**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure personnel provided basic life support, which included CPR, to a resident requiring 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 7 residents (Resident #1) reviewed for cardio-pulmonary resuscitation. RN E failed initiate CPR when FM C told him Resident #1 was unresponsive on [DATE]. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator and DON on [DATE] at 4:04 PM at exit. The noncompliance began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the investigation began. This failure could place residents at risk of not receiving life-saving measures, medical complications, distress, and up to and including death. Findings included: Record review of Resident #1's face sheet dated [DATE] reflected she was an [AGE] year-old female that was admitted on [DATE]. DX (diagnosis) included: Unspecified Dementia (memory loss), Mood Disturbance (disruption in emotional state), Anxiety (feeling of worry), Other Symbolic Dysfunctions (affecting speech and memory). The face sheet did not reflect Resident #1's advance directive as it was left blank. Record review of Resident #1's quarterly MDS dated [DATE] reflected she had a Bims score of 3, indicating severe cognitive impairment; Section GG resident functional abilities reflected she required extensive assistance for bed mobility, transfers, eating, toilet, she was a hospice patient, and all medications and DX were addressed. Record review of Resident #1's care plan dated [DATE] reflected the staff and/or responsible party have been provided the information explaining the Advanced Directive process and following Date Initiated: [DATE]. interventions .Obtain a copy of my [full code] status physician order Family and staff are aware of my Full code status .Send the copy of my [full code] status with me on all transfer to physician appointments or hospital .Upon admission my family or I have received a copy of the Advanced Directive and Resident Rights. ADL care reflected Resident #1 required extensive assistance from staff with self-care, transfer, ADL, hygiene .The resident has a terminal prognosis r/t Alzheimer's Disease. (disease causing a decline in cognitive function) Record review of Resident #1's MD orders dated [DATE] reflected resident was a full code .Hospice to evaluate and treat as Indicated, [DATE] .Resident/Responsible Party is aware of Diagnosis: Yes. Record review of Resident #1's progress notes reflected the following: On [DATE] at 3:56 PM, by RN E This nurse was called into room [room number] at 1505 (3:05 PM) resident was not breathing, this nurse (RN E) assessed pulse and respiration and initiated [code blue] and CPR started on the resident and 911 EMS was called, Nurses were doing CPR on the patient when EMS staff arrived by 3:09 PM [EMS] started working on the resident till 4:00 PM. Pulse and BP noted on the resident and EMS staff took her to [hospital.] Resident left the facility with EMS exactly 4:00 PM signed [RN E] Nursing - Registered Nurse (RN) [e-signed.] RN E's note did not mention that the family was present in the room not that the family as the initial notification to him when Resident #1 became unresponsive. Record review of Resident #1's progress notes dated [DATE] at 9:17 PM by ADON reflected the following: Resident expired. An observation of Resident #1 was not conducted as she expired on [DATE] at the hospital. During an interview with ADM on [DATE] at 11:00 AM stated that he was notified by the ADON on of the incident [DATE] at 3:10 PM. ADM said he proceeded to the facility to meet with the corporate staff to investigate the incident. ADM stated that upon his arrival the investigation was initiated. ADM said that his investigation revealed that FM C notified RN E that Resident #1 was nonresponsive. ADM said the resident was a full code. ADM said the hospice nurse was contacted to ensure advance directive due to HLV leaving DNR documents for the family to sign on [DATE] at 10:00 AM. HLVN and ADON both confirmed that Resident #1 was a full code. ADM said a code blue was initiated by RN E. ADM said that RN A immediately assisted with the code blue on Resident #1 in her room until EMS arrived. ADM said there were family members present in the room. The family members were later identified as (FM C and FM T). ADM said he had not interviewed the family that was present, only the POA. ADM said on [DATE] and [DATE] all active staff were in-serviced on CPR protocol, Code Blue, and DNR protocol. After the education, the staff were required to take a test on their knowledge of the incident. All staff passed. ADM said the training and monitoring was ongoing and this was an isolated incident. He stated that RN E was immediately suspended pending investigation findings and terminated on [DATE]. During an interview with DON on [DATE] at 11:10 AM stated she was not working the day of the incident ([DATE]). The DON stated that she was in-service on [DATE] and she has been a monitoring, auditing, and educating staff on CPR (task conducted to save a life during cardiac arrest), code Blue (procedures of the facility), and DNR protocol. The DON stated that (RN E) failed to check code status for Resident #1 and follow administrative and MD orders to initiate CPR and call 911 when she was found unresponsive. The DON expects all nursing staff to review advance directives on assigned residents, know where to locate the information in the electronical files, initiate CPR, and call 911 immediately for residents that have an advanced code of full code. The DON said it was her expectation that the staff continue CPR until EMS arrived and take over. The DON stated the risk to residents when the advance directive was not followed included: failure to honor the resident's wishes and death if no CPR was initiated. DON said the facility initiated corrective actions immediately to ensure other resident's safety and this was an isolated incident. The DON said RN E was terminated on [DATE] at 9:22 AM via phone. During an interview with ED on [DATE] at 11:20 AM stated that he was notified of the incident with Resident #1. ADM said other corporate staff and ADM reported to the facility and investigated. ED said RN E failed to follow the care guidelines for all residents advance directives, initiate CPR immediately for residents that were full code, and notify 911 when a resident was fund non-responsive. The ED expects all staff to follow MD orders and leadership directives quickly to alleviate any delay in care or services for residents. The ED stated that he assisted with the investigation and training along with other corporate staff to ensure staff were trained immediately and residents were safe. The ED stated that RN E was immediately suspended on [DATE] pending the investigation findings, then terminated on [DATE] at 9:22 AM via phone. ED stated that he will be referring RN E nursing license. The ED stated the risk to residents when the advance directives for CPR/full code were not followed included failure to honor the resident's wishes and death if no CPR (task conducted to save a life during cardiac arrest) was initiated. During an interview with ADON on [DATE] at 11:25 AM who stated she received a call from the HLVN and CNA B at 2:45 PM stating that RN E was asked to conduct CPR (task conducted to save a life during cardiac arrest) for Resident #1, and he had not initiated the lifesaving actions for Resident #1. HLVN told the ADON that Resident #1's DNR form had not been signed by the POA or MD, so CPR should be the first course of action for the resident to save her life. ADON notified RN E and CNA B to activate a code blue and initiate CPR and call 911. The ADON headed to the facility along with ADM, ED, and other corporate staff to investigate, educate, monitor, audit staff knowledge and competency on trainings on CPR and code blue protocol. The ADON said all active staff were trained and evaluated on training protocol's and they all passed the test. The ADON said Resident #1 was sent out via ambulance and RN E was suspended pending investigation findings. The ADON said RN E was terminated on [DATE] after the investigation determined he did not follow advance directive protocol for Resident #1. ADON said she did not know if the facility ADM referred RN E to the BON. The ADON stated she expected all staff to be knowledgeable on resident's advance directive and act immediately by calling a code blue, initiating CPR, and notifying 911. The ADON said she expects the nursing staff to continue CPR until EMS arrive and take over care. The ADON said the risk to residents included failure to honor the resident's and families wishes and death if no CPR was initiated. During an interview with CNA B on [DATE] at 11:30 AM revealed she observed FM C telling RN E on [DATE] at 2:40 PM that Resident #1 was full code and he needed to conduct CPR. CNA B overheard FM C talking to RN E at the nursing station. CNA B said she intervened and spoke with FM C to address concerns that Resident #1 was full code and RN E had not initiated CPR. CNA B immediately checked the chart and notified the ADON via phone to report Resident #1's advance directive (full code). The ADON reviewed Resident #1's file and confirmed that Resident #1 was a full code requiring CPR. The ADON told RN E to initiate CPR immediately, call a code blue, and notify 911. CNA B observed RN E take the Crash Cart and head to resident room. CNA B stated she notified RN A of the code blue at the nursing station and LVN T to notify 911 and get Resident #1's files prepared for transport via EMS. CNA B was seeking additional staff to assist with the code blue. CNA B said RN E headed to the resident room with the crash cart to initiate CPR. CNA B stated that she told RN A to go and assist RN E with a code blue. CNA B said she then asked LVN T to contact 911 and gather medical documents for the transport with EMS. CNA B stated she did not enter the room, nor did she observe RN E initiate CPR. CNA B said the risk to residents included failure to honor the resident's and families rights and death if no CPR was initiated. CNA B said all nursing staff were required to know resident advance directive status and immediately conduct CPR for full code to residents until EMS arrives. CNA B said she was not in the room with RN E and RN A to confirm that CPR was initiated immediately. CNA B said she told RN A and LVN T of the code blue verbally at the nurse's station. CNA B said she did not make an announcement on the PA system notifying staff of a code blue on [DATE]. CNA B said that several family members were resident in the room with Resident #1. During an interview with [NAME] on [DATE] at 11:59 AM stated Resident #1 was on hospice and her advance directive on [DATE] at the time of the incident was full code. [NAME] said FM C called HLVN concerned that RN E had not initiated CPR on Resident #1. [NAME] said FM C told RN E several times that Resident #1 was full code, and he ignored her request for 10 to 15 minutes and returned to the nursing station. During an interview with HLVN G on [DATE] at 12:25 PM stated she visited the facility at 10:45 AM. HLVN G stated she received a call from a family member name (later identified as FM C) unknown inquiring about Resident #1's advance directive. HLVN G stated she spoke with RN E time unknown to confirm that the resident did not have a DNR for AD and he (RN E) should proceed with CPR. HLVN then contacted the ADON to report FM C's concerns about RN E not initiating CPR. HLVN told ADON that Resident #1 was full code indicating that the staff would administer CPR and call 911. During an interview with LVN T on [DATE] at 1:25 PM who stated that CNA B called her over to the nursing station on [DATE] at 3:00 PM and asked her to contact EMS for a code blue of a resident, and to gather face sheet, Medication list, and care plan to provide to the EMS when they arrive to transport Resident #1. LVN T said she called 911 at 3:00 PM and they arrived at 3:20 PM. LVN T said she waited at the front door for EMS and escorted them to the Resident #1's room and provided the transfer documents. LVN T said she did not enter the room and could not confirm if CPR was in progress on Resident #1 by RN E or RN A. LVN T family in the room and observed the EMS taking Resident #1 out on a stretcher (tall bed with wheels) while continuing to provide breathing support. LVN T stated she was trained on CPR protocol and code blue on [DATE]. She completed the testing was knew the location in the electronic files to access resident's advance Directives. LVN T stated that risk to residents included failure to honor the resident's choices and death if no CPR was initiated. LVN T did not remember if an announcement was conducted over the PA system notifying all staff of a code blue. During an interview with RN A on [DATE] at 1:57 PM revealed she was notified by CNA B on [DATE] at 3:00 PM that a code blue was activated and to go and assist RN E on the three hundred Hall with CPR protocol. RN A said upon arrival to Resident #1's room, she observed the facilities crash cart outside of Resident #1's room in the hallway. RN A entered Resident #1's room and observed RN E standing in the room talking with family and he had not initiated CPR on Resident #1. RN A said she had observed Resident #1 lying down on the bed unresponsive, assessed her pulse, and then RN E asked if the Resident #1 was a full code, and he (RN A) said yes and 911 had been called. RN A proceed to position Resident #1 and initiated CPR. RN A said the facility staff did not announce a code blue over the PA system. RN A stated she was notified by CNA B verbally at the nursing station. RN A said after she initiated CPR RN E left the room before EMS arrived, therefore he was not available to communicate with the EMS staff on specifics about the patient (Resident #1) and care. During an interview with the Administrator on [DATE] at 5:00 PM, he stated the IJ occurred on [DATE] after the charge nurse (RN E) failed to check code status, initiate code blue, call 911, and initiate CPR protocol for Resident #1 when she was found unresponsive. He stated the hospice company provided the DNR form, however despite directions from family member, hospice nurse, and the ADON he failed to ensure the POA and Resident #1's rights were represented. Resident #1's POA expressed her desire for a DNR order earlier in the day with HLVN. ADM stated the risk to residents not receiving immediate actions for full code status and CPR included failure to honor the resident's wishes, distress, and death if CPR was not initiated. ADM said the facility initiated corrective actions immediately on [DATE] when the failure was identified to ensure other resident's safety, and this was an isolated incident. A phone interview was attempted with RN E on [DATE] at 1:39 PM and a voicemail was left requesting a return call for an interview was left. RN E did not return the call, and he was not interviewed prior to exit on [DATE]. During an interview with Residents #1's POA on [DATE] at 3:32 PM, who stated that she was not present when Resident #1 became non-responsive on [DATE]. POA said she left to allow other family members (FM C and FM T) and others to visit the resident after she was notified by hospice HLVN G that Resident #1 was declining. POA stated that the HLVN discussed changing Resident #1's advance directive to a DNR early that morning and ordered morphine to keep Resident #1 comfortable. POA stated Resident #1 was declining in health and she did not want Resident #1 to be resuscitated. The POA said she had not signed the DNR documents for Resident #1 at the time of the incident ([DATE]). POA stated that the resident passed away before she could return to the facility and sign the DNR. The POA provided contact information for FM H who was present with others in the room when Resident #1 died. She did not have the phone number for FM C and others that were present on [DATE]. Review of RN E personnel file reflected a disciplinary action dated [DATE] reflecting Recommended Action: termination. Rule Infracted (violation): Failure to Follow [Facility] Policy .facts regarding incident: On [DATE], a [Resident #1] went into full code. The resident, although on hospice, did not have a DNR in place. At the time of the full code, you failed to perform CPR at that moment which is against [Facility] Policy and CPR had to be initiated by another nurse. This failure to follow policy which requires CPR with no DNR in place Expectations for [facility] associate's behavior: The follow [facility] Policy at all times when it comes to the health and welfare of our residents. Solutions & corrective action to be taken: Immediate termination of employment Associate's statement: was blank Note to Associate: Continued performance problems will result in further disciplinary action, up to and including termination. Associate's Signature verifies that (1) This Disciplinary Action has been presented to me; (2) the Associate does not necessarily agree with its content; and (3) the Associate has had an opportunity to respond to the counseling. Associate signature and date reflected Delivered by phone 9:22 AM. Supervisors signature and date [ED] [DATE] Copy to: Associate's Personnel file Witness (in the event Associate refuses to sign) Associate HR if suspend/terminated. An attempted phone interview with FM H on [DATE] at 3:47 PM a voicemail was left requesting a return call for an interview. FM H did not return call and the interview was not conducted. Record review of the facility's Inservice dated [DATE] policy titled CPR-AED Policy revised [DATE] reflected the following: Full Code/DNR by ADON and [facility) dated [DATE], titled QAPI reflected Immediately on [DATE] nurse who was responsible for resident was suspended pending investigation. Review of in-services on [DATE] reflected, corporate staff in-serviced Administrator and DON on CPR policy that included education on full code status and when to initiate a full code. In serviced on if verbal consent also given however if the DR has not signed the DNR form the resident will remain a full code until DNR paperwork has been signed and facility has copy. Competency was verified via quiz. Review of in-services dated [DATE] DON/Designee initiated in-services with the nursing staff on CPR policy that included education on full code status and when to initiate a full code. In serviced on if verbal consent also given to nursing staff however, if the DNR has not been signed the resident will remain a full code until DNR paperwork has been signed and facility has copy. Competency was verified via quiz. Nursing staff was not allowed to work until in servicing had been completed. the above content was incorporated into new hire orientation by Administrator effective [DATE]. Review of audit on [DATE], an audit was completed of all resident code status by DON/Designee. Medical Director was notified on [DATE] In order to monitor current residents for potential risk, SW/designee will audit the code status of all residents weekly x 4 weeks and monthly thereafter to ensure accuracy. Any negative findings will be corrected and reported to the QAPI committee to ensure continued compliance. