1 was gasping for air and they could not find a pulse, so they initiated CPR, since Resident #1 was full code. LVN A stated she wasn't sure who performed CPR on Resident #1, but it was done. When LVN A was asked why she documented CPR was initiated, if she could not identify who performed CPR, she stated she believed it was RN B. In an initial interview on 02/24/23 at 12:22 PM, RN B stated he was the Unit Manager and was called to the dining room by CNA C because Resident #1 was not responding. He stated when he entered the dining room Resident #1 was slumped over in her wheelchair and was not responding. RN B stated he found a slight pulse via the neck, so he and CNA C moved Resident #1 to her room. He stated once they got her on the bed, he was assessing vitals and he could not find a pulse on the wrist or neck. RN B stated the Activity Director (AD), ADON, and DON had come to Resident #1's room, while he was getting vitals. He stated they initiated CPR. When RN B was asked who performed CPR, he stated he was in and out of the room getting things, but he believed it was the DON . In an initial interview with the DON on 02/24/23 at 1:20 PM, she stated CNA C found Resident #1 unresponsive in the dining room. The DON stated CNA C called LVN A and RN B to the dining room. She stated it was reported that it was a sudden change in condition because the resident had been observed 5 minutes earlier by LVN A and she was her normal self. The DON stated she, the ADON, the AD, and RN B were in Resident #1's room. She stated when she entered Resident #1's room she heard her making shallow breaths and she was connected to the pulse oximeter, and it read 60. The DON stated she did not perform CPR because Resident #1 had a pulse, via the pulse oximeter. She stated she was stimulating Resident #1's chest by rubbing it and her pulse increased to 67. The DON stated EMS arrived just a couple minutes after she arrived at Resident #1's room. She stated EMS took over and immediately started CPR. The DON stated she did not know why EMS immediately started CPR, since Resident #1 had a pulse. She stated it was their policy not to perform CPR, if resident had a pulse. The DON stated she did see LVN A's documentation in Resident #1's medical record, and it was inaccurate. She stated she did know why LVN A documented CPR was done, when it was not done. She stated this was false documentation and was a risk to the resident because it was an inaccurate depiction of the resident's care. In a follow up interview on 02/24/23 at 3:28 PM, RN B stated he did not provide correct information in his initial interview because he was reading from LVN A's documentation in Resident #1's medical record. He stated no one performed CPR because Resident #1 had a pulse via the pulse oximeter. He stated on 02/21/23 CNA C called him to the dining room because Resident #1 was unresponsive. He stated he checked Resident #1's wrist and could not get a pulse, so she tried her neck and there was a faint pulse. RN B stated he and CNA C took Resident #1 to her room. He said the AD was in the dining room and he told him to go get LVN A. RN B stated he and CNA C transferred Resident #1 to her bed and he started to get vitals. He stated Resident #1 was not responding. RN B stated the AD and LVN A entered Resident #1's room. He stated he told LVN A to call code blue and told the AD to call 911. RN B stated he continued to get vitals. He stated he was not getting a pulse via the wrist or neck, but once the pulse oximeter was placed on Resident #1's finger it read at 60. RN B stated he did not remember where he got the pulse oximeter from or the timeframe between not getting a pulse and when he applied the pulse oximeter to Resident #1's finger. When RN B was asked, why didn't he just start CPR prior to applying the pulse oximeter, when he could not get a pulse on Resident #1's wrist or neck, he said because he left the room to get the crash cart. He stated he doesn't remember if he got the pulse oximeter off the crash cart. RN B stated he was supposed to perform CPR if the resident was unresponsive and there was no pulse . In a follow up interview on 02/27/23 at 10:49 AM, the DON stated she did not know why the EMS incident report would indicate there was no pulse when they arrived. She stated maybe that was their interpretation of things or maybe when she stepped away and they took over Resident #1 loss her pulse. The DON stated she did see that LVN A documented in Resident #1's medical records that she was unresponsive and had no pulse at some point. She stated she believed this was inaccurately documented, but the entire time she was around Resident #1 she had a pulse, via the pulse oximeter. When the DON was asked if she ever checked Resident #1's neck for a pulse, she stated she did check Resident #1's neck and there was a pulse. The DON stated she was never informed by LVN A or RN B that at some point during the situation, they were unable to locate a pulse. She stated if Resident #1 was unresponsive and LVN A or RN B could not find a pulse, then they should have immediately started CPR. In a follow up interview on 02/27/23 at 1:16 PM, LVN A stated her documentation was inaccurate. She stated CPR was never done on Resident #1. LVN A stated she was in and out of Resident #1's room bringing equipment for the code blue and at one point, she saw the DON touching Resident #1's chest, so she assumed she was doing CPR and documented it. LVN A stated she never performed CPR on Resident #1 because she always had a pulse when she took her vitals. LVN A was asked why she documented in Resident #1's medical record at 13:30 Resident still unresponsive, unable to locate pulse, if she always had a pulse and why in her initial interview, she said they were unable to locate a pulse. LVN A stated when RN B was getting vitals in Resident #1's room, he asked her to go get the glucometer. She stated when she returned to the room to give RN B the glucometer, she heard him saying