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Record review of the facility's Full Code/DNR Quiz for staff dated [DATE] reflected the following information questions .1. An RP/POA for a resident communicates verbally that they would like the residents code status changed from CPR to a DNR. Prior to completion of DNR form and physicians order the resident codes you must .Initiate CPR Do nothing until the form is back 2. A patient is listed as a Full Code and becomes pulseless. What should you do first? Begin CPR immediately and call for help .3. A patient becomes unresponsive and pulseless. You are unsure of their code status. What is the first action you should take? Start CPR immediately Call the provider for clarification. Double check the medical record .4. Who is responsible for knowing a resident's code status? All members of the care team. Monitoring of the facility's Plan included record review of Resident #1, #2, #3, #4, #5, #6, and #7's medical charts for compliance with advance directives orders, and notifications. All resident's charts reflected active Advance Directives on the face sheet, MD orders, Care plan with specific interventions and communication with RP. Interviews were conducted with facility staff across all three shifts on [DATE] from 11:00 AM through 2:55 PM. The staff included, ADM, ADON, CNA B, CNA L, DON, ED, HR, LVN T, MA G, MA R, RN A, RN T, and SW. The interviews revealed they had all received in-service training and could accurately describe how to determine the resident's code status, how to determine whether DNR documentation was complete, how and when to initiate CPR, code blue, and how long they should continue CPR. Record review of facility policy titled CPR dated [DATE] reflected In the event of cardiopulmonary arrest of a resident/patient without DNR status, life support measures will be initiated according to either the American Heart Association/American Red Cross guidelines or per State Guidelines. According to the 2001 American Heart Association, BLS (Basic Life Support) for Healthcare Providers, prompt initiation of CPR remains the standard of care .Rescuers who initiate BLS should continue until one of the following occurs: Restoration of effective spontaneous circulation and ventilation; Transfer of care to emergency medical responders or other trained personnel who continue BLS or initiate advanced life support; Transfer of care to a physician who determines that resuscitation should be discontinued; Inability to continue resuscitation because of exhaustion, because environmental hazards endanger the rescuer, or because continued resuscitation would jeopardize the lives of others; Recognition of reliable criteria for determination of death; or Presentation of a valid no-CPR order to the rescuers. At least one person at the scene of the arrest will remain with the victim and initiate the Code Blue procedure Any clinical employee trained in Basic Life Support may initiate CPR .The Emergency Medical System (911 or local number) will be activated immediately. Advanced Life Support functions will be instituted by paramedics with the EMS system EMS will transport resident/patient to the emergency room of the transfer agreement hospital .Guidelines: Person Responsible in a Code Blue Situation: Person Responsible in a Code Blue Situation: Any physician in the facility, becomes Team Leader for directing a code This facility is not currently equipped with defibrillator or cardiac drugs to conduct ACLS measures. In the event a physician is in the facility at the time of the code and gives specific order for the treatment of the resident/patient within the capabilities of the facilities equipment and supplies, such orders will be carried out .Nurse manager/charge nurse - delegated code responsibility as part of shift assignment for nursing staff present person to record, persons to do CPR, person to call 911, (or appropriate local number) physician and family if social workers not present Resident's/Patient's assigned nurse - available to give report Director of Nursing if in facility - Dismisses unnecessary personnel .Assures the EMS has been contacted of transport if physician not present, supervises code activities, Observes performance of Code Team and makes recommendations on code review, Delegates contacting and providing emotional support to resident's/patient's family to administrative representative, social worker or recreational therapy Social Services, if in facility, to support family members Person who discovers arrest: Calls for help while placing resident/patient in flat position on back C. Nurses Responding: Establish a patent airway .Use lift, jaw lift technique, or nasal airway. Do not hyperextend neck of any resident/patient .remove dentures if they are obstructing the airway .Begin CPR - one person rate in accordance with current American Heart Association/American Red Cross standards use single use resuscitation mask mouth-to-mouth or mouth to nose until [NAME] bag is obtained . Documentation: Time arrest called, date and location-information must be complete on every Record .Ventilation-Note time started and stopped, types of ventilation and by whom .External massage-Chart time started and stopped and each person involved .Persons responding-Record names of people responding to the Code Blue .- if possible, give department name also .Time, Pulse, Pupils, Skin - The patient's/resident's condition at intervals should be recorded with regard to BP, pulse, pupils, and skin Pulse -weak, thready, slow, unobtainable, bounding, femoral only, etc. (further, similar). Pupils - pinpoint, dilated fixed, non-reactive, unequal, etc. (further, similar) . Skin - warm, dry, cold, clammy, cyanotic, pale, etc. (further, similar) . Time EMS called, arrived, and departed with resident/patient Condition of resident/patient on departure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to consult with the resident's physician and notify the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for notification of changes. The facility failed to notify and consult with the Resident #1's physician and notify the resident's representative when Resident #1 was coughing up blood on 01/06/24 and her blood sugar level dropped to 52 mg/dl on 01/07/24. Resident #1 was hospitalized on [DATE] and expired on 01/08/24. An Immediate Jeopardy (IJ) was identified on 01/11/24 at 2:25 PM. While the IJ was removed on 01/12/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks of a delay in medical treatment, which could lead to worsening of their condition, hospitalization, or death. Findings included: Record review of Resident #1's electronic Face Sheet, dated 01/10/24, revealed a [AGE] year-old female who originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident #1 had diagnoses which included the following: diabetes, 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), hypertension (blood pressure that is higher than normal), acute respiratory failure (often caused by a disease or injury that affects your breathing), acute kidney failure, gastro-esophageal reflux disease (a common condition in which the stomach contents move up into the esophagus), heart failure, and unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS revealed Resident #1 was diabetic but did not require insulin injections. Further review reflected Resident #1 required moderate to substantial assistance with mobility in rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed transfer, toilet transfer, and shower transfer. Further review of the MDS revealed Resident #1 was occasionally incontinent of urine, and always incontinent of bowel. Record review of Resident #1's Care Plan, initiated on 03/12/20, reflected Resident #1 had congestive heart failure and the interventions included monitor vital signs every shift and notify MD of significant abnormalities, inform physician of any insomnia or anxiety, monitor/document/report PRN any s/sx of Congestive Heart Failure: . dry cough . wheezes upon auscultation (listening to sounds) of the lungs .lethargy. The Care Plan reflected Resident #1 had diabetes and the interventions included Notify MD if BS <60 or >300. The Care Plan reflected Resident #1 needed dialysis due to end stage renal disease and one of the interventions included monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Further review reflected Resident #1 needed oxygen therapy and one of the interventions included Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis (coughing up blood from some part of the lungs (respiratory tract)), Cough . Record review of Resident #1's electronic clinical record revealed a progress note by LVN A, dated 01/07/24 at 12:09 AM, reflected Patient c/o hemoptysis (coughing up blood from some part of the lungs (respiratory tract) and needing additional breathing treatment. Patient lung sound with some congestion. Patient noted to be laying supine at the foot of the bed without elevation of the head. Suggestion made to have her moved to head of bed so she could be elevated but patient declined. Assisted patient with propping her head up with a pillow and advised her that her next breathing treatment was due at 0200. Also advised that if the coughing persisted with blood tinged mucous, we would need to elevate her head more. Patient voiced agreement and understanding. Record review of Resident #1's electronic clinical record revealed a progress note by LVN B, dated 01/07/24 at 11:20 PM, reflected Resident blood sugar checked on or around 2050 (8:50 PM) resident reading 52, resident awake and responding to this nurse, gave resident snack and juice before also administering glucose gel, brought resident a sandwich and advised her to eat, rechecked blood sugar and received a reading of 72, resident refused to continue eating and this nurse to leave, gave the resident more juice and crackers and told her I would be back to check her reading gain shortly. Arrived back in residents room on or around 2130 (9:30 PM), resident awake but no longer verbalizing with the nurse, resident coughed at nurse, took finger stick and got a reading of 56, resident, left room to get glucagon inject, other hall nurses stepped in to assist this nurse, When arrived back in room resident was given glucagon. Assisting nurse unable to palpate pulse, code blue, CPR started on or around 2145 (9:45 PM). 911 called, 12 rounds of CPR performed, before EMS arrived approx. (approximately) 5 mins later and took over CPS (CPR). Resident transported to hospital by EMS. RP notified, NP notified, DON notified. Record review of Resident #1's hospital records, dated 01/07/24, reflected Resident #1 admitted into the ER on [DATE] at 10:18 PM. The records reflected Resident #1 was discharged from the ER and into Intensive Care unit on 01/08/24 at 1:05 AM. The ER notes dated 01/07/24, reflected [Resident #1] is a 68 y.o. female who present to the ED in cardiac arrest with CPR in progress. History is obtained from EMS personnel. Per report, the patient is a resident of a nursing facility, she was last seen around an hour prior to arrival where she was treated for hypoglycemia with glucagon. Around 40 minutes prior to arrival nursing staff stated they went to check on the patient and she was found unresponsive in bed, CPR was initiated at bedside and EMS was called. At the time of EMS arrival she was found to be in asystole. A king airway was placed and CPR was continued per ACLS protocols. EMS reports at least 30 minutes of CPR prior to arrival. She was persistently hypoglycemic and received 250cc D10 bolus (a single, large dose of insulin) prior to arrival. Resident #1's diagnosis included cardiac arrest, hypoglycemia, and end stage renal disease. The hospital records indicated Resident expired on 01/08/24 at 4:55 PM. In an interview on 01/10/24 at 11:59 AM, LVN A stated she worked on 01/06/24 from 10PM to 6AM and was assigned to Resident #1. LVN A stated Resident #1 had a breathing treatment scheduled per the MAR, so she went into her room to provide it. She stated Resident #1 was laying at the foot of the bed, and when she asked her why, Resident #1 said the mattress was more comfortable at the foot of the bed. LVN A stated Resident #1 did not have her nasal cannula in, so her O2 was low but not dangerously low. She stated she could not remember the exact number. LVN A stated she put the nasal cannula back in, and her vitals went back to normal. LVN A stated she provided Resident #1 her breathing treatment and she tolerated it well. LVN A stated Resident #1 said she was coughing up blood and showed her the tissue which had blood on it. LVN A stated she did not think to notify the MD because Resident #1 said she was coughing up blood at the hospital and they had just released her the same day (01/06/24), so she thought Resident #1 was ok. LVN A stated she was supposed to notify the MD if there were changes of condition, but she checked Resident #1's lungs and it was a little congested but was not severe. LVN A stated she did not notify Resident #1's family nor the DON. LVN A stated she told Resident #1 if she continued to cough up blood, then she would need to move her to the head of the bed and prop up her head, which would help with the congestion. LVN A stated she checked on Resident #1 a little later and saw she was at the top of the bed and was sleeping. She stated she notified LVN B of Resident #1's condition when she arrived to relieve her on 01/07/24 at 6:00 AM. In an interview on 01/10/24 at 1:35 PM, LVN B stated she worked a double on 01/07/24 from 6AM to 10PM and was assigned to Resident #1. LVN B stated when she started her shift at 6AM, LVN A told her that Resident #1 had been spitting up blood. She stated she was familiar with Resident #1 and that was not normal. LVN B stated she did not contact the MD or Resident #1's family. She stated she did not contact the MD because when she gave her, the breathing treatments, everything seemed fine, and she did not ever see Resident #1 coughing or spitting up blood. LVN B stated in hindsight, that was a change of condition, and she should have contacted the MD and Resident #1's family. LVN B stated she was doing evening BS and when she checked Resident #1's BS it was in the low 50's. She stated she could not recall the exact number. LVN B stated she gave Resident #1 food and glucose gel to ger her BS back up. LVN B stated she did not take Resident #1's vitals, so she was unaware of her BP or O2 level. She stated after applying the glucose gel and Resident #1 eating her BS was back up to the 70's. LVN B stated she was not for sure what a normal BS range was, but she believed it was between 70-80. LVN B stated she told Resident #1 to continue to eat the sandwich while she finished getting the other resident's BS. LVN B stated she did not contact the MD about the low BS because the normal procedures were to try interventions before contacting the MD. She stated she was able to get Resident #1's BS back to normal range after her interventions. LVN B stated a drop in BS was considered a change of condition, and even after getting the BS back to normal range, she did not notify the MD. LVN B stated once she finished getting the rest of the resident's evening BS, she returned to check on Resident #1. She stated Resident #1 she was not verbally responding but was coughing. LVN B stated she checked Resident #1's BS and it was back in the 50's. LVN B stated she got help from LVN C and gave Resident #1 a glucagon injection. She stated Resident #1 was not responding, so they started CPR and called EMS. LVN B stated when EMS arrived, they continued to give Resident #1 CPR and took her to the hospital. In an interview on 01/10/24 at 2:01 PM, the DON stated she had only been working at the facility for two weeks, so she was getting to know the residents. The DON stated she did not know a lot about Resident #1 or the situation that happened because LVN B did not contact her and called the ADMN instead. The DON stated the ADMN notified her that Resident #1 was found unresponsive by LVN B, who did CPR and called EMS. She stated Resident #1 was sent to the hospital. She stated she had not spoken to LVN B about the incident. The DON stated she had never heard that Resident #1 was spitting up blood. She stated that should have been reported to the MD right away, because it was considered a change of condition. The DON stated even if the resident reported to the nurse that she was spitting up blood in the hospital, she should have still contacted the MD. The DON stated she was not aware of the issue with Resident #1's BS. She stated when the BS drops, the expectation was to first take care of the resident. The DON stated the facility had standing orders for glucose gel and glucagon inject depending on if the resident was responsive. She stated after attending the to the resident with one of those interventions, then staff should notify the MD, DON, and family because there was a change of condition. In an interview on 01/11/24 at 10:50 AM, the ADMN stated on Sunday night (01/07/24) he received a call from LVN B that Resident #1 was found unresponsive. He stated LVN B told him that Resident #1's BS was low like 50 and she gave her glucose gel and was able to get it back up to 70. The ADMN stated LVN B reported when she went back into Resident #1's room to check on her, she was unresponsive. He stated LVN B reported she had performed CPR and called EMS, who transported Resident #1 to the hospital. The ADMN stated he was aware the previous night that LVN A reported Resident #1 was coughing up blood-tinged sputum. He stated LVN A reported it was pinkish in color and was not a lot. The ADMN stated both situations were a change of condition and should have been reported to the MD/NP. He stated they had started in-servicing the nurses on change of condition. An attempt to interview the MD was completed via phone on 01/11/24 at 11:51 AM and on 01/12/24 on 10:47 AM. The facility's MD had not returned the call. In an interview on 01/11/24 at 1:07 PM, the NP stated he was not notified about any issues with Resident #1, until 01/07/24, when they found her unresponsive. He stated he was on-call for the MD and the staff were supposed to call him if residents had change of conditions. The NP stated on 01/07/24 he received a text from LVN C that LVN B found Resident #1 unresponsive, and she was sent to the hospital. He stated he immediately called LVN C back, and it was informed that Resident #1 had been coughing up blood and her BS had dropped to 52. The NP stated those are considered critical conditions and staff should have notified him. He stated he would have ordered Resident #1 to be sent back to the hospital. In a phone interview on 01/12/24 at 10:36 AM, LVN C stated on 01/07/24 she was at the nurse's station and overheard LVN B telling Med Aide D that she did not know what to do because Resident #1's BS was 50 and she would not eat. LVN C stated she asked LVN B did she give Resident #1 glucose gel and she said no, she did not have any. LVN C stated she gave LVN B glucose gel, which LVN B administered to Resident #1. LVN C stated when she went to room to assess Resident #1, she was cold to touch and was not responding. She stated she started sternal rubs, while she was checking Resident #1's pulse. LVN C stated she could not get a pulse on Resident #1, so they started CPR and called EMS. She stated they did CPR for about ten minutes until EMS arrived. She stated while she was in the room with Resident #1, she was never able to get a pulse. LVN C stated once EMS arrived, they took over and continued CPR. LVN C stated she contacted the NP. She stated Resident #1 was transported to the hospital. LVN C stated she did not know if LVN B took Resident #1's vitals, but she should have when her BS dropped to 50. She stated they had standing orders for BS. LVN C stated when BS drops below 60, they were supposed to give glucose gel, but if the resident was unresponsive, they were supposed to give glucagon inject. LVN C stated once they have provided the gel or inject, they were supposed to notify MD/NP, DON, and family, and then check the BS again in 15 minutes after administering the gel/inject. LVN C stated LVN B told her the overnight nurse reported that Resident #1 had been spitting up blood. She stated they were supposed to notify the MD/NP right away for that. LVN C stated when the overnight nurse provided LVN B with that information, she should have told her she needed to contact the MD/NP. In a phone interview on 01/12/24 at 10:56 AM, Med Aide D stated about 8/9 PM she was at the nurse's station and LVN B told her that Resident #1's BS was like 50, she could not get her to eat, and did not know what to do. Med Aide D stated LVN C heard them talking and jumped in to help. She stated LVN C told LVN B to give Resident #1 the gel to get her BS up. She stated LVN B and LVN C went to Resident #1's room. Med Aide D stated she later went to Resident #1's room and heard LVN B and LVN C saying Resident #1 was not responding. She stated they were doing CPR on the resident. She stated they called EMS and Resident #1 was sent to the hospital. In a phone interview on 01/12/24 at 2:14 PM, RN E stated she worked the overnight shift on 01/06/24 but was not assigned to Resident #1. RN E stated she and LVN A were at the nurses' station and CNA F said Resident #1 was coughing up blood. She stated LVN A asked her what she should do, should she call EMS. RN E stated she told her to go assess Resident #1. She stated LVN A headed towards Resident #1's room. RN E stated she assumed Resident #1 was ok because she did not get sent the hospital. RN E stated she did not know if LVN A contacted the MD, but she assumed she did. She stated coughing up blood is a change of condition, so they were supposed to notify the MD/NP. In a phone interview on 01/12/24 at 6:01 PM, CNA F stated she worked overnight on 01/06/24 and was assigned to Resident #1. CNA F stated she got to work a little early and started doing rounds. She stated she saw Resident #1 was laying at the foot of the bed and was coughing. CNA F stated she asked Resident #1 if she was ok, and Resident #1 said she was coughing up blood and to get the nurse. She stated as Resident #1 pulled the tissue away from her mouth she saw the blood on the tissue. CNA F stated LVN A was at the nurse's station, and she told her that Resident #1 was coughing up blood. She stated LVN A asked RN E what was she supposed to do. She said RN E told her to go assess Resident #1. CNA F stated she walked away from the nurse's station and continued to do rounds. CNA F stated about 15 minutes later she passed by Resident #1's room and saw LVN A was checking Resident #1's chest with a stethoscope. CNA F stated throughout the night Resident #1 kept pressing her call light to be repositioned from the top to bottom of bed. She stated Resident #1 was coughing throughout the night and was spitting into tissues. CNA F stated it seemed as if she could not get comfortable and was restless, which was not normal for Resident #1. She stated she did report these things to LVN A, and she was surprised that Resident #1 was not sent back to the hospital. In a phone interview on 01/17/24 at 2:03 PM, Resident #1's FM stated she received a call from the facility on Sunday night (01/07/24) that Resident #1 was found unresponsive, the facility did CPR, and she was sent to the hospital. Resident #1's FM stated she was not notified that Resident #1's BS had dropped low, nor was she notified that Resident #1 was coughing up blood the previous night. The FM stated if the facility would have called her about Resident #1 coughing up blood, she would have told them to send her back to the hospital. A record review of the facility's policy titled Nursing Care of the Older Adult with Diabetes Mellitus, dated November 2020, reflected Purpose: To provide an overview of diabetes in the older adult, its symptoms and complications and principles of glucose monitoring . Glycemic Targets: 5. Manage hypoglycemia according to protocols and provider orders. 6. Establish provider notification protocols, for example: a. Call provider and DON/Designee immediately if resident is hypoglycemic (<70 mg/dl) . A record review of the facility's policy titled Change of Condition and Physician/Family Notification, dated January 2023, reflected Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: . A significant change in resident's physical, mental, or psychosocial status. (See below for examples). A need to significantly alter treatment. Transfer of the resident from the facility. Procedures: When any of the above situations exist, the licensed nurse will contact the resident's family and their physician . Each attempt will be charged as to time the call was made, who was spoken to, and what information was given to the physician . Examples of Significant Changes: . a sudden change in mental status including agitation, lethargy, sudden lack of responsiveness or manic behavior, bleeding .emesis . This failure resulted in an identification of an Immediate Jeopardy on 01/11/2024 at 2:25 PM. The Administrator was informed and provided the IJ template on 01/11/2024 at 2:26 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: Immediately on January 10, 2024, CCS inserviced Administrator and DON on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. Competency was verified via quiz. Immediately on January 11, 2024, CCS2024, CCS inserviced Administrator and DON on diabetic policy and procedures, and abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. On January 10, 2024, Administrator and DON initiated inservices with the licensed nurses on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP, diabetic policy and procedures, and abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed. On January 11, 2024, Administrator and DON initiated inservices with staff on change of condition, abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. Staff will not be allowed to work until inservicing has been completed. On January 10, 2024 an audit was conducted by DON/Designee to identify other residents with potential change of condition. Via direct observation, staff interviews, and record review, no other residents were identified as having a change of condition. Medical Director was notified on January 10, 2024, by Administrator. Medical Director was notified on January 11, 2024 of the IJ situation by Administrator. On January 12, 2024 Social Services completed life satisfaction rounds with residents in regards to change of condition. In order to monitor current residents for potential risk, DON, and CCS will monitor residents for change of condition to include diabetic changes in blood sugar daily beginning January 11, 2024, for 30 days on all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition. DON compliance will be monitored weekly by CCS for 90 days. Social Services/Designee will complete life satisfaction rounds weekly with residents in regards to change of condition for 90 days. Administrator will monitor compliance of Social Services Director/Designee. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition, quality of care and abuse and neglect. If any issues are identified, the physician will be contacted for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Monitoring of the plan of removal included: Interviews were conducted on 01/12/24 from 12:25 to 3:10 PM with 2 RNs, 7 LVN, 3 CMAs, 11 CNAs, 2 HK, the Staffing Coordinator, Activity Director, SW, ADON, DON and ADMN, who worked multiple shifts, revealed they had all been in-serviced on Abuse & Neglect policy, Change of Conditions policy, and nurses on Diabetes Mellitus policy. The staff were able to identify examples of abuse & neglect and changes in condition and were knowledgeable on who they should report to. The nursing staff were able to identify the ranges in BS levels that were not normal, and they were knowledgeable on protocols to follow and who they needed to report to. The staff reported verifying their competency via a quiz. In an interview on 01/12/24 at 2:37 PM, the CCS stated she had in serviced the ADMN and DON on the change of condition policy, abuse & neglect policy, and the diabetic policy. She stated their competency was verified via quizzes. The CCS stated for the next 30 days she and the DON would be monitoring BS levels for any changes of condition. She stated this would be documented on their log. The CSS stated if they identified any changes, they would contact the MD and family/POA immediately. A record review of the facility's documented titled Personnel Action Form, dated 01/10/24, reflected LVN A began suspension on 01/10/24. A record review of the facility's documented titled Personnel Action Form, dated 01/10/24, reflected LVN B began suspension on 01/10/24. A record review of in-services titled Change of Condition, Abuse & Neglect and Nursing Care of older Adult with Diabetes Mellitus, dated from 01/10/24 to 01/12/24, conducted by the ADON and DON, reflected all staff were educated on policy and procedures including assessments and notification to MD/NP regarding change of condition. All staff were in-serviced on policy and procedures regarding abuse and neglect including who to report to. The nursing staff were educated on diabetic policy and procedures which included parameters of BS levels and when to call the MD/NP. The records reflected the staff were quizzed on the competency of these policies. A record review of Life Satisfaction Rounds, dated 01/12/24 reflected the SW completed safety rounds with no negative responses on 20 residents from multiple halls asking 1. Do you feel you receive quality care from your nurse? 2. Are the nurses responsive to your care needs? 3. Do you feel safe at [facility]? 4. If you have a concern regarding the care you receive from a nurse, who would you speak with?. The Administrator were informed the Immediate Jeopardy was removed on 01/12/24 at 3:45 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect a resident's right to be free from deprivation of goods for 1 of 5 residents (Resident #1) reviewed for abuse. 1. The facility failed to provide Resident #1 with goods necessary to avoid physical harm, when the nurses did not report to the resident's MD/NP change of conditions including her coughing up blood on 01/06/24, her blood sugar reaching a level of 52 mg/dl on 01/07/24. 2. LVN B failed to take Resident #1's vitals when her BS dropped to 52 mg/dl. Resident #1 was found approximately 40 minutes later unresponsive with no pulse, which led to her being hospitalized on [DATE]. Resident #1 expired on 01/08/24. An Immediate Jeopardy (IJ) was identified on 01/11/24 at 2:25 PM. While the IJ was removed on 01/12/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks of not obtaining the care that was needed, which could lead to worsening of their condition, hospitalization, or death. Findings included: Record review of Resident #1's electronic Face Sheet, dated 01/10/24, revealed a [AGE] year-old female who originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident #1 had diagnoses which included the following: diabetes, 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), hypertension (blood pressure that is higher than normal), acute respiratory failure (often caused by a disease or injury that affects your breathing), acute kidney failure, gastro-esophageal reflux disease (a common condition in which the stomach contents move up into the esophagus), heart failure, and unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS revealed Resident #1 was diabetic but did not require insulin injections. Further review reflected Resident #1 required moderate to substantial assistance with mobility in rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed transfer, toilet transfer, and shower transfer. Further review of the MDS revealed Resident #1 was occasionally incontinent of urine, and always incontinent of bowel. Record review of Resident #1's Care Plan, initiated on 03/12/20, reflected Resident #1 had congestive heart failure and the interventions included monitor vital signs every shift and notify MD of significant abnormalities, inform physician of any insomnia or anxiety, monitor/document/report PRN any s/sx of Congestive Heart Failure: . dry cough . wheezes upon auscultation (listening to sounds) of the lungs .lethargy. The Care Plan reflected Resident #1 had diabetes and the interventions included Notify MD if BS <60 or >300. The Care Plan reflected Resident #1 needed dialysis due to end stage renal disease and one of the interventions included monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Further review reflected Resident #1 needed oxygen therapy and one of the interventions included Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis (coughing up blood from some part of the lungs (respiratory tract)), Cough . Record review of Resident #1's electronic clinical record revealed a progress note by LVN A, dated 01/07/24 at 12:09 AM, reflected Patient c/o hemoptysis (coughing up blood from some part of the lungs (respiratory tract)) and needing additional breathing treatment. Patient lung sound with some congestion. Patient noted to be laying supine at the foot of the bed without elevation of the head. Suggestion made to have her moved to head of bed so she could be elevated but patient declined. Assisted patient with propping her head up with a pillow and advised her that her next breathing treatment was due at 0200. Also advised that if the coughing persisted with blood tinged mucous, we would need to elevate her head more. Patient voiced agreement and understanding. Record review of Resident #1's electronic clinical record revealed a progress note by LVN B, dated 01/07/24 at 11:20 PM, reflected Resident blood sugar checked on or around 2050 (8:50 PM) resident reading 52, resident awake and responding to this nurse, gave resident snack and juice before also administering glucose gel, brought resident a sandwich and advised her to eat, rechecked blood sugar and received a reading of 72, resident refused to continue eating and this nurse to leave, gave the resident more juice and crackers and told her I would be back to check her reading gain shortly. Arrived back in residents room on or around 2130 (9:30 PM), resident awake but no longer verbalizing with the nurse, resident coughed at nurse, took finger stick and got a reading of 56, resident, left room to get glucagon inject, other hall nurses stepped in to assist this nurse, When arrived back in room resident was given glucagon. Assisting nurse unable to palpate pulse, code blue, CPR started on or around 2145 (9:45 PM). 