he could not find a pulse, so she documented it. LVN A stated she did not see RN B start CPR when she heard him say he could not find a pulse. She stated she did not start CPR when she heard RN B say he could not find a pulse because he was the unit manager and had taken over the situation. In an interview on 02/28/23 at 10:01 AM, CNA C stated she was in the dining room feeding a resident and LVN A was in there as well. She stated Resident #1 asked for more tea and LVN A refilled the tea. CNA C stated Resident #1 was acting normal . She stated about 5 minutes later she saw Resident #1 slumped over in her wheelchair. CNA C stated she went to check on Resident #1. She said she called her name and tapped her shoulder, but she was not really responding. CNA C stated she was just mumbling in a low voice, and she could not understand what she was saying. She stated normally Resident #1 talked and was understandable. CNA C stated the resident would not lift her head and continued to stay slumped over in her wheelchair. She stated she ran into the hall to get help. CNA C stated she went down the hall looking for LVN A but found RN B. She stated RN B said he wanted to take her to her room, so she helped take the resident to the room and transferred her to the bed. CNA C stated RN B was calling Resident #1's name but she was not responding. She stated the AD and LVN A came into Resident #1's room, so she left the room. In an interview on 02/28/23 at 11:58 AM, the AD stated he was in the dining room making pancakes and he heard CNA C calling Resident #1's name. He stated when he looked in that direction, he saw Resident #1 was slumped over in the wheelchair. The AD stated he had just talked to her a few minutes earlier when he gave her pancakes. He stated Resident #1 was fine. The AD stated CNA C told him to get LVN A. He stated he located LVN A in a resident's room and she was doing something to a g-tube. The AD stated LVN A finished connecting the g-tube and then they started towards the dining room. He stated he saw RN B and CNA C in the hall taking Resident #1 to her room. The AD stated he and LVN A followed. He stated once they entered the room CNA C left the room. He stated he saw RN B and LVN A trying to get vitals and they were checking Resident #1's wrist and neck. The AD stated he heard them saying they couldn't find Resident #1's pulse. He stated they told him to call 911 and get Resident #1's face sheet. The AD stated he left the room. He stated as he was leaving the room, he saw the DON and ADON heading towards Resident #1's room. The AD stated when he returned to Resident #1's room, he saw RN B, the ADON and the DON around the resident. He stated Resident #1 was connected to the pulse oximeter. The AD stated he didn't know when they connected Resident #1 to the machine because he left the room. He stated he was standing in Resident #1's room on the phone with 911 and answering their questions. The AD stated EMS arrived about 6-7 minutes after he called them. He stated he was in the room when they arrived. The AD stated as soon as they entered, RN B, the ADON and the DON immediately moved out of the way, and the EMS worker stepped in. The AD stated the first thing EMS did was check Resident #1's neck, said there was no pulse, and started chest compressions. He stated they got this machine and suctioned her neck. The AD stated after they suctioned her neck, EMS put a blue device over her mouth and was squeezing it. He stated they continued to do CPR for about 15 minutes. The AD stated EMS was not able to bring Resident #1 back. In an interview on 02/28/23 at 2:55 PM, the facility's Marketing RP stated she was a RN, so the facility required her to be in-serviced on CPR. She stated she was happy to see staff were being in-serviced on CPR because she witnessed the incident that happened to Resident #1. She stated she was in the hallway and saw a nurse (doesn't know their name) moving the AED in a fast pace. The Marketing RP stated she followed the nurse to Resident #1's room. She stated when she arrived at the room, she observed Resident #1 laying on bed gasping for air and her pupils were dilated. The Marketing RP stated the gasping sound Resident #1 made seemed as if her airway was clogged, and she was not breathing properly. She stated the DON was rubbing the resident's chest for stimulation but was not performing CPR. The Marketing RP stated she was wondering why they were not doing CPR because it was clear to her Resident #1 was not breathing and was dying. The Marketing RP stated she did not say anything because the DON was right there, and she was following chain of command. She stated the AD was in the room on the phone with 911 and she heard him say to the DON they were saying to do CPR. The Marketing RP stated the DON said to the AD, but she has a pulse. She stated she did not see the DON checking Resident #1's pulse. She stated they were using the pulse oximeter on Resident #1, but based on her training that was not reliable, especially in this situation. She stated the pulse oximeter measures oxygen in the blood but Resident #1 was not breathing well because she could hear her gasping for air, so they should have been getting the pulse from the carotid artery (neck). The Marketing RP stated while she was in the room, she did not observe anyone checking for a pulse via Resident #1's neck. She stated she did not know if they checked prior to her entering the room. She stated she was in the room approximately 3 to 4 minutes before EMS arrived. She stated once EMS arrived the DON stepped back, and they took over. The Marketing RP stated EMS checked the resident's pulse via the neck and she heard EMS say she had no pulse, so they immediately started with chest compressions. She stated EMS suctioned Resident #1 and continued with CPR. The Marketing RP stated EMS worked on Resident #1 for 28 minutes and then pronounced Resident #1 dead. A record review of the facility's policy titled Cardiopulmonary Resuscitation, dated 5/19/11, revealed Procedure: 1. Assess for unresponsiveness. Tap the resident's shoulder and ask the resident if he/she is alright. 2. When the resident is unresponsive, immediately call for emergency help and notify staff of Code Blue. Call emergency assistance. Ensure the first responder called EMS and returns to the scene with any AED (defibrillator). If you are alone and cannot alert anyone to call EMS, YOU MUST call EMS prior to beginning CPR and obtain the AED. 3. After EMS has been called, implement the CPR protocol as outlined below (chest compressions-Airway-Breathing (C-A-B) . 5. Check the unresponsive resident for a pulse for no longer than 10 seconds c. Adult- check for a pulse at carotid artery. This was determined to be an Immediate Jeopardy (IJ) on 02/27/23 at 3:50 PM. The Administrator was notified. The Administrator was provided with the IJ Template on 02/27/23 at 3:56 PM. The following Plan of Removal (POR) submitted by the facility was accepted on 02/28/23 at 12:15 PM: Interventions: On 2/27/23 All resident records were audited by the DON, ADON, and/or regional nursing staff to ensure that a code status was current and that the care plan reflected that order. On 2/27/23, Regional Nurse consultant immediately in-serviced, DON and ADON on CPR initiation, notification of physician, DNR, and documentation. On 2/27/23 all licensed nurses were in serviced by the DON, ADON, and/or regional nursing staff regarding: All staff not present will not resume duties until in-serviced before start of shift. o Initiating CPR in the absence of a DNR . Either: A Texas Out of Hospital DNR or Physician's order for DNR If a resident is found, unconscious, absent of breathing and heart rate, with an absence of a DNR or physicians order for DNR, CPR will be immediately initiated at the same scene resident is found. o How to obtain the residents code status in PCC (resident record, EMAR , POC ) o Nurses not stopping CPR unless: Receive a physician order to stop CPR, by phone or in person. EMS takes over the CMS/Code o Do not stop CPR unless the above criteria are met. o Notifying the physician and family of any resident change in condition. On 2/27/23 all nursing staff were in-serviced by the DON, ADON, and/or regional nursing staff on how to locate a resident's code status in PCC (resident record, EMAR, POC). All staff not present will not resume duties until in-serviced before start of shift. On 2/27/23 at 4:25 PM the Medical Director was notified regarding the plan the facility initiated an ADHOC plan for this occurrence. Monitoring: At least 5 times per week, orders will be reviewed by the DON and/or ADON and ensure that advanced directive orders are entered correctly. The DON and/or ADON will interview at least 10 licensed nurses per week and questions will include: o When should you start CPR? o When can you stop CPR? o Where to locate a resident's code status? o How to initiate a resident/representative request for DNR The DON/ADON will review Real Time and PCC at least 5 times per week to monitor that the physician/family was notified of resident changes in condition. Findings will be reviewed by the QAPI committee and changes will be made as needed. In the daily standup meeting, the IDT will discuss any new admissions' code status and take further action as required. Monitoring of the facility's Plan of Removal included the following: A record review of the medical records for the 89 residents in the facility revealed a code status was current and that the care plan reflected that order. A record review of the in-services dated 02/27/23, conducted by the facility's Regional Nurse Consultant, on DNR, CPR, Documentation, Notification of Physician & Family revealed signatures by the DON and ADON. A record review of the in-services dated 02/24/23 to 02/28/23, conducted by the DON, on CPR, revealed 41 signatures from multiple shifts and multiple departments (LVN/RNs and CNAs) had received in-services which covered all aspects of the POR. A record review of the in-services dated 02/27/23 on Advance Directive, conducted by the DON, revealed 41 signatures from multiple shifts and multiple departments (LVN/RNs, CNAs, Housekeeping, Social Services, Activities,) had received in-services which covered all aspects of the POR. A record review of the in-services dated 02/27/23 on Verify Code Status in [medical records], conducted by the DON, revealed 28 signatures from multiple shifts and multiple departments (LVN/RNs and CNAs) had received in-services which covered all aspects of the POR. A record review of the in-services dated 02/27/23 on Documentation, conducted by the DON, revealed 30 signatures from multiple shifts and multiple departments (LVN/RNs and CNAs) had received in-services which covered all aspects of the POR. Interviews were conducted on 02/28/23 from 12:28 PM to 3:50 PM with the Administrator, DON, Activity Director, Marketing RP, 2 RNs, 8 LVNs, 8 CNAs, 1- Restorative Aide, from multiple shifts . The staff all indicated they were in-serviced on CPR, Advance Directives, Verify Code Status, and Documentation, which included: If a resident was found, unconscious, absent of breathing and heart rate, with an absence of a DNR or physicians order for DNR, CPR would be immediately initiated at the same scene the resident was found, how to obtain the residents code status in (medical records, not stopping CPR unless getting physician order or CMS take over), how to locate a resident's code status, and ensuring documentation was accurate of any incidents of CPR. The Administrator was informed the Immediate Jeopardy was removed on 02/28/22 at 3:55 PM. The facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #65) of five residents reviewed for quality of care. The facility failed to care plan, assess, follow physician orders to replace Resident #65's catheter monthly, and notify provider, NP K, of Resident #65's indwelling catheter monthly replacement refusals. The facility failed to routinely assess a wound to Resident #65's left groin and failed to identify an abscess had formed prior to his hospitalization on 03/10/22. These failures resulted in Resident #65 being hospitalized from [DATE] through 03/14/22 with diagnoses of urosepsis, respiratory failure, and an abscess to his left groin. An Immediate Jeopardy (IJ) situation was identified on 03/17/22 at 11:47 AM. While the IJ was removed on 03/19/22, the facility remained out of compliance at a scope of isolated, at the severity level of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents with indwelling catheters at risk for serious infections such as urosepsis, hospitalization, or death and residents with wounds at risk for worsening wounds, sepsis, or hospitalization. Findings Included: Review of Resident #65's MDS assessment, dated 02/24/22, reflected he was [AGE] year-old male admitted to the facility on [DATE]. His BIMS score was 15 which indicated he did not have a cognitive impairment. The assessment of his behavior reflected Resident #65 did not reject care and did not have any other behavioral symptoms. His functional status assessment reflected Resident #65 could perform bed mobility, transfers, locomotion off unit, and eating with supervision. The assessment reflected he required extensive one person assistance with toilet use and personal hygiene. Resident #65's urinary status was not rated, and he was always continent of bowel. His diagnoses included: peripheral vascular disease (blood circulation disorder), obstructive and reflux uropathy (when urine cannot drain through the urinary tract), diabetes mellitus, low back pain, and muscle weakness. Review of Resident #65's care plans, dated 03/18/22, revealed the plan did not address Resident #65 refusing to have his catheter replaced, replacement of the catheter, or education provided to Resident #65 regarding catheter risks or benefits. Review of Resident #65's order summary report, dated 03/18/22, reflected orders entered on 03/16/22 included: Empty catheter bag every shift, Foley catheter #16 with 10mL to be changed in the ER on ly as needed, and Foley catheter care twice a day and as needed. On 03/17/22 an order for a midline for IV antibiotics and an order for Meropenem 1 gram intravenously every 8 hours for a UTI. The following orders were entered on 03/18/22: Change catheter bag every two weeks and PRN, and Change foley catheter as needed. (Unless the resident has a specific order like [Resident #65] who has his changed every month in the ER. Review of Resident #65's hospital records, dated 03/15/22, reflected the resident was admitted to the hospital on [DATE]. The records reflected Resident #65 presented to the hospital with altered mental status, he had a chronic indwelling catheter, and had a history of klebsiella (type of bacteria) UTI. The resident was given antibiotics and fluids and he became short of breath which progressed to agonal (gasping) breathing. He was intubated (tube inserted into the trachea for artificial ventilation), placed on a vent (machine for artificial ventilation that delivers air or oxygen) and was admitted to the ICU. His diagnoses included: severe sepsis (with MDR Klebsiella and Proteus [bacteria]) in the setting of chronic indwelling urinary catheter, acute respiratory failure, acute kidney injury, abscess of left groin, and ischemic cardiomyopathy (heart's decreased ability to pump blood properly, due to heart damage), complex PVD, iliac aneurysm (bulging and weakness in the wall of the iliac artery), chronic back and lower extremity pain, and urinary incontinence. The records reflected Resident #65 had an indwelling urinary catheter due to a history of ureteral stricture (scarring that narrows the tube that carries urine out of the body) and the foley was being managed by an outpatient urologist. The ICU doctor ordered to maintain the indwelling foley, consult urology to change the foley because the resident had a history of difficult placement and was likely the source of the resident's infection given his history of klebsiella and group b strep (type of bacteria) UTI. The ICU doctor documented, Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently, and I personally spent this critical care time directly and personally managing the patient . This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure . The resident was extubated (removal of tube used for artificial breathing) on 03/11/22. A foley catheter was placed on 03/11/11 by a physician. On 03/10/22, Resident #65 labs showed: WBC 17.2 H (normal 4.5 to 11; high indicated infection); sodium 128 L (normal 135 to 145); UA showed a pH of 9.0 H (normal 4.6 to 8); ABG reflected a pH of 7.079 (critical low, normal 7.35 to 7.45. Indicated extreme acidosis, a common feature of many acute/critical conditions that warrant admission to intensive care unit). Review of the facility provided documentation of each time Resident #65's foley catheter was replaced reflected the following documented in progress notes: 1. 10/15/21- nurse documented the resident was sent to the hospital for a catheter replacement due to leakage. 2. 12/12/21- nurse documented Resident #65 refused to have his foley catheter changed and stated it would be changed at the doctor's office. 3. 02/01/22- nurse documented the resident was sent to the hospital for a foley catheter replacement. 4. 03/16/22- NP K documented the intermittent issue, chronic foley needs Urology to follow [due to] difficulty replacing foley. foley has been replaced 10/16 in the hospital replaced again 11/17. Replaced 02/01/22. Review of an outside referral form dated 09/13/21 reflected Resident #65 was referred to urology by MD L for foley catheter replacement once a month. Review of Resident #65's TAR for September 2021 reflected an order for the resident to be referred to the urologist on 09/18/21 for catheter management. Review of Resident #65's wound assessments reflected Resident #65 had a wound assessment on 02/07/22 and did not have another wound assessment until 03/09/22. The assessment on 03/09/22 reflected a surgical wound to Resident #65's groin which was present on admission. Wound measurements were area 1.4 cm squared, length 1.6 cm, width 1.6 cm, and depth was not applicable. The assessment of the wound on 03/16/22 after Resident #65 returned from the hospital reflected a surgical wound to his groin, and the measurements were area 3.9 cm squared, length 2.6 cm, width 2.3 cm, and depth was not applicable. Review of Resident #65's weekly skin assessments on the following dated: 12/21/21, 02/02/22, 2/10/22, 02/17/22, 02/24/22, 03/03/22, and 03/10/22 all reflected his skin condition as normal and indicated there were not any new wounds. Review of Resident #65's February 2022 and March 2022 MARs and TARs reflected the following order with a start date of 02/14/22: Cleanse wound to left groin with normal saline, pat dry, apply calcium alginate, and cover with dressing daily. The following dates were not initialed as completed: 02/20/22, 03/01/22, 03/02/22, 03/05/22, and 03/09/22. Further review reflected Resident #65 did not have an order for catheter care. Resident #65 had an order for changing his foley catheter once a month on the 10th of every month which was scheduled to be completed at 11 PM. In an interview on 03/16/22 at 12:15 PM, Resident #65 said he had lived at the facility for a year. He said he had an indwelling foley since his admission into the facility because of a spinal injury that caused him to not be able to feel when he needed to void. Resident #65 said he was hospitalized from [DATE] until 03/15/22 due to an infection in his penis. Resident #65 said he could not recall any of the events leading to his hospitalization, and said the next thing I knew, I was in the hospital, in the ICU. Resident #65 said he was unaware his foley catheter was to be changed monthly. Resident #65 said the nurses at the facility had never replaced his indwelling foley. Resident #65 said he had refused for the nurses to replace his catheter a couple of times before because anytime they attempted to change it, it was in the middle of the night, and because he thought only a doctor or nurse practitioner were able to replace his indwelling catheter. Resident #65 said he was unaware an abscess had developed in his left groin area and was unaware if it was treated in the hospital. Resident #65 said his family member was with him at the facility and she called 911 on 03/10/22. Resident #65 gave HHSC Surveyor his family member's telephone number and requested she be interviewed. In a telephone interview on 03/16/22 at 12:52 PM, Resident #65's family member said she had arrived to visit Resident #65 on 03/10/22 at around 3:30 PM. She stated when she arrived, she spoke to LVN I who could not provide her any information regarding Resident #65's medical appointment on 03/10/22 or regarding his falls on 03/08/22 and 03/10/22. She stated when she entered Resident #65's room, she found him in his bed, unresponsive, gasping for air, and his hands were blue. She also stated she did not think Resident #65 had been bathed because he smelled terrible. She stated she called for the nurse, and LVN I arrived and said, whenever they were in there earlier, [Resident #65] was fine. She said LVN I began trying to assess Resident #65, and she told him she called 911 on her cellphone because of his unresponsiveness and gasping for air. She stated she was there when EMS arrived, and it was difficult for them to transfer him onto the stretcher because he was heavy and smelled poorly. In an interview on 03/19/22 at 10:19 AM, CNA G said she was the CNA assigned to Resident #65 on 03/10/22. She said on that day, she helped the resident get up and dressed at around 9 AM because he had and outside appointment at 11 AM. She said initially Resident #65 had refused to go to his appointment, but when she reminded him it was a cardiology appointment he agreed to get up. She said Resident #65 would normally be more vocal and joke with her, but he was not acting like himself that day. CNA G said Resident #65 did not normally require help getting dressed and she let LVN M know that Resident #65 was acting funny; he was acting different. CNA G said Resident #65 went to his appointment and when he returned, he told her he didn't feel good. She stated she asked Resident #65 what was wrong, and he told her he did not know. She said Resident #65 requested to go to bed. CNA G said Resident #65 did not normally require assistance with transfers, but since she noted he was not acting like himself, she asked him to wait until she got another CNA to help. CNA G said when Resident #65 returned from his appointment he was not able to follow instructions. CNA G said she left the room to get help and when she returned, she found Resident #65 lying on the floor, flat on his back by his bed. CNA G said she left to go get LVN M and she and LVN M went to see Resident #65 immediately. CNA G said after LVN M assessed Resident #65, they got him off the floor and into his bed using a sling and the lift machine. CNA G said Resident #65 did not usually use a sling or a lift, but she knew he was diabetic, and he seemed drained. CNA G said she thought Resident #65 would be sent to the hospital. CNA G said she had never seen a nurse attempt to replace Resident #65's indwelling catheter. CNA G said on the morning of 03/10/22, Resident #65 had run over his foley catheter drainage bag, and it was leaking prior to him leaving for his appointment. She said because it was leaking, he did not have any urine in his catheter drainage bag when he returned from his appointment. In an interview on 03/19/22 at 10:49 AM, LVN M said she had never replaced Resident #65's foley catheter because it was scheduled to be changed on the night shift. She said she was his nurse on 03/10/22 and on that morning she checked his blood sugar, gave him insulin, and gave him Norco because he always wants pain meds. LVN M said CNA G assisted him in getting ready for his appointment. LVN M said Resident #65 looked sleepy in the morning. LVN M said when Resident #65 returned from his appointment he went to the nurse's station at around 1:30 PM and informed her he was back and requested to go to bed. She said CNA G was going to look for another person to assist with a transfer and he went to the room to wait for the CNAs. LVN M at around 1:50 [PM] CNA G came to tell me [Resident #65] was on the floor. LVN M said Resident #65 was not a fall risk and he usually did things by himself and transferred himself. LVN M said when she went to see Resident #65, he was lying flat on his back on the floor. LVN M said she asked him if he hit his head, and he said no. LVN M said she checked Resident #65's vital signs, helped get him into the bed. LVN M said she did not check Resident #65's blood sugar at that time. LVN M said she notified the doctor and the RP of Resident #65's fall. LVN M said the doctor gave her instructions to monitor because Resident #65 said he didn't hit his head. LVN M said CNA G did not tell her Resident #65 looked different or that Resident #65 had told her he did not feel well. LVN M said if CNA G had given her that information, she would have called the doctor and told them about all the changes and would suggest getting some bloodwork or a UA. In an interview on 03/16/22 at 3:10 PM, LVN H said she was assigned to work with Resident #65 and regularly worked with him. She said Resident #65 had an order to change the foley catheter monthly, but he refused. LVN H said she could not recall if she documented his refusals or notified the provider. LVN H said Resident #65 was able to empty his own foley drainage bag and indicated he did not need an indwelling catheter. LVN H said the reason's Resident #65 had a catheter were all in here, while pointing at her head. LVN H was not aware if Resident #65 had an order for catheter care and when asked if she had performed catheter care for Resident #65, LVN H stated, [Resident #65] does what [Resident #65] wants, and did not answer if she had performed catheter care for Resident #65. In an interview on 03/16/22 at 3:14 PM, RN O said she worked with Resident #65 routinely but had not worked with him since January 2022. She said previously there was an order to send Resident #65 to the hospital to replace his foley catheter but she not aware of the last time it was changed. RN O said Resident #65 was able to call 911 on his own when he noted his catheter was leaking and it needed to be changed. RN O did not know if Resident #65 had an order for catheter care. In an interview on 03/16/22 at 3:18 PM, the DON said Resident #65 was very alert and very verbal. She said if anything was wrong with him, or pain, he'll go to the nurse. The DON said if the nurse did not respond right away, Resident #65 would go to her. She said Resident #65 had been at the facility for a year and was admitted with a foley catheter and a sore on his left groin and the wound was not healing. The DON said Resident #65 was previously referred to a urologist, but his insurance had denied the referral. The DON did not know if the physician or NP K was notified Resident #65's insurance had denied the urology consult. The DON reviewed Resident #65 February 2022 TAR in the electronic record and said Resident #65's foley catheter replacement was scheduled on the 10th of the month at 11 PM because that was when the facility scheduled foley catheter changes, on the 10 PM to 6AM shift. She said she was unaware that was one of the reasons Resident #65 refused to have his foley catheter replaced. The DON said she was not aware Resident #65 did not have orders for catheter care and because he was in an out of the hospital, the orders for catheter care must have been missed on one of his re-admission orders. The DON said she was also the facility's WCN, and Resident #65 was not seen by a wound care doctor, and he was followed by MD P, who was a vascular surgeon. The DON said she saw the wound the day before he went to the hospital on [DATE] and she did not see an abscess. The DON said she was responsible for completing wound care on 03/01/22, 03/02/22, and 03/09/22 and wound care assessments weekly. The DON said they were not completed because she had a lot of new responsibilities as the DON, and it was difficult maintain her duties as WCN as well. She said at times she delegated for the charge nurses to do the wound care. Documentation of each time Resident #65's foley catheter had been replaced since September 2021 was requested by HHSC surveyor. The records provided did not reflect Resident #65's foley catheter was changed: September2021, December 2021, and January 2022. In a telephone interview on 03/17/22 at 12:24 PM, NP K said she was not aware Resident #65 was refusing having his indwelling catheter replaced and she expected to be notified of any refusals. NP K said she expected catheter care to be done daily and as needed and did not know if Resident #65 had an order for catheter care because it should be a facility protocol. NP K said she was not notified Resident #65 could not see a urologist due to insurance issues, stated she should have been notified, and felt Resident #65 needed to be seen by a urologist. In an interview on 03/17/22 at 12:30 PM, MD L said it was likely he was Resident #65's primary physician. He said he did not remember all of their names but Resident #65 sounded familiar. MD L said he was aware Resident #65 frequently refused to have his catheter replaced and obviously we are trying to get the patient to comply with standard of care and getting his catheter routinely replaced and obviously there's a higher risk for urosepsis the longer it stays in there. MD L said he did not remember if he personally educated Resident #65 on his indwelling catheter. MD L said, There's little we can do, a lot of patients have mental health clouding their issues. They're not compliant patients. MD L said he did not have any comment on that resident believing only a doctor or nurse practitioner could change his indwelling catheter. MD L said, We made every attempt to get him to a urologist but cannot control insurance. In an interview on 03/18/22 at 12:57 PM, the DON said if a resident refused to have their indwelling catheter replaced, she expected the nurse to document in a progress note and notify the on-call provider. The DON said she spoke with Resident #65 and he told her having the indwelling catheter replaced hurt him and told her only a doctor could replace it. The DON said she did not know if Resident #65 had trauma to his urethra. The DON said she had talked to the SW because Resident #65 wanted a urologist to see him, but she did not know when that occured. The DON said she asked Resident #65 if he had a urologist and she did not remember what Resident #65 said so the SW was looking for a urologist. The DON said all the urologists around the area did not take Resident #65's insurance. The DON said it had not been discussed for the facility doctor to replace Resident #65's indwelling catheter because the doctor that comes here is the NP, [MD L] doesn't even come. He comes once a month for QAPI meeting. The DON said Resident #65 had been in and out of the hospital so the order for catheter just dropped, indicating the orders for catheter care had been omitted and not re-started on one of Resident #65's re-admission order sets. In an interview on 03/18/22 at 1:49 PM, the SW stated Resident #65 had an order for a urology consult since September 2021. The SW said the outpatient clinic to which Resident #65 was referred took a long time, they said it could take from 14-90 days for Resident #65 to get an appointment. The SW said he looked up clinics online that accepted Resident #65's insurance, but when he called, none accepted Resident #65's insurance. The SW said he recently spoke with the case worker at Resident #65's insurance company and he told them he was having trouble and they sent him a list of 3 doctors. He said when he contacted those doctor's offices, they told him they did not accept his insurance. The SW said he thought the facility would cover the cost for the resident to see a urologist if a resident is private pay, then their provider will say get them seen right now. The SW said certain residents may need to pay private to see a specialist. The SW said he had never had a situation of not finding a specialist for a resident and he thought it would be the ADM that would make that decision to cover the cost for the specialist. The SW said Resident #65 told him he had been going to the hospital to have his foley catheter replaced and the hospital nurse and doctor had told Resident #65 that as long as he did not have a urologist, he could go to the hospital to get it changed. The SW said Resident #65 was very vocal about what he wants, and Resident #65 knew when his foley catheter needed to be changed. The SW said it was discussed multiple times in the facility's daily morning meeting, which ADM A and the DON attended, that nurses were hesitant to change Resident #65's indwelling foley because there was complications, and they were not able to do it here. The SW said when Resident #65's catheter replacement came up in the morning meetings, the plan discussed was to find the urologist, which was his responsibility. In an interview on 03/18/22 at 2:13 PM, ADM A said Resident #65 refuses to get the catheter removed; we do educate him on that, well, nursing does. He said Resident #65 had mentioned he wanted a urologist's opinion, and the facility had made several appointments but then they were told they did not accept Resident #65's insurance. ADM A said Resident #65 had been at the facility for about a year and the foley catheter became an issue around September 2021. ADM A said Resident #65 did not want the foley catheter removed because he did not want to wear adult briefs and did not like to be wet. ADM A said Resident #65 was using the need for a urologist as an excuse to not having the foley catheter removed. ADM A said Resident #65 was content with the foley. ADM A said if a urologist who accepted Resident #65's insurance could not be found, the facility would cover the cost for him to see a urologist. ADM A said anytime Resident #65 when to the ER he saw a urologist. ADM A said, If it was an emergency, the facility would cover the cost for a urologist. In a telephone interview on 03/19/22 at 12:13 PM, MDS Nurse E said she was aware Resident #65 refused to have his foley catheter replaced with one night nurse and she said, some people have said [Resident #65] refused. MDS Nurse E said she care planned Resident #65 for refusing to wear a privacy bag but did not remember if she had care planned the refusals of having his foley catheter changed. MDS Nurse E said she went to meet with Resident #65 and asked him why he refused having his indwelling catheter replaced, and he stated because only a doctor could replace it. MDS Nurse E did not recall when she spoke to Resident #65 or if she had documented their conversation. MDS Nurse E said she spoke with the SW and asked that he to try to find someone to replace Resident #65's indwelling catheter. MDS Nurse E stated Resident #65's foley catheter replacement refusals should have been care planned. In an interview on 03/18/22at 03:37 PM, ADM B stated her first day working at the facility was 03/10/22 and she was not aware of any concerns regarding Resident #65's foley cath. ADM B said, we stepped in this morning and got [Resident #65] an appointment with a urologist. ADM B said it did not matter if a resident's insurance did not cover the cost for them to see a specialist. She said it was the facility's responsibility to pay for them to be seen if needed. ADM B said after a reasonable attempt was made to find a specialist in network, the facility should step in to have the resident seen. ADM B said the time she expected to elapse in finding an in-network specialist should be a week or so, but if the need was urgent, they should not wait even a week. Review of the facility's undated policy titled urinary elimination reflected in part: Record and report the reason for catheterization, type, and size of catheter inserted . record amount of urine on intake and output (I&O) flowsheet record in the EHR or chart . Report persistent catheter-related pain, inadequate urine output, and discomfort to healthcare provider . Document your evaluation of patient learning . Symptoms of a UTI in an older adult may be difficult to recognize and may only be indicated by a change in mental status . older adults have increased risks for UTI . Providing regular perineal hygiene, preventing catheter-related trauma, and removing indwelling catheters as soon as possible are important interventions to reduce the risk of [CAUTI]. Review of the undated facility form titled Indwelling Cath Audit Tool reflected nurses were expected to relate the reason for the indwelling catheter, record output appropriately or as ordered, complete pericare during catheter care, and verify the physicians order included an acceptable diagnosis for indwelling catheter use. Review of the untitled facility policy titled, Wound Care, reflected the following: Facility has a treatment who completes . weekly skin and wound evaluations on all ulcers and surgical wounds. This includes taking weekly photos and measurements. Rounds with the Wound Physician once a week. Charge nurse completes initial assessment and treatment on all skin/wounds . if the treatment nurse in not available in the facility, the Charge Nurses will be responsible for the initial assessment of all pressure injuries and surgical wounds . Charge nurse will notify the physician/NP and responsible party of all new wounds and document notification with the RP's name. According to the website https://www.merckmanuals.com/professional/genitourinary-disorders/urinary-tract-infections-utis/catheter-associated-urinary-tract-infections, accessed on 03/25/22, .A catheter-associated urinary tract infection (UTI) is a UTI in which the positive culture was taken when an indwelling urinary catheter had been in place for > 2 calendar days. Patients with indwelling bladder catheters are predisposed to bacteriuria and UTIs. Symptoms may be vague or may suggest sepsis. Diagnosis depends on the presence of symptoms. Testing includes urinalysis and culture after the catheter has been removed and a new one inserted. The most effective preventive measures are avoiding unnecessary catheterization and removing catheters as soon as possible . According to the website https://www.merckmanuals.com/professional/critical-care-medicine/sepsis-and-septic-shock/sepsis-and-septic-shock, accessed on 03/25/22, . Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. In septic shock, there is critical reduction in tissue perfusion; acute failure of multiple organs, including the lungs, kidneys, and liver, can occur. Common causes in immunocompetent patients include many different species of gram-positive and gram-negative bacteria . Signs include fever, hypotension, oliguria (abnormally small amounts of urine), and confusion. Diagnosis is primarily clinical combined with culture results showing infection; early recognition and treatment is critical. Treatment is aggressive fluid resuscitation, antibiotics, surgical excision of infected or necrotic tissue and drainage of pus, and supportive care . An Immediate Jeopardy (IJ) situation was identified on 03/17/22 at 11:47 AM. ADM A, ADM B, the DON, and the RDCO were notified, and a POR was requested. While the IJ was removed on 03/19/22, the facility remained out of compliance at a scope of isolated, at the severity level of actual 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. The POR reflected the following: Two identified residents with indwelling urinary catheter. One identified resident with indwelling catheter and groin wound, who was hospitalized with sepsis. 1. Director of Nursing Services verified resident's catheter orders 3.17.22. Director of Nursing Services 3.16.22 2. LNAC, MDS updated resident's care plan to include catheter care 3.17.22. LVN, LNAC, MDS LVN, Director of Care Coordination 3.17.22 3. Director of Nursing Services reviewed physician orders, pertaining to the resident's catheter, with the resident 3.17.22 Director of Nursing Services 3.17.22. 4. The Director of Clinical of Operations, RN, WCC, CDP will educate the DNS, ADNS, LNAC, RNAC, and DCC related to updating Catheter care plans, assessing catheters upon admission and as needed, inputting orders, change in condition using the Interact Program, assessing wounds and following all MD orders related to wounds. Initiated 3/17/22, Complete 3/18/22 Midnight, DCO 5. Director of Care Coordination began education with nursing staff 3.17.22. Education includes assessing catheters upon admission and as needed, inputting orders and updating care plans related to catheter care. Also, Change in Condition, using the Interact Program. Director of Care Services 3.17.22 6. Director of Clinical Operations and Director of Nursing Services explained the Risk vs Benefits of having an indwelling catheter to the resident 3.17.22. Resident chose to keep the catheter at this time. Director of Clinical Operation and Director of Nursing Services Initiated 3.17.22 One identified resident with a surgical wound to the left groin. 1. Upon the residents return from the hospital, on 3.16.22, Director of Nursing Services assessed the surgical wound, to the resident's groin area. Photos were taken of the wound. There were no signs of infection and the resident did not exhibit any signs of poor care. Director of Nursing Services 1.16.22. 2. Director of Nursing Services verified the residents wound care orders on 3.16.22. Director of Nursing Services 3.16.22 3. LVN Charge Nurse assessed wound on 3.17.22. Nurse verified proper staging, correct treatmen[TRUNCATED]