911 called, 12 rounds of CPR performed, before EMS arrived approx. (approximately) 5 mins later and took over CPS (CPR). Resident transported to hospital by EMS. RP notified, NP notified, DON notified. Record review of Resident #1's hospital records, dated 01/07/24, reflected Resident #1 admitted into the ER on [DATE] at 10:18 PM. The records reflected Resident #1 was discharged from the ER and into Intensive Care unit on 01/08/24 at 1:05 AM. The ER notes dated 01/07/24, reflected [Resident #1] is a 68 y.o. female who present to the ED in cardiac arrest with CPR in progress. History is obtained from EMS personnel. Per report, the patient is a resident of a nursing facility, she was last seen around an hour prior to arrival where she was treated for hypoglycemia with glucagon. Around 40 minutes prior to arrival nursing staff stated they went to check on the patient and she was found unresponsive in bed, CPR was initiated at bedside and EMS was called. At the time of EMS arrival she was found to be in asystole. A king airway was placed and CPR was continued per ACLS protocols. EMS reports at least 30 minutes of CPR prior to arrival. She was persistently hypoglycemic and received 250cc D10 bolus (a single, large dose of insulin) prior to arrival. Resident #1's diagnosis included cardiac arrest, hypoglycemia, and end stage renal disease. The hospital records indicated Resident expired on 01/08/24 at 4:55 PM. In an interview on 01/10/24 at 11:59 AM, LVN A stated she worked on 01/06/24 from 10PM to 6AM and was assigned to Resident #1. LVN A stated Resident #1 had a breathing treatment scheduled per the MAR, so she went into her room to provide it. She stated Resident #1 was laying at the foot of the bed, and when she asked her why, Resident #1 said the mattress was more comfortable at the foot of the bed. LVN A stated Resident #1 did not have her nasal cannula in, so her O2 was low but not dangerously low. She stated she could not remember the exact number. LVN A stated she put the nasal cannula back in, and her vitals went back to normal. LVN A stated she provided Resident #1 her breathing treatment and she tolerated it well. LVN A stated Resident #1 said she was coughing up blood and showed her the tissue which had blood on it. LVN A stated she did not think to notify the MD because Resident #1 said she was coughing up blood at the hospital and they had just released her the same day (01/06/24), so she thought Resident #1 was ok. LVN A stated she was supposed to notify the MD if there were changes of condition, but she checked Resident #1's lungs and it was a little congested but was not severe. LVN A stated she did not notify Resident #1's family nor the DON. LVN A stated she told Resident #1 if she continued to cough up blood, then she would need to move her to the head of the bed and prop up her head, which would help with the congestion. LVN A stated she checked on Resident #1 a little later and saw she was at the top of the bed and was sleeping. She stated she notified LVN B of Resident #1's condition when she arrived to relieve her on 01/07/24 at 6:00 AM. In an interview on 01/10/24 at 1:35 PM, LVN B stated she worked a double on 01/07/24 from 6AM to 10PM and was assigned to Resident #1. LVN B stated when she started her shift at 6AM, LVN A told her that Resident #1 had been spitting up blood. She stated she was familiar with Resident #1 and that was not normal. LVN B stated she did not contact the MD or Resident #1's family. She stated she did not contact the MD because when she gave her, the breathing treatments, everything seemed fine, and she did not ever see Resident #1 coughing or spitting up blood. LVN B stated in hindsight, that was a change of condition, and she should have contacted the MD and Resident #1's family. LVN B stated she was doing evening BS and when she checked Resident #1's BS it was in the low 50's. She stated she could not recall the exact number. LVN B stated she gave Resident #1 food and glucose gel to ger her BS back up. LVN B stated she did not take Resident #1's vitals, so she was unaware of her BP or O2 level. She stated after applying the glucose gel and Resident #1 eating her BS was back up to the 70's. LVN B stated she was not for sure what a normal BS range was, but she believed it was between 70-80. LVN B stated she told Resident #1 to continue to eat the sandwich while she finished getting the other resident's BS. LVN B stated she did not contact the MD about the low BS because the normal procedures were to try interventions before contacting the MD. She stated she was able to get Resident #1's BS back to normal range after her interventions. LVN B stated a drop in BS was considered a change of condition, and even after getting the BS back to normal range, she did not notify the MD. LVN B stated once she finished getting the rest of the resident's evening BS, she returned to check on Resident #1. She stated Resident #1 she was not verbally responding but was coughing. LVN B stated she checked Resident #1's BS and it was back in the 50's. LVN B stated she got help from LVN C and gave Resident #1 a glucagon injection. She stated Resident #1 was not responding, so they started CPR and called EMS. LVN B stated when EMS arrived, they continued to give Resident #1 CPR and took her to the hospital. In an interview on 01/10/24 at 2:01 PM, the DON stated she had only been working at the facility for two weeks, so she was getting to know the residents. The DON stated she did not know a lot about Resident #1 or the situation that happened because LVN B did not contact her and called the ADMN instead. The DON stated the ADMN notified her that Resident #1 was found unresponsive by LVN B, who did CPR and called EMS. She stated Resident #1 was sent to the hospital. She stated she had not spoken to LVN B about the incident. The DON stated she had never heard that Resident #1 was spitting up blood. She stated that should have been reported to the MD right away, because it was considered a change of condition. The DON stated even if the resident reported to the nurse that she was spitting up blood in the hospital, she should have still contacted the MD. The DON stated she was not aware of the issue with Resident #1's BS. She stated when the BS drops, the expectation was to first take care of the resident. The DON stated the facility had standing orders for glucose gel and glucagon inject depending on if the resident was responsive. She stated after attending the to the resident with one of those interventions, then staff should notify the MD, DON, and family because there was a change of condition. In an interview on 01/11/24 at 10:50 AM, the ADMN stated on Sunday night (01/07/24) he received a call from LVN B that Resident #1 was found unresponsive. He stated LVN B told him that Resident #1's BS was low like 50 and she gave her glucose gel and was able to get it back up to 70. The ADMN stated LVN B reported when she went back into Resident #1's room to check on her, she was unresponsive. He stated LVN B reported she had performed CPR and called EMS, who transported Resident #1 to the hospital. The ADMN stated he was aware the previous night that LVN A reported Resident #1 was coughing up blood-tinged sputum. He stated LVN A reported it was pinkish in color and was not a lot. The ADMN stated both situations were a change of condition and should have been reported to the MD/NP. He stated they had started in-servicing the nurses on change of condition. An attempt to interview the MD was completed via phone on 01/11/24 at 11:51 AM and on 01/12/24 on 10:47 AM. The facility's MD had not returned the call. In an interview on 01/11/24 at 1:07 PM, the NP stated he was not notified about any issues with Resident #1, until 01/07/24, when they found her unresponsive. He stated he was on-call for the MD and the staff were supposed to call him if residents had change of conditions. The NP stated on 01/07/24 he received a text from LVN C that LVN B found Resident #1 unresponsive, and she was sent to the hospital. He stated he immediately called LVN C back, and it was informed that Resident #1 had been coughing up blood and her BS had dropped to 52. The NP stated those are considered critical conditions and staff should have notified him. He stated he would have ordered Resident #1 to be sent back to the hospital. In a phone interview on 01/12/24 at 10:36 AM, LVN C stated on 01/07/24 she was at the nurse's station and overheard LVN B telling Med Aide D that she did not know what to do because Resident #1's BS was 50 and she would not eat. LVN C stated she asked LVN B did she give Resident #1 glucose gel and she said no, she did not have any. LVN C stated she gave LVN B glucose gel, which LVN B administered to Resident #1. LVN C stated when she went to room to assess Resident #1, she was cold to touch and was not responding. She stated she started sternal rubs, while she was checking Resident #1's pulse. LVN C stated she could not get a pulse on Resident #1, so they started CPR and called EMS. She stated they did CPR for about ten minutes until EMS arrived. She stated while she was in the room with Resident #1, she was never able to get a pulse. LVN C stated once EMS arrived, they took over and continued CPR. LVN C stated she contacted the NP. She stated Resident #1 was transported to the hospital. LVN C stated she did not know if LVN B took Resident #1's vitals, but she should have when her BS dropped to 50. She stated they had standing orders for BS. LVN C stated when BS drops below 60, they were supposed to give glucose gel, but if the resident was unresponsive, they were supposed to give glucagon inject. LVN C stated once they have provided the gel or inject, they were supposed to notify MD/NP, DON, and family, and then check the BS again in 15 minutes after administering the gel/inject. LVN C stated LVN B told her the overnight nurse reported that Resident #1 had been spitting up blood. She stated they were supposed to notify the MD/NP right away for that. LVN C stated when the overnight nurse provided LVN B with that information, she should have told her she needed to contact the MD/NP. In a phone interview on 01/12/24 at 10:56 AM, Med Aide D stated about 8/9 PM she was at the nurse's station and LVN B told her that Resident #1's BS was like 50, she could not get her to eat, and did not know what to do. Med Aide D stated LVN C heard them talking and jumped in to help. She stated LVN C told LVN B to give Resident #1 the gel to get her BS up. She stated LVN B and LVN C went to Resident #1's room. Med Aide D stated she later went to Resident #1's room and heard LVN B and LVN C saying Resident #1 was not responding. She stated they were doing CPR on the resident. She stated they called EMS and Resident #1 was sent to the hospital. In a phone interview on 01/12/24 at 2:14 PM, RN E stated she worked the overnight shift on 01/06/24 but was not assigned to Resident #1. RN E stated she and LVN A were at the nurses' station and CNA F said Resident #1 was coughing up blood. She stated LVN A asked her what she should do, should she call EMS. RN E stated she told her to go assess Resident #1. She stated LVN A headed towards Resident #1's room. RN E stated she assumed Resident #1 was ok because she did not get sent the hospital. RN E stated she did not know if LVN A contacted the MD, but she assumed she did. She stated coughing up blood is a change of condition, so they were supposed to notify the MD/NP. In a phone interview on 01/12/24 at 6:01 PM, CNA F stated she worked overnight on 01/06/24 and was assigned to Resident #1. CNA F stated she got to work a little early and started doing rounds. She stated she saw Resident #1 was laying at the foot of the bed and was coughing. CNA F stated she asked Resident #1 if she was ok, and Resident #1 said she was coughing up blood and to get the nurse. She stated as Resident #1 pulled the tissue away from her mouth she saw the blood on the tissue. CNA F stated LVN A was at the nurse's station, and she told her that Resident #1 was coughing up blood. She stated LVN A asked RN E what was she supposed to do. She said RN E told her to go assess Resident #1. CNA F stated she walked away from the nurse's station and continued to do rounds. CNA F stated about 15 minutes later she passed by Resident #1's room and saw LVN A was checking Resident #1's chest with a stethoscope. CNA F stated throughout the night Resident #1 kept pressing her call light to be repositioned from the top to bottom of bed. She stated Resident #1 was coughing throughout the night and was spitting into tissues. CNA F stated it seemed as if she could not get comfortable and was restless, which was not normal for Resident #1. She stated she did report these things to LVN A, and she was surprised that Resident #1 was not sent back to the hospital. In a phone interview on 01/17/24 at 2:03 PM, Resident #1's FM stated she received a call from the facility on Sunday night (01/07/24) that Resident #1 was found unresponsive, the facility did CPR, and she was sent to the hospital. Resident #1's FM stated she was not notified that Resident #1's BS had dropped low, nor was she notified that Resident #1 was coughing up blood the previous night. The FM stated if the facility would have called her about Resident #1 coughing up blood, she would have told them to send her back to the hospital. A record review of the facility's policy titled Nursing Care of the Older Adult with Diabetes Mellitus, dated November 2020, reflected Purpose: To provide an overview of diabetes in the older adult, its symptoms and complications and principles of glucose monitoring . Glycemic Targets: 5. Manage hypoglycemia according to protocols and provider orders. 6. Establish provider notification protocols, for example: a. Call provider and DON/Designee immediately if resident is hypoglycemic (<70 mg/dl) . A record review of the facility's policy titled Change of Condition and Physician/Family Notification, dated January 2023, reflected Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: . A significant change in resident's physical, mental, or psychosocial status. (See below for examples). A need to significantly alter treatment. Transfer of the resident from the facility. Procedures: When any of the above situations exist, the licensed nurse will contact the resident's family and their physician . Each attempt will be charged as to time the call was made, who was spoken to, and what information was given to the physician . Examples of Significant Changes: . a sudden change in mental status including agitation, lethargy, sudden lack of responsiveness or manic behavior, bleeding .emesis . A record review of the facility's policy titled Abuse Prohibition Policy, dated 11/07/23, reflected Intent: This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect . Policy: The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents . Definitions: Neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, good or services that a resident(s) requires but the facility fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect incudes cases where the facility's indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in physical harm, pain, mental anguish, or emotional distress. This failure resulted in an identification of an Immediate Jeopardy on 01/11/2024 at 2:25 PM. The Administrator was informed and provided the IJ template on 01/11/2024 at 2:26 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: Immediately on January 10, 2024, CCS inserviced Administrator and DON on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. Competency was verified via quiz. Immediately on January 11, 2024, CCS2024, CCS inserviced Administrator and DON on diabetic policy and procedures, and abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. On January 10, 2024, Administrator and DON initiated inservices with the licensed nurses on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP, diabetic policy and procedures, and abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed. On January 11, 2024, Administrator and DON initiated inservices with staff on change of condition, abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. Staff will not be allowed to work until inservicing has been completed. On January 10, 2024 an audit was conducted by DON/Designee to identify other residents with potential change of condition. Via direct observation, staff interviews, and record review, no other residents were identified as having a change of condition. Medical Director was notified on January 10, 2024, by Administrator. Medical Director was notified on January 11, 2024 of the IJ situation by Administrator. On January 12, 2024 Social Services completed life satisfaction rounds with residents in regards to change of condition. In order to monitor current residents for potential risk, DON, and CCS will monitor residents for change of condition to include diabetic changes in blood sugar daily beginning January 11, 2024, for 30 days on all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition. DON compliance will be monitored weekly by CCS for 90 days. Social Services/Designee will complete life satisfaction rounds weekly with residents in regards to change of condition for 90 days. Administrator will monitor compliance of Social Services Director/Designee. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition, quality of care and abuse and neglect. If any issues are identified, the physician will be contacted for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Monitoring of the plan of removal included: Interviews were conducted on 01/12/24 from 12:25 to 3:10 PM with 2 RNs, 7 LVN, 3 CMAs, 11 CNAs, 2 HK, the Staffing Coordinator, Activity Director, SW, ADON, DON and ADMN, who worked multiple shifts, revealed they had all been in-serviced on Abuse & Neglect policy, Change of Conditions policy, and nurses on Diabetes Mellitus policy. The staff were able to identify examples of abuse & neglect and changes in condition and were knowledgeable on who they should report to. The nursing staff were able to identify the ranges in BS levels that were not normal, and they were knowledgeable on protocols to follow and who they needed to report to. The staff reported verifying their competency via a quiz. In an interview on 01/12/24 at 2:37 PM, the CCS stated she had in serviced the ADMN and DON on the change of condition policy, abuse & neglect policy, and the diabetic policy. She stated their competency was verified via quizzes. The CCS stated for the next 30 days she and the DON would be monitoring BS levels for any changes of condition. She stated this would be documented on their log. The CSS stated if they identified any changes, they would contact the MD and family/POA immediately. A record review of the facility's documented titled Personnel Action Form, dated 01/10/24, reflected LVN A began suspension on 01/10/24. A record review of the facility's documented titled Personnel Action Form, dated 01/10/24, reflected LVN B began suspension on 01/10/24. A record review of in-services titled Change of Condition, Abuse & Neglect and Nursing Care of older Adult with Diabetes Mellitus, dated from 01/10/24 to 01/12/24, conducted by the ADON and DON, reflected all staff were educated on policy and procedures including assessments and notification to MD/NP regarding change of condition. All staff were in-serviced on policy and procedures regarding abuse and neglect including who to report to. The nursing staff were educated on diabetic policy and procedures which included parameters of BS levels and when to call the MD/NP. The records reflected the staff were quizzed on the competency of these policies. A record review of Life Satisfaction Rounds, dated 01/12/24 reflected the SW completed safety rounds with no negative responses on 20 residents from multiple halls asking 1. Do you feel you receive quality care from your nurse? 2. Are the nurses responsive to your care needs? 3. Do you feel safe at [facility]? 4. If you have a concern regarding the care you receive from a nurse, who would you speak with?. The Administrator were informed the Immediate Jeopardy was removed on 01/12/24 at 3:45 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility nurses failed to identify and report to Resident #1's MD/NP change of conditions, including her coughing up blood on 01/06/24 and her blood sugar reaching a level of 52 mg/dl on 01/07/24, which led to her not being provided with needed care and services. Resident #1 was hospitalized on [DATE] and expired on 01/08/24. An Immediate Jeopardy (IJ) was identified on 01/11/24 at 2:25 PM. While the IJ was removed on 01/12/23, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks of not obtaining the care that was needed, which could lead to worsening of their condition, hospitalization, or death. Findings included: Record review of Resident #1's electronic Face Sheet, dated 01/10/24, revealed a [AGE] year-old female who originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident #1 had diagnoses which included the following: diabetes, 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), hypertension (blood pressure that is higher than normal), acute respiratory failure (often caused by a disease or injury that affects your breathing), acute kidney failure, gastro-esophageal reflux disease (a common condition in which the stomach contents move up into the esophagus), heart failure, and unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15, which indicated Resident #1's cognition was intact. The MDS revealed Resident #1 was diabetic but did not require insulin injections. Further review reflected Resident #1 required moderate to substantial assistance with mobility in rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair to bed transfer, toilet transfer, and shower transfer. Further review of the MDS revealed Resident #1 was occasionally incontinent of urine, and always incontinent of bowel. Record review of Resident #1's Care Plan, initiated on 03/12/20, reflected Resident #1 had congestive heart failure and the interventions included monitor vital signs every shift and notify MD of significant abnormalities, inform physician of any insomnia or anxiety, monitor/document/report PRN any s/sx of Congestive Heart Failure: . dry cough . wheezes upon auscultation (listening to sounds) of the lungs .lethargy. The Care Plan reflected Resident #1 had diabetes and the interventions included Notify MD if BS <60 or >300. The Care Plan reflected Resident #1 needed dialysis due to end stage renal disease and one of the interventions included monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Further review reflected Resident #1 needed oxygen therapy and one of the interventions included Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis (coughing up blood from some part of the lungs (respiratory tract)), Cough . Record review of Resident #1's electronic clinical record revealed a progress note by LVN A, dated 01/07/24 at 12:09 AM, reflected Patient c/o hemoptysis (coughing up blood from some part of the lungs (respiratory tract) and needing additional breathing treatment. Patient lung sound with some congestion. Patient noted to be laying supine at the foot of the bed without elevation of the head. Suggestion made to have her moved to head of bed so she could be elevated but patient declined. Assisted patient with propping her head up with a pillow and advised her that her next breathing treatment was due at 0200. Also advised that if the coughing persisted with blood tinged mucous, we would need to elevate her head more. Patient voiced agreement and understanding. Record review of Resident #1's electronic clinical record revealed a progress note by LVN B, dated 01/07/24 at 11:20 PM, reflected Resident blood sugar checked on or around 2050 (8:50 PM) resident reading 52, resident awake and responding to this nurse, gave resident snack and juice before also administering glucose gel, brought resident a sandwich and advised her to eat, rechecked blood sugar and received a reading of 72, resident refused to continue eating and this nurse to leave, gave the resident more juice and crackers and told her I would be back to check her reading gain shortly. Arrived back in residents room on or around 2130 (9:30 PM), resident awake but no longer verbalizing with the nurse, resident coughed at nurse, took finger stick and got a reading of 56, resident, left room to get glucagon inject, other hall nurses stepped in to assist this nurse, When arrived back in room resident was given glucagon. Assisting nurse unable to palpate pulse, code blue, CPR started on or around 2145 (9:45 PM). 911 called, 12 rounds of CPR performed, before EMS arrived approx. (approximately) 5 mins later and took over CPS (CPR). Resident transported to hospital by EMS. RP notified, NP notified, DON notified. Record review of Resident #1's hospital records, dated 01/07/24, reflected Resident #1 admitted into the ER on [DATE] at 10:18 PM. The records reflected Resident #1 was discharged from the ER and into Intensive Care unit on 01/08/24 at 1:05 AM. The ER notes dated 01/07/24, reflected [Resident #1] is a 68 y.o. female who present to the ED in cardiac arrest with CPR in progress. History is obtained from EMS personnel. Per report, the patient is a resident of a nursing facility, she was last seen around an hour prior to arrival where she was treated for hypoglycemia with glucagon. Around 40 minutes prior to arrival nursing staff stated they went to check on the patient and she was found unresponsive in bed, CPR was initiated at bedside and EMS was called. At the time of EMS arrival she was found to be in asystole. A king airway was placed and CPR was continued per ACLS protocols. EMS reports at least 30 minutes of CPR prior to arrival. She was persistently hypoglycemic and received 250cc D10 bolus (a single, large dose of insulin) prior to arrival. Resident #1's diagnosis included cardiac arrest, hypoglycemia, and end stage renal disease. The hospital records indicated Resident expired on 01/08/24 at 4:55 PM. In an interview on 01/10/24 at 11:59 AM, LVN A stated she worked on 01/06/24 from 10PM to 6AM and was assigned to Resident #1. LVN A stated Resident #1 had a breathing treatment scheduled per the MAR, so she went into her room to provide it. She stated Resident #1 was laying at the foot of the bed, and when she asked her why, Resident #1 said the mattress was more comfortable at the foot of the bed. LVN A stated Resident #1 did not have her nasal cannula in, so her O2 was low but not dangerously low. She stated she could not remember the exact number. LVN A stated she put the nasal cannula back in, and her vitals went back to normal. LVN A stated she provided Resident #1 her breathing treatment and she tolerated it well. LVN A stated Resident #1 said she was coughing up blood and showed her the tissue which had blood on it. LVN A stated she did not think to notify the MD because Resident #1 said she was coughing up blood at the hospital and they had just released her the same day (01/06/24), so she thought Resident #1 was ok. LVN A stated she was supposed to notify the MD if there were changes of condition, but she checked Resident #1's lungs and it was a little congested but was not severe. LVN A stated she did not notify Resident #1's family nor the DON. LVN A stated she told Resident #1 if she continued to cough up blood, then she would need to move her to the head of the bed and prop up her head, which would help with the congestion. LVN A stated she checked on Resident #1 a little later and saw she was at the top of the bed and was sleeping. She stated she notified LVN B of Resident #1's condition when she arrived to relieve her on 01/07/24 at 6:00 AM. In an interview on 01/10/24 at 1:35 PM, LVN B stated she worked a double on 01/07/24 from 6AM to 10PM and was assigned to Resident #1. LVN B stated when she started her shift at 6AM, LVN A told her that Resident #1 had been spitting up blood. She stated she was familiar with Resident #1 and that was not normal. LVN B stated she did not contact the MD or Resident #1's family. She stated she did not contact the MD because when she gave her, the breathing treatments, everything seemed fine, and she did not ever see Resident #1 coughing or spitting up blood. LVN B stated in hindsight, that was a change of condition, and she should have contacted the MD and Resident #1's family. LVN B stated she was doing evening BS and when she checked Resident #1's BS it was in the low 50's. She stated she could not recall the exact number. LVN B stated she gave Resident #1 food and glucose gel to ger her BS back up. LVN B stated she did not take Resident #1's vitals, so she was unaware of her BP or O2 level. She stated after applying the glucose gel and Resident #1 eating her BS was back up to the 70's. LVN B stated she was not for sure what a normal BS range was, but she believed it was between 70-80. LVN B stated she told Resident #1 to continue to eat the sandwich while she finished getting the other resident's BS. LVN B stated she did not contact the MD about the low BS because the normal procedures were to try interventions before contacting the MD. She stated she was able to get Resident #1's BS back to normal range after her interventions. LVN B stated a drop in BS was considered a change of condition, and even after getting the BS back to normal range, she did not notify the MD. LVN B stated once she finished getting the rest of the resident's evening BS, she returned to check on Resident #1. She stated Resident #1 she was not verbally responding but was coughing. LVN B stated she checked Resident #1's BS and it was back in the 50's. LVN B stated she got help from LVN C and gave Resident #1 a glucagon injection. She stated Resident #1 was not responding, so they started CPR and called EMS. LVN B stated when EMS arrived, they continued to give Resident #1 CPR and took her to the hospital. In an interview on 01/10/24 at 2:01 PM, the DON stated she had only been working at the facility for two weeks, so she was getting to know the residents. The DON stated she did not know a lot about Resident #1 or the situation that happened because LVN B did not contact her and called the ADMN instead. The DON stated the ADMN notified her that Resident #1 was found unresponsive by LVN B, who did CPR and called EMS. She stated Resident #1 was sent to the hospital. She stated she had not spoken to LVN B about the incident. The DON stated she had never heard that Resident #1 was spitting up blood. She stated that should have been reported to the MD right away, because it was considered a change of condition. The DON stated even if the resident reported to the nurse that she was spitting up blood in the hospital, she should have still contacted the MD. The DON stated she was not aware of the issue with Resident #1's BS. She stated when the BS drops, the expectation was to first take care of the resident. The DON stated the facility had standing orders for glucose gel and glucagon inject depending on if the resident was responsive. She stated after attending the to the resident with one of those interventions, then staff should notify the MD, DON, and family because there was a change of condition. In an interview on 01/11/24 at 10:50 AM, the ADMN stated on Sunday night (01/07/24) he received a call from LVN B that Resident #1 was found unresponsive. He stated LVN B told him that Resident #1's BS was low like 50 and she gave her glucose gel and was able to get it back up to 70. The ADMN stated LVN B reported when she went back into Resident #1's room to check on her, she was unresponsive. He stated LVN B reported she had performed CPR and called EMS, who transported Resident #1 to the hospital. The ADMN stated he was aware the previous night that LVN A reported Resident #1 was coughing up blood-tinged sputum. He stated LVN A reported it was pinkish in color and was not a lot. The ADMN stated both situations were a change of condition and should have been reported to the MD/NP. He stated they had started in-servicing the nurses on change of condition. An attempt to interview the MD was completed via phone on 01/11/24 at 11:51 AM and on 01/12/24 on 10:47 AM. The facility's MD had not returned the call. In an interview on 01/11/24 at 1:07 PM, the NP stated he was not notified about any issues with Resident #1, until 01/07/24, when they found her unresponsive. He stated he was on-call for the MD and the staff were supposed to call him if residents had change of conditions. The NP stated on 01/07/24 he received a text from LVN C that LVN B found Resident #1 unresponsive, and she was sent to the hospital. He stated he immediately called LVN C back, and it was informed that Resident #1 had been coughing up blood and her BS had dropped to 52. The NP stated those are considered critical conditions and staff should have notified him. He stated he would have ordered Resident #1 to be sent back to the hospital. In a phone interview on 01/12/24 at 10:36 AM, LVN C stated on 01/07/24 she was at the nurse's station and overheard LVN B telling Med Aide D that she did not know what to do because Resident #1's BS was 50 and she would not eat. LVN C stated she asked LVN B did she give Resident #1 glucose gel and she said no, she did not have any. LVN C stated she gave LVN B glucose gel, which LVN B administered to Resident #1. LVN C stated when she went to room to assess Resident #1, she was cold to touch and was not responding. She stated she started sternal rubs, while she was checking Resident #1's pulse. LVN C stated she could not get a pulse on Resident #1, so they started CPR and called EMS. She stated they did CPR for about ten minutes until EMS arrived. She stated while she was in the room with Resident #1, she was never able to get a pulse. LVN C stated once EMS arrived, they took over and continued CPR. LVN C stated she contacted the NP. She stated Resident #1 was transported to the hospital. LVN C stated she did not know if LVN B took Resident #1's vitals, but she should have when her BS dropped to 50. She stated they had standing orders for BS. LVN C stated when BS drops below 60, they were supposed to give glucose gel, but if the resident was unresponsive, they were supposed to give glucagon inject. LVN C stated once they have provided the gel or inject, they were supposed to notify MD/NP, DON, and family, and then check the BS again in 15 minutes after administering the gel/inject. LVN C stated LVN B told her the overnight nurse reported that Resident #1 had been spitting up blood. She stated they were supposed to notify the MD/NP right away for that. LVN C stated when the overnight nurse provided LVN B with that information, she should have told her she needed to contact the MD/NP. In a phone interview on 01/12/24 at 10:56 AM, Med Aide D stated about 8/9 PM she was at the nurse's station and LVN B told her that Resident #1's BS was like 50, she could not get her to eat, and did not know what to do. Med Aide D stated LVN C heard them talking and jumped in to help. She stated LVN C told LVN B to give Resident #1 the gel to get her BS up. She stated LVN B and LVN C went to Resident #1's room. Med Aide D stated she later went to Resident #1's room and heard LVN B and LVN C saying Resident #1 was not responding. She stated they were doing CPR on the resident. She stated they called EMS and Resident #1 was sent to the hospital. In a phone interview on 01/12/24 at 2:14 PM, RN E stated she worked the overnight shift on 01/06/24 but was not assigned to Resident #1. RN E stated she and LVN A were at the nurses' station and CNA F said Resident #1 was coughing up blood. She stated LVN A asked her what she should do, should she call EMS. RN E stated she told her to go assess Resident #1. She stated LVN A headed towards Resident #1's room. RN E stated she assumed Resident #1 was ok because she did not get sent the hospital. RN E stated she did not know if LVN A contacted the MD, but she assumed she did. She stated coughing up blood is a change of condition, so they were supposed to notify the MD/NP. In a phone interview on 01/12/24 at 6:01 PM, CNA F stated she worked overnight on 01/06/24 and was assigned to Resident #1. CNA F stated she got to work a little early and started doing rounds. She stated she saw Resident #1 was laying at the foot of the bed and was coughing. CNA F stated she asked Resident #1 if she was ok, and Resident #1 said she was coughing up blood and to get the nurse. She stated as Resident #1 pulled the tissue away from her mouth she saw the blood on the tissue. CNA F stated LVN A was at the nurse's station, and she told her that Resident #1 was coughing up blood. She stated LVN A asked RN E what was she supposed to do. She said RN E told her to go assess Resident #1. CNA F stated she walked away from the nurse's station and continued to do rounds. CNA F stated about 15 minutes later she passed by Resident #1's room and saw LVN A was checking Resident #1's chest with a stethoscope. CNA F stated throughout the night Resident #1 kept pressing her call light to be repositioned from the top to bottom of bed. She stated Resident #1 was coughing throughout the night and was spitting into tissues. CNA F stated it seemed as if she could not get comfortable and was restless, which was not normal for Resident #1. She stated she did report these things to LVN A, and she was surprised that Resident #1 was not sent back to the hospital. In a phone interview on 01/17/24 at 2:03 PM, Resident #1's FM stated she received a call from the facility on Sunday night (01/07/24) that Resident #1 was found unresponsive, the facility did CPR, and she was sent to the hospital. Resident #1's FM stated she was not notified that Resident #1's BS had dropped low, nor was she notified that Resident #1 was coughing up blood the previous night. The FM stated if the facility would have called her about Resident #1 coughing up blood, she would have told them to send her back to the hospital. A record review of the facility's policy titled Nursing Care of the Older Adult with Diabetes Mellitus, dated November 2020, reflected Purpose: To provide an overview of diabetes in the older adult, its symptoms and complications and principles of glucose monitoring . Glycemic Targets: 5. Manage hypoglycemia according to protocols and provider orders. 6. Establish provider notification protocols, for example: a. Call provider and DON/Designee immediately if resident is hypoglycemic (<70 mg/dl) . A record review of the facility's policy titled Change of Condition and Physician/Family Notification, dated January 2023, reflected Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: . A significant change in resident's physical, mental, or psychosocial status. (See below for examples). A need to significantly alter treatment. Transfer of the resident from the facility. Procedures: When any of the above situations exist, the licensed nurse will contact the resident's family and their physician . Each attempt will be charged as to time the call was made, who was spoken to, and what information was given to the physician . Examples of Significant Changes: . a sudden change in mental status including agitation, lethargy, sudden lack of responsiveness or manic behavior, bleeding .emesis . This failure resulted in an identification of an Immediate Jeopardy on 01/11/2024 at 2:25 PM. The Administrator was informed and provided the IJ template on 01/11/2024 at 2:26 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: Immediately on January 10, 2024, CCS inserviced Administrator and DON on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. Competency was verified via quiz. Immediately on January 11, 2024, CCS2024, CCS inserviced Administrator and DON on diabetic policy and procedures, and abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. On January 10, 2024, Administrator and DON initiated inservices with the licensed nurses on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP, diabetic policy and procedures, and abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed. On January 11, 2024, Administrator and DON initiated inservices with staff on change of condition, abuse and neglect policy and procedures in regards to change of condition. Competency was verified via quiz. Staff will not be allowed to work until inservicing has been completed. On January 10, 2024 an audit was conducted by DON/Designee to identify other residents with potential change of condition. Via direct observation, staff interviews, and record review, no other residents were identified as having a change of condition. Medical Director was notified on January 10, 2024, by Administrator. Medical Director was notified on January 11, 2024 of the IJ situation by Administrator. On January 12, 2024 Social Services completed life satisfaction rounds with residents in regards to change of condition. In order to monitor current residents for potential risk, DON, and CCS will monitor residents for change of condition to include diabetic changes in blood sugar daily beginning January 11, 2024, for 30 days on all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition. DON compliance will be monitored weekly by CCS for 90 days. Social Services/Designee will complete life satisfaction rounds weekly with residents in regards to change of condition for 90 days. Administrator will monitor compliance of Social Services Director/Designee. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition, quality of care and abuse and neglect. If any issues are identified, the physician will be contacted for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Monitoring of the plan of removal included: Interviews were conducted on 01/12/24 from 12:25 to 3:10 PM with 2 RNs, 7 LVN, 3 CMAs, 11 CNAs, 2 HK, the Staffing Coordinator, Activity Director, SW, ADON, DON and ADMN, who worked multiple shifts, revealed they had all been in-serviced on Abuse & Neglect policy, Change of Conditions policy, and nurses on Diabetes Mellitus policy. The staff were able to identify examples of abuse & neglect and changes in condition and were knowledgeable on who they should report to. The nursing staff were able to identify the ranges in BS levels that were not normal, and they were knowledgeable on protocols to follow and who they needed to report to. The staff reported verifying their competency via a quiz. In an interview on 01/12/24 at 2:37 PM, the CCS stated she had in serviced the ADMN and DON on the change of condition policy, abuse & neglect policy, and the diabetic policy. She stated their competency was verified via quizzes. The CCS stated for the next 30 days she and the DON would be monitoring BS levels for any changes of condition. She stated this would be documented on their log. The CSS stated if they identified any changes, they would contact the MD and family/POA immediately. A record review of the facility's documented titled Personnel Action Form, dated 01/10/24, reflected LVN A began suspension on 01/10/24. A record review of the facility's documented titled Personnel Action Form, dated 01/10/24, reflected LVN B began suspension on 01/10/24. A record review of in-services titled Change of Condition, Abuse & Neglect and Nursing Care of older Adult with Diabetes Mellitus, dated from 01/10/24 to 01/12/24, conducted by the ADON and DON, reflected all staff were educated on policy and procedures including assessments and notification to MD/NP regarding change of condition. All staff were in-serviced on policy and procedures regarding abuse and neglect including who to report to. The nursing staff were educated on diabetic policy and procedures which included parameters of BS levels and when to call the MD/NP. The records reflected the staff were quizzed on the competency of these policies. A record review of Life Satisfaction Rounds, dated 01/12/24 reflected the SW completed safety rounds with no negative responses on 20 residents from multiple halls asking 1. Do you feel you receive quality care from your nurse? 2. Are the nurses responsive to your care needs? 3. Do you feel safe at [facility]? 4. If you have a concern regarding the care you receive from a nurse, who would you speak with?. The Administrator were informed the Immediate Jeopardy was removed on 01/12/24 at 3:45 PM. The facility remained out of compliance at a severity level of no actual harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for adequate supervision. The facility failed to supervise and implement a wander guard device when Resident #1 set off the alarm on the door near the laundry area, in an attempt to exit the facility. Resident #1 was later successful in exiting the same door, because the RN Supervisor did not reset the alarm after the first attempt. The the outside temperature was approximately 100 degrees and Resident #1 was located on the facility's property near the gazebo. The noncompliance was identified as PNC. The IJ began on 07/30/23 and ended on 07/31/23. The facility had corrected the noncompliance before the survey began. This failure could place the residents with exit seeking behaviors at risk for injury. Findings included: Record review of Resident #1's electronic Face Sheet, dated 08/01/23, revealed a [AGE] year-old female who last admitted to the facility on [DATE]. Resident #1 had diagnoses which included the following: history of falling, schizoaffective disorder bipolar type (is a mental illness that can affect your thoughts, mood and behavior), muscle weakness, unspecified lack of coordination, unsteadiness on feet, and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). Record review of Resident #1's Comprehensive MDS, dated [DATE], revealed a BIMS score of 3, which indicated Resident #1's cognition was severely impaired. The MDS revealed Resident #1 exhibited the behavior of wandering daily, which placed the resident at significant risk of getting to a potentially dangerous pace (e.g., stairs, outside of the facility). Further review of the MDS revealed Resident #1 required extensive assistance by one-person for the following ADLs: bed mobility, locomotion on/off unit, dressing, eating, toilet use, and personal hygiene and extensive assistance by two-persons for transfers. Record review of Resident #1's care plan, last reviewed on 07/31/23, revealed Resident #1 had been evaluated as a wandering risk due to decreased safety awareness, confusion, wandering behavior (trying to exit building) saying she wants to go home date initiated on 02/16/23. The care plan reflected and updated on 07/30/23- Resident noted with increased exit seeking behaviors. Wander guard placed on resident. Physician and RP notified. Resident placed on 1:1 (one to one) monitoring. The interventions included check my location frequently, observe me for S/S of agitation, repetitive verbalizations of wanting to leave/go home, restlessness, report increased behaviors to nurses for further intervention, provide me re-orientation as needed, wandering alert bracelet to be checked by nurse for placement and function every shift and PRN, if bracelet is removed please replace or place on increase monitoring of my whereabouts. Record review of Resident #1's Wander Data Assessment, dated 07/27/23, reflected she scored a 23. The assessment reflected Wander Data Total Score: I. Total Score: 0-6-Low 7-11=Moderate 12 and above =High, and since Resident #1 scored a 23 she was categorized as High Risk for Wandering A record review of Resident #1's Progress Note, dated 07/30/23 at 3:04 PM, written by the RN Supervisor, reflected This Nurse was at the nurses desk and the alarm went off when it was dictated that it was the alarm for the laundry area, it was checked, and patient [Resident #1] was observed in that direction, and she was redirected. A record review of Resident #1's Progress Note, dated 07/30/23 at 4:26 PM, written by the RN Supervisor, reflected patient Physician notified of wander guard placement, Patient observed at the laundry exit door location. Patient [family member] informed. A record review of the Resident #1's Progress Note labeled Late Entry, dated 07/31/23 at 3:53 PM, written by LVN A, reflected Exited seeking noted with resident. Resident noted outdoors in grassy area toward the gazebo. Resident stated that she was just wanted to be outside. Resident assessed no injuries noted. Resident on monitoring system. Notified DON. Notified responsible party/ [family member]. Notified Nurse Practitioner. In an interview on 08/01/23 at 2:19 PM, LVN A stated on 07/30/23 she had exited a resident's room on the 200-hall and was headed towards the nurse's station. LVN A stated as she approached the nurse's station, Resident #2 came from the exit door near the laundry area, rushing towards her frantically saying Resident #1 was outside in the heat. LVN A stated she believed it was around 2:30 PM, because she remembered looking at the clock when she entered the resident's room on the 200-hall, and it was 1:35 PM. She stated she remembered looking at the clock again and it was a little after 2:00 PM, and she thought to herself that she had been in the resident's room for a long time. LVN A stated she left the room about 20-30 minutes after she last looked at the clock. LVN A stated she never heard an alarm going off while she was in the resident's room or as she was walking down the hall towards the nurse's station. She stated the RN Supervisor was sitting at the nurse's station when Resident #2 notified them that Resident #1 was outside. LVN A stated they went to get Resident #1 from outside. LVN A stated Resident #1 was in the grass area near the gazebo. She stated she did a head-to-toe assessment on Resident #1, and she did not have any injuries. LVN A stated she did not know how Resident #1 got out of the building because she did not think Resident #1 was strong enough to push open the exit door. She stated the wander guard device was put back on the resident after she exited the facility. When LVN A was asked about the RN Supervisor's documentation dated 07/30/23 at 3:04 PM, LVN A stated as she and the RN Supervisor was heading to get Resident #1, the RN Supervisor told her Resident #1 had set the alarm off earlier by that door and she had to tell her to get away from the door. In an interview on 08/01/23 at 3:39 PM, ADON C stated she completed Resident #1's Wander Data assessment on 07/27/23 after she readmitted from the hospital to the facility on [DATE]. She stated Resident #1 was a high risk for wandering, but she was not exit seeking. ADON C stated some behaviors that were exit seeking included residents going to the exit doors and trying to get out or verbalizing they wanted to leave he facility. She stated at the time Resident #1 re-admitted on [DATE] she did not exhibit any of those behaviors, so she was not requried to put the wander guard device on her. In a phone interview on 08/02/23 at 9:39 AM, the Investigator read the RN Supervisor's Progress Note dated 07/30/23 at 3:04 PM and asked the RN Supervisor where was Resident #1 observed when she went to respond to the alarm. The RN Supervisor stated Resident #1 was found in front of the vending machines by the door, but she had not exited. The RN Supervisor stated she redirected Resident #1 back into the hallway. She stated later Resident #2 came to the nurse's station and stated Resident #1 was outside. The RN Supervisor stated the alarm did not go off. She stated she and LVN A went to get Resident #1 from outside. She stated she was in the grass area near the exit door. The RN Supervisor stated she did not document the second incident because LVN A was the nurse for Resident #1, so she assessed her and documented that incident. The RN Supervisor stated Resident #1 had a wander guard device before she went to the hospital, but it was not put back on after she re-admitted on [DATE]. The RN Supervisor stated she placed the wander guard device back on Resident #1 after she exited the facility. When the RN Supervisor was asked why didn't she put it on when she was found the first time by the door, she stated she intervened by re-directing her away from the door. During an observation and interview on 08/02/23 at 10:40 AM, the Maintenance Director (MD) stated with the door by the laundry area, if someone pressed on the door for a few seconds the alarm would go off for 15 seconds and the door would unlock. The MD stated the door would not lock again, unless someone resets it by putting in the code. He stated the door had an emergency release to allow everyone to evacuate for fire hazards. The Investigator pressed on the door for approximately 3 to 4 seconds, and the alarm went off for approximately 15 seconds. After setting off the alarm, the Investigator observed the door was unlocked and would not latch on to the door frame. The door was partially opened and when the Investigator lightly touched the door, it completely opened. The MD was observed putting in the code and then the door latched back to the doorframe and locked. In a follow up phone interview on 08/02/23 at 10:54 AM, LVN A stated the RN Supervisor told her that Resident #1 was by that door earlier and had set the alarm off. She stated she did not specify what time this happened, she only stated it was earlier that day. LVN A stated she was not notified of this incident until they were on their way to get Resident #1 from outside. LVN A stated she did not hear the alarm go off earlier that day, but she was in and out of resident's room providing care. LVN A stated if the RN Supervisor would have told her that Resident #1 attempted to leave out of the door earlier, then she would have had the wander guard put back on. In an interview on 08/02/23 at 11:58 AM, the ADON B stated on 07/30/23 she was at the nurse's station with the RN Supervisor, and they heard the alarm going off . She stated they looked at the panel and saw it was coming from the 200 hall. The ADON B stated she told the RN Supervisor to be on the safe side she would check halls 100 and 400. She stated the RN Supervisor headed towards the 200 Hall. The ADON B stated she checked halls 100 and 400 and saw no issues, so she headed to the 300 Hall, where she was assigned because she had to do a resident's tube feeding. The ADON B said she did not know anything after that. She stated the RN Supervisor never reported to her that she found Resident #1 by the door. The ADON B said she did not witness Resident #2 coming to the nurse's station to let the RN Supervisor know Resident #1 was outside. The ADON B stated she did not see LVN A coming towards the nurse's station from the direction of the 200 hall. The ADON B stated this happened about 1pm on 07/30/23. She stated she knew it was about 1pm because it happened about one hour before shift change, which was at 2pm. In an interview on 08/02/23 at 12:29 PM, Resident #2 stated she did witness the incident with Resident #1 exiting the facility. Resident #2 stated she was coming into the building from outside, and she saw Resident #1 kick the door and it opened. She stated the door was not locked, so it just swung open, and the alarm did not go off. Resident #2 stated when she went outside the door was unlocked. Resident #2 stated Resident #1 did not have that thing on her leg to set off the alarm. Resident #2 stated she told Resident #1 that it was hot outside, and she shouldn't be outside. She said Resident #1 went around her and still went outside. Resident #2 stated she knew Resident #1 wore that thing on her leg, and should not be outside by herself, so she went inside to the nurse's station and told them that Resident #1 was outside. Resident #2 stated LVN A was standing in front of the nurse's station, and the RN Supervisor was sitting at the nurse's station. She stated they went outside to get Resident #1. She stated she knew who the ADON was, and she was not at the nurse's station. In an interview on 08/01/23 at 2:50 PM, the DON stated she was not working at the building on 07/30/23, when Resident #1 got out of the building. She stated she was filling in at a sister facility. The DON stated she was told that Resident #1 pushed the door open and got out of the facility. The DON stated Resident #1 had a wander guard device prior to her going to the hospital and when she re-admitted it was not put back on. She stated she believed the admitting nurse did not put the device back on because the resident wandered but was not exit seeking. The DON stated after this incident, they changed their policy, which required the wander guard device to be put on if residents were high risk for wandering or eloping, even if they were not exit seeking. She stated on 07/31/23 the staff was in-serviced regarding the elopement situation and monitoring the doors. A record review of the facility's policy titled Wanderer Management, Monitoring System & Resident Elopement Protocol, last reviewed date 01/2023 , reflected Purpose: To provide a system to alert staff that a resident may be attempting leave the facility. Policy: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible . Procedures: 4. Residents identified as risk for elopement shall be provided one of the following: a. Door alarms on exit doors. b. A personal safety device that alerts staff of resident effort to leave the facility. c. Signaling device to the arm or angle or as permitted by the manufacturer . An Immediate Jeopardy (IJ) was identified to have existed from 07/30/23 through 07/31/23 on 08/02/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. The facility took the following actions to correct the non-compliance prior to the investigation: An observation on 08/01/23 at 11:22 AM revealed Resident #1 had a wander guard device in place upon entrance to the facility. In interviews with the RN Supervisor on 08/02/23 at 9:39 AM and LVN A on 08/01/23 at 2:19 PM they stated the wander guard was put on Resident #1 on 07/30/23 after she exited the facility. A record review on 08/01/23 of Resident #1's progress notes revealed a wander guard device was put on Resident #1 when she exited the facility on 07/30/23. A record review of the facility's in-services dated 07/31/23 conducted by the DON, reflected all nursing staff were educated on wander guard devices and monitoring wandering behaviors. All staff were in-serviced that they should be doing rounds to ensure exit doors are closed and locked, in-putting codes to ensure doors had been reset after the alarm had gone off, and monitoring wandering residents and reporting if they witness exit seeking behaviors. Interviews were conducted from 08/01/23 to 08/04/23 at various times, with five nurses, six CNAs, three Med Aides, and two ADONs, from various shifts. The nursing staff were able to identify procedures of assessing and applying the wander guards to residents who were elopement risk. The staff were able to identify wandering and exit seeking behaviors and were knowledgeable on who exit seeking behaviors should be reported to. The staff were knowledgeable that exit doors required resetting by entering the code once the alarm had been activated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the resident was free from abuse for 1 (Residents #1) of 3 residents reviewed for abuse. 1. The facility failed to protect Resident #1 from continued abuse. Resident #1 was verbally abused twice by MA B. MA B told Resident #1 you need to shut up, CNA A witnessed the incident did not act, and MA B worked another 7 days and verbally abused Resident #1 again. An Immediate Jeopardy was identified on 05/18/23. The IJ Template was provided to the facility on [DATE] at 6:48 p.m. While the Immediate Jeopardy was removed on 05/19/22, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need of continuation of in-servicing and monitoring the plan of removal. This failure could cause actual harm and place all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #1's face sheet, dated 05/19/23, revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses that included: quadriplegia, seizures, depression, and anxiety. Review of Resident #1's quarterly MDS assessment, dated 05/09/23, revealed she had a BIMs score of 12: mildly impaired for decision making. The resident had the ability to understand, with clear speech, with no documented behaviors and required extensive assistance of two staff members to complete ADLs. Review of Resdient#1's Plan of Care dated 05/17/23 reflected, 1. [Resident #1] had potential to be verbally aggressive (screams at and uses vulgarity on staff) and refuses, care. Interventions included: if resident is agitated, let her know you will be back or ask another staff to take over to deescalate the situation. Assess resident's coping skills and support system. For her to call if she needs to. 2. [Resident #1] has a mood problems Anxiety D/O, resident lashes out at staff and kicks them out of the room refuses care. The Resident has been provided the phone numbers of both the Administrator and the assistant administrator. [Resident # 1] has told staff I will make everyone miserable because I am miserable Offered Psych services, declined. Interventions included: administer medications, monitor mood to determine if problems seem to be related to external causes medications, treatments, concern over diagnosis. [Resident #1] alleged staff said to her I can walk .you can't, I can wipe myself .you can't Also she does not like rounding in the hall in the morning-she alleged another resident was verbally abuse and the other resident denied allegation. Interventions included: Investigation initiated by Abuse Coordinator. Review of MA B punch detail report reflected the MA B worked on 05/01/23 on the 6:00 a.m. to 2:00 p.m. shift (when incident occurred), then worked the 6:00 p.m. to 2:00 p.m. shift on the following dates: 05/02/23, 05/03/23, 05/08/23, 05/09/23, 05/10/23, 05/11/23, and on 05/12 23 from 6:00 a.m. to 9:52 a.m., when he was suspended. Review of the daily schedules reflected MA B worked on Hall 100 on 05/01/23, 05/02/23, 05/03/23, 05/08/23, 05/09/23, 05/10/23, 05/11/23, and 05/12/23. Interview on 05/18/23 at 12:00 p.m. with Resident #1 revealed she had reported that she had been verbally abused by MA B. Resident #1 said the first time it happened, on 05/01/23, she did not report to the Administrator, because she was tired that the previous administration did not listen to her and the day it happened a new administrator was supposed to come. During this interview the resident provided a name of a witness (CNA A) to the incident that occurred and then became upset and did not want to talk anymore. Interview on 05/18/23 at 12:35 p.m. with CNA A revealed she had been off the day (05/12/23) the second time the allegation of abuse was made by Resident #1. CNA A said there had been another time before that on 05/01/23. CNA A said she was on the hallway right by Resident #1's room around 7:00 a.m. in the morning and MA B came down the hallway talking loudly. CNA A said she told him to lower his voice, that residents were still sleeping, when Resident #1 said from her room, You need to be quiet; you are too loud. I am still trying to sleep. CNA A said MA B said to Resident #1 You need to shut your door then. CNA A said Resident #1 said This is my house and if I want my door open, I can have it. CNA A said she observed MA B to the doorway of Resident #1's room, tell her you need to shut up and then left her room. The CNA stated she knew she was supposed to report to the Administrator, but she did not report it to anyone because she was afraid of the previous administration retaliating against her and she would lose her job. The CNA said the previous administration did not seem to take concerns seriously. CNA A stated there was no other staff around and there were no other residents that were awake that said anything at that time. In a confidential interview on 05/18/23 at 12:45 p.m. with five residents revealed they did not have any problems with MA B. In an interview on 05/18/23 at 1:15 p.m. with Resident #1 revealed she was asleep around 7:00 a.m., and she heard someone talking loudly. She said she heard CNA A tell the person to lower their voice, I yelled out of my room that they I was trying to sleep and be quiet. [MA B] stood in my doorway and said you need to shut your door. Resident #1 stated, this is my house, and I can have my door open if I want. The resident said MA B came into her room and said then you need to shut up and he left her room When the resident was asked who she reported it to, she stated, I called the state because I got tired of telling the previous administration about my concerns and they never listened. Then when it happened again [MA B telling me to shut up], I told the new Administrator on the 12th of this month. In a later interview on 05/18/23 at 1:45 p.m. Resident #1 identified the day that this incident occurred was on 05/01/23. Resident #1 stated that [MA B] continued to work on her hallway, until he was suspended. Interview on 05/18/23 at 3:00 p.m. with the Administrator revealed she was the abuse prevention coordinator and was the person responsible for investigating and reporting incidents. She stated allegations of abuse were reported if there was injury within two hours. She stated if the cognitive level of the involved resident was low (BIMs) the incident was reported within eight hours, and if there was no injury it was reported within 24 hours. She stated she followed the provider letter related to reporting incidents to guide her when reporting. The Administrator stated she picked a sample of staff and residents when she was investigating. She stated she would try to interview the staff and the residents in the area where the incident was reported to occur. She stated that way she could get a random selection of what the residents and staff understanding was of the incident that may have occurred. She stated she did not interview all the staff. The Administrator said when Resident #1 reported the allegation of abuse on 05/12/23 of [MA B] telling her to shut up and [MA B] B told her to shut up the week before, she started her investigation, interviewing the staff members that were at the facility that day and suspending the staff that was alleged to be involved. She said she did not recall if she asked Resident #1 about any witnesses. The Administrator stated she had completed her investigation and was awaiting the state's visit before she decided concerning the staff, which had been suspended. Interview on 05/18/23 at 5:55 p.m. with the Administrator revealed she used the facility's policy and procedure for abuse investigations. She stated she went by the information that was provided to her by Resident #1. She stated, I placed everything she told me in the investigation report and then I begin my investigation. I start my investigation on the day the allegation occurred and then I start my in-service and in-service the staff that requires training. The Administrator stated she was not aware there was a witness to verbal abuse related Resident #1's allegation. Interview on 05/18/23 at 7:10 p.m. with the Administrator revealed the previous investigation for allegation on 05/12/23 had been completed, with the five-day period allowed, when the investigator had made her aware of the witness, she had found she started interviewing all the staff and had kept the two pervious employees [MA B and CNA MM] suspended and she would be suspending the employee [CNA A] that did not report the abuse. The Administrator stated the facility had a corporate hotline to call and Resident #1 had been previously provided the personal cell phone number of the Administrator, Regional [NAME] President, and Regional Nurse Consultant. Resident #1 had been instructed she could call those numbers any time of the day or night. The Administrator stated Resident #1 had not hesitated to call those numbers in the past. Interview on 05/19/23 at 1:52 p.m. with MA B revealed on 05/12/23 at 7:30 a.m. she was passing medications on the hallway that Resident #1 lived on. MA B stated Resident #1 started yelling and screaming at him, some horrible things. I have never had any problems with [Resident #1], we got along fine, until 05/12/23 when she started yelling and cussing me. In fact, she told me she was glad I was working here, it really hurt my feelings the things that she said to me. MA B said that was not the first time he had ever had any problems with [Resident #1], she had gotten upset with me the week before (MA B could not identify what day) saying [MA B] was too loud, [MA B] just gave [Resident #1] her space and she was fine. MA B stated he knew better then to tell any resident to shut up because that could be considered abuse. MA B said there was no other staff or residents on the hallway when the incident 05/12/23, occurred. MA B stated he was suspended on 05/12/23, after providing a statement to the Administrator and has not returned to work yet. Interview on 05/18/23 at 7:20 p.m. with the DON revealed staff to resident verbal abuse should be treated as an allegation of abuse and should be reported immediately. Review of the facility's Provider Investigation Report, incident date 05/12/23 at 7:30 a.m. and reported to HHSC on 05/12/23 at 4:45 p.m., reflected an incident category of abuse, staff to resident verbal altercation. The report's description of the allegation revealed, On last week, [Resident #1] alleged [MA B] told her to shut up. The report's description of injury revealed there were no injuries. The report's description of assessment revealed, .the ADON performed Head to Toe Assessment. No injuries or adv [adverse] reaction, no changes in resident behaviors noted. The report's provider response revealed upon investigation Resident #1 alleged that on 05/12/23 staff member MA B verbally abused her telling her to shut up. The Physician and Ombudsman were notified. Abuse/Neglect/Exploitation In-service. Employee interviews and statements were completed. Employees were in-serviced on Resident Abuse. Staff statements noted no further concerns or further witnesses to allegations made. The report indicated the findings were unconfirmed. Further review reflected the investigations focused on the allegation made on 05/12/23, not the previous week (05/01/23). Review of the in-service training reported dated 05/12/23-05/16/23 reflected Abuse/Neglect comments: -resident to resident, -Verbal abuse, -mental, --forms of abuse -misappropriation, -report immediately. CNA A was not listed on the training and MA B had been suspended. Review of the employee file for CNA A reflected in-service training dated 12/08/22 for abuse prohibition (prevention). Review of the employee file for MA B reflected in-service training dated 04/20/23 for abuse prohibition (prevention). Review of the facility Abuse Prohibition policy, revised dated 03/2023, reflected each resident has the right to be free from abuse, mistreatment . the facility will prohibit neglect, mental or physical abuse . the facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations . the policy definition of verbal abuse includes as the use of oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents . or within their hearing distance regardless of their age, ability to comprehend, of disability .Investigation: The facility will thoroughly investigate all alleged violations and take appropriate actions . The Administrator and DON were notified of the Immediate Jeopardy on 05/18/23 at 6:48 p.m. The IJ template was provided. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/19/23 at 4:56 p.m. and reflected the following: Immediately on May 18, 2023, at 5:30pm, [CNA A] was suspended for failure to report an allegation of abuse. Immediately on May 18, 2023, RN, CCS, RVP, and COO in serviced, Administrator and DON/RN on the policy and procedures of abuse policies and procedures to include reporting procedures on what to report, how to conduct a thorough investigation with the importance of interviewing all witnesses and development of a timeline of events. The Administrator and DON were able to verbalize the training material back to, RN, CCS, RVP, and COO and deemed competent in their knowledge. Training initiated on May 18, 2023 and completed on May 18, 2023. On 5/18/2023, the Administrator, DON, CCS' initiated in servicing of department heads and staff on the policy and procedures of abuse to include reporting any and all allegations of abuse/neglect, reporting if they witness any issues with abuse/neglect and/or customer service, to whom to report and in what timeframe to report, and location of posting that is available with numbers for whom to report. Comprehension of training will be validated by successful responses to verbal scenarios presented to each employee. Training initiated on May 18, 2023, and will be completed on May 19, 2023. (See attached Policy and Procedure regarding reporting). Staff will not be allowed to work their next scheduled shift until in servicing has been completed. This will be monitored by Administrator. Grievances will be audited by Administrator/Designee and completed on 5/19/2023. Life Satisfaction rounds will be completed by Social Services/Designee and completed on 5/19/2023. Medical Director was notified of IJ by, Administrator. The above training material will be incorporated into the new hire orientation by, Administrator/, RN, DON/designee effective May 19, 2023, and ongoing. Monthly quizzes will be completed with staff for 3 months. After 3 months, quarterly for 3 quarters. In order to monitor current residents for potential risk, IDT team will review and discuss all grievances and allegations daily for 30 days. The IDT team consists of Administrator, DON, ADONs, and Social Worker. RN, CCS and RVP will review all allegations and investigations for 30 days. After 30 days, the IDT will follow the above process monthly. Thereafter, QA will monitor quarterly up to a year. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. Monitoring of the facility's Plan of Removal to confirm the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) included the following: Interviews were conducted on 05/19/23 starting at 5:00 p.m. and continued through 05/19/23 at 8:00 p.m. with 10 nurses, and 15 CNAs, 2 housekeepers, 3 kitchen staff, one van driver, and 4 MAs from various shifts regarding in-services with policy and procedures of abuse to include reporting any and all allegations of abuse/neglect, reporting if they witness any issues with abuse/neglect and/or customer service, to whom to report and in what timeframe to report, and location of postings that were available with numbers for whom to report. Comprehension of training would be validated by: The staff members were able to: Describe the correct process for reporting abuse and neglect. Describe the process for reporting if they witness abuse. Describe the process of customer service. Describe the process of whom to report to and timeframe to report. Describe the location of posting that are available with numbers for whom to report. Interviewed staff members and shifts were: LVN C -worked 10:00 p.m. to 6:00 a.m. LVN D-worked 6:00 a.m. to 2:00 p.m. LVN E- worked 6:00 a.m. to 2:00 p.m. LVN F- worked 6:00 a.m. to 2:00 p.m. RN G- worked 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. LVN H- worked all shifts ADON I- worked all shifts LVN J- worked 6:00 am to 2:00 p.m. LVN H - worked 10:00 p.m. to 2:00 p.m. RN I - worked 10:00 a.m. to 2:00 p.m. LVN J - worked 6:00 a.m. to 2:00 p.m. LVN K - worked 2:00 p.m. to 10:00 p.m. LVN L - worked 2:00 p.m. to 10:00 p.m. LVN M- worked the 10:00 p.m. to 6:00 a.m. MA N- worked 6:00 a.m. to 2:00 p.m. MA O- worked 2:00 p.m. to 10:00 p.m. MA P- worked 6:00 a.m. to 2:00 p.m. MA Q-worked 2:00 p.m. to 10:00 p.m. CNA R-worked 6:00 a.m. to 2:00 p.m. CNA S-worked 6:00 a.m. to 2:00 p.m. CNA T-worked 6:00 a.m. to 2:00 p.m. CNA U-worked 6:00 a.m. to 2:00 p.m. CNA V- worked 2:00 p.m. to 10:00 p.m. CNA W- worked 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. CNA X - worked 2:00 p.m. to 10:00 p.m. CNA Y - worked 2:00 p.m. to 10:00 p.m. CNA Z - worked 2:00 p.m. to 10:00 p.m. CNA AA -worked- 10:00 p.m. to 6:00 a.m. CNA BB - worked 10:00 p.m. to 6:00 a.m. CNA CC - worked all shifts CNA DD - worked 10:00 p.m. to 6:00 a.m. CNA EE - worked 6:00 a.m. to 2:00 p.m. CNA FF - worked 6:00 a.m. to 2:00 p.m. Housekeeper GG- worked 7: 00 a.m. to 3:00 p.m. Housekeeper HH - worked 7:00 a.m. to 3:00 p.m. KA II - worked 12:00 p.m. to 7: 00 p.m. Cook JJ - worked 6:00 p.m. to 2:00 p.m. KA KK- worked 11:00 a.m. to 7:00 p.m. VD LL - worked 8:00 a.m. to 5:00 p.m. An interview with the DON on 05/19/23 at 1:30 p.m. revealed going forward the facility would be following the policy and procedure for reporting abuse and neglect. She stated the staff would be monitored by the compliance testing that would be given on a month-by-month basis An interview with the Administrator on 05/19/23 at 2:00 p.m. revealed going forward the facility would be following the policy and procedure for reporting and investigating neglect. She stated she would ensure the facility completed and continued the proficiency training and testing for abuse and neglect. The Administrator was notified on 05/19/23 at 4:56 p.m., the Immediate Jeopardy was removed. While the immediacy was removed on 05/19/23, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours to the administrator or the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for one of 1 resident (Resident #1) reviewed for reporting incident allegations. 1. CNA A failed to report an observation on 05/01/23 of verbal abuse involving Resident #1 and MA B, who told Resident #1 to you need to shut up to the abuse coordinator (Administrator). MA B worked another 7 days before Resident #1 reported to the abuse coordinator on 05/12/23 that MA B had verbally abused her again. 2. CNA A witnessed MA B verbally abuse Resident #1. CNA A was aware she should have reported it and due to fear of retaliation did not report it, therefore; exposing the resident to another incident of verbal abuse by MA A. CNA A had multiple opportunities and days to tell the Administrator but did not. The Administrator was informed that CNA A was a witness per surveyor intervention during the investigation. CNA A's failure to report to the Administrator exposed Resident #1 to a repeated incident of verbal abuse. 3. The Administrator investigated the allegations made by Resident #1 on 05/12/23 but did not investigate the first allegation of abuse 05/01/23 provided by Resident #1 at the time she reported the abuse allegation that occurred on 05/01/23. The Administrator and did not discover CNA A had observed the verbal abuse by MA B, allowing MA B to be able to work another 7 days, which provided the potential for further abuse to Resident #1 as well as other residents. An Immediate Jeopardy was identified on 05/18/23. The IJ Template was provided to the facility on [DATE] at 6:48 p.m. While the Immediate Jeopardy was removed on 05/19/22, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need of continuation of in-servicing and monitoring the plan of removal. This failure could place residents at risk for abuse. Findings included: Review of Resident #1's face sheet, dated 05/19/23, revealed she was a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses that included: quadriplegia, seizures, depression, and anxiety. Review of Resident #1's quarterly MDS assessment, dated 05/09/23, revealed she had a BIMs score of 12: mildly impaired for decision making. The resident had the ability to understand, with clear speech, with no documented behaviors and required extensive assistance of two staff members to complete ADLs. Review of Resdient#1's Plan of Care dated 05/17/23 reflected, 1. [Resident #1] had potential to be verbally aggressive (screams at and uses vulgarity on staff) and refuses, care. Interventions included: if resident is agitated, let her know you will be back or ask another staff to take over to deescalate the situation. Assess resident's coping skills and support system. For her to call if she needs to. 2. [Resident #1] has a mood problems Anxiety D/O, resident lashes out at staff and kicks them out of the room refuses care. The Resident has been provided the phone numbers of both the Administrator and the assistant administrator. [Resident # 1] has told staff I will make everyone miserable because I am miserable Offered Psych services, declined. Interventions included: administer medications, monitor mood to determine if problems seem to be related to external causes medications, treatments, concern over diagnosis. [Resident #1] alleged staff said to her I can walk .you can't, I can wipe myself .you can't Also she does not like rounding in the hall in the morning-she alleged another resident was verbally abuse and the other resident denied allegation. Interventions included: Investigation initiated by Abuse Coordinator. Review of MA B punch detail report reflected the MA B worked on 05/01/23 on the 6:00 a.m. to 2:00 p.m. shift (when incident occurred), then worked the 6:00 p.m. to 2:00 p.m. shift on the following dates: 05/02/23, 05/03/23, 05/08/23, 05/09/23, 05/10/23, 05/11/23, and on 05/12 23 from 6:00 a.m. to 9:52 a.m., when he was suspended. Review of the daily schedules reflected MA B worked on Hall 100 on 05/01/23, 05/02/23, 05/03/23, 05/08/23, 05/09/23, 05/10/23, 05/11/23, and 05/12/23. Interview on 05/18/23 at 12:00 p.m. with Resident #1 revealed she had reported that she had been verbally abused by MA B. Resident #1 said the first time it happened, on 05/01/23, she did not report to the Administrator, because she was tired that the previous administration did not listen to her and the day it happened a new administrator was supposed to come. During this interview, the resident provided a name of a witness (CNA A) to the incident that occurred and then became upset and did not want to talk anymore. Interview on 05/18/23 at 12:35 p.m. with CNA A revealed she had been off the day (05/12/23) the second time the allegation of abuse was made by Resident #1. CNA A said there had been another time before that on 05/01/23. CNA A said she was on the hallway right by Resident #1's room around 7:00 a.m. in the morning and MA B came down the hallway talking loudly. CNA A said she told him to lower his voice, that residents were still sleeping, when Resident #1 said from her room, You need to be quiet; you are too loud. I am still trying to sleep. CNA A said MA B said to Resident #1 You need to shut your door then. CNA A said Resident #1 said This is my house and if I want my door open, I can have it. CNA A said she observed MA B to the doorway of Resident #1's room, telling her you need to shut up and then left her room. The CNA stated she knew she was supposed to report to the Administrator, but she did not report it to anyone because she was afraid of the previous administration retaliating against her and she would lose her job. The CNA said the previous administration did not seem to take concerns seriously. CNA A stated there was no other staff around and there were no other residents that were awake that said anything at that time. In a confidential interview on 05/18/23 at 12:45 p.m. with five residents revealed they did not have any problems with MA B. In an interview on 05/18/23 at 1:15 p.m. with Resident #1 revealed she was asleep around 7:00 a.m., and she heard someone talking loudly. She said she heard CNA A tell the person to lower their voice, I yelled out of my room that they I was trying to sleep and be quiet. [MA B] stood in my doorway and said you need to shut your door. Resident #1 stated, this is my house, and I can have my door open if I want. The resident said MA B came into her room and said then you need to shut up and he left her room When the resident was asked who she reported it to, she stated, I called the state because I got tired of telling the previous administration about my concerns and they never listened. Then when it happened again [MA B telling me to shut up], I told the new Administrator on the 12th of this month. In a later interview on 05/18/23 at 1:45 p.m. Resident #1 identified the day that this incident occurred was on 05/01/23. Resident #1 stated that [MA B] continued to work on her hallway, until he was suspended. Interview on 05/18/23 at 3:00 p.m. with the Administrator revealed she was the abuse prevention coordinator and was the person responsible for investigating and reporting incidents. She stated allegations of abuse were reported if there was injury within two hours. She stated if the cognitive level of the involved resident was low (BIMs) the incident was reported within eight hours, and if there was no injury it was reported within 24 hours. She stated she followed the provider letter related to reporting incidents to guide her when reporting. The Administrator stated she picked a sample of staff and residents when she was investigating. She stated she would try to interview the staff and the residents in the area where the incident was reported to occur. She stated that way she could get a random selection of what the residents and staff understanding was of the incident that may have occurred. She stated she did not interview all the staff. The Administrator said when Resident #1 reported the allegation of abuse on 05/12/23 of [MA B] telling her to shut up and [MA B] B told her to shut up the week before, she started her investigation, interviewing the staff members that were at the facility that day and suspending the staff that was alleged to be involved. She said she did not recall if she asked Resident #1 about any witnesses. The Administrator stated she had completed her investigation and was awaiting the state's visit before she decided concerning the staff, which had been suspended. Interview on 05/18/23 at 5:55 p.m. with the Administrator revealed she used the facility's policy and procedure for abuse investigations. She stated she went by the information that was provided to her by Resident #1. She stated, I placed everything she told me in the investigation report and then I begin my investigation. I start my investigation on the day the allegation occurred and then I start my in-service and in-service the staff that requires training. The Administrator stated she was not aware there was a witness to verbal abuse related Resident #1's allegation. Interview on 05/18/23 at 7:10 p.m. with the Administrator revealed the previous investigation for allegation on 05/12/23 had been completed, with the five-day period allowed, when the investigator had made her aware of the witness, she had found she started interviewing all the staff and had kept the two pervious employees [MA B and CNA MM] suspended and she would be suspending the employee [CNA A] that did not report the abuse. The Administrator stated the facility had a corporate hotline to call and Resident #1 had been previously provided the personal cell phone number of the Administrator, Regional [NAME] President, and Regional Nurse Consultant. Resident #1 had been instructed she could call those numbers any time of the day or night. The Administrator stated Resident #1 had not hesitated to call those numbers in the past. Interview on 05/19/23 at 1:52 p.m. with MA B revealed on 05/12/23 at 7:30 a.m. she was passing medications on the hallway that Resident #1 lived on. MA B stated Resident #1 started yelling and screaming at him, some horrible things. I have never had any problems with [Resident #1], we got along fine, until 05/12/23 when she started yelling and cussing me. In fact, she told me she was glad I was working here, it really hurt my feelings the things that she said to me. MA B said that was not the first time he had ever had any problems with [Resident #1], she had gotten upset with me the week before (MA B could not identify what day) saying [MA B] was too loud, [MA B] just gave [Resident #1] her space and she was fine. MA B stated he knew better then to tell any resident to shut up because that could be considered abuse. MA B said there was no other staff or residents on the hallway when the incident 05/12/23, occurred. MA B stated he was suspended on 05/12/23, after providing a statement to the Administrator and has not returned to work yet. Interview on 05/18/23 at 7:20 p.m. with the DON revealed staff to resident verbal abuse should be treated as an allegation of abuse and should be reported immediately. Review of the facility's Provider Investigation Report, incident date 05/12/23 at 7:30 a.m. and reported to HHSC on 05/12/23 at 4:45 p.m., reflected an incident category of abuse, staff to resident verbal altercation. The report's description of the allegation revealed, On last week, [Resident #1] alleged [MA B] told her to shut up. The report's description of injury revealed there were no injuries. The report's description of assessment revealed, .the ADON performed Head to Toe Assessment. No injuries or adv [adverse] reaction, no changes in resident behaviors noted. The report's provider response revealed upon investigation Resident #1 alleged that on 05/12/23 staff member MA B verbally abused her telling her to shut up. The Physician and Ombudsman were notified. Abuse/Neglect/Exploitation In-service. Employee interviews and statements were completed. Employees were in-serviced on Resident Abuse. Staff statements noted no further concerns or further witnesses to allegations made. The report indicated the findings were unconfirmed. Further review reflected the investigations focused on the allegation made on 05/12/23, not the previous week (05/01/23). Review of the in-service training reported dated 05/12/23-05/16/23 reflected Abuse/Neglect comments: -resident to resident, -Verbal abuse, -mental, --forms of abuse -misappropriation, -report immediately. CNA A was not listed on the training and MA B had been suspended. Review of the employee file for CNA A reflected in-service training dated 12/08/22 for abuse prohibition (prevention). Review of the employee file for MA B reflected in-service training dated 04/20/23 for abuse prohibition (prevention). Review of the facility Abuse Prohibition policy, revised dated 03/2023, reflected each resident has the right to be free from abuse, mistreatment . the facility will prohibit neglect, mental or physical abuse . the facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations . the policy definition of verbal abuse includes as the use of oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents . or within their hearing distance regardless of their age, ability to comprehend, of disability .Investigation: The facility will thoroughly investigate all alleged violations and take appropriate actions . The Administrator and DON were notified of the Immediate Jeopardy on 05/18/23 at 6:48 p.m. The IJ template was provided. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/19/23 at 4:56 p.m. and reflected the following: Immediately on May 18, 2023, at 5:30pm, [CNA A] was suspended for failure to report an allegation of abuse. Immediately on May 18, 2023, RN, CCS, RVP, and COO in serviced, Administrator and DON/RN on the policy and procedures of abuse policies and procedures to include reporting procedures on what to report, how to conduct a thorough investigation with the importance of interviewing all witnesses and development of a timeline of events. The Administrator and DON were able to verbalize the training material back to, RN, CCS, RVP, and COO and deemed competent in their knowledge. Training initiated on May 18, 2023, and completed on May 18, 2023. On 5/18/2023, the Administrator, DON, CCS' initiated in servicing of department heads and staff on the policy and procedures of abuse to include reporting any and all allegations of abuse/neglect, reporting if they witness any issues with abuse/neglect and/or customer service, to whom to report and in what timeframe to report, and location of posting that is available with numbers for whom to report. Comprehension of training will be validated by successful responses to verbal scenarios presented to each employee. Training initiated on May 18, 2023 and will be completed on May 19, 2023. (See attached Policy and Procedure regarding reporting). Staff will not be allowed to work their next scheduled shift until in servicing has been completed. This will be monitored by Administrator. Grievances will be audited by Administrator/Designee and completed on 5/19/2023. Life Satisfaction rounds will be completed by Social Services/Designee and completed on 5/19/2023. Medical Director was notified of IJ by, Administrator. The above training material will be incorporated into the new hire orientation by, Administrator/, RN, DON/designee effective May 19, 2023, and ongoing. Monthly quizzes will be completed with staff for 3 months. After 3 months, quarterly for 3 quarters. In order to monitor current residents for potential risk, IDT team will review and discuss all grievances and allegations daily for 30 days. The IDT team consists of Administrator, DON, ADONs, and Social Worker. RN, CCS and RVP will review all allegations and investigations for 30 days. After 30 days, the IDT will follow the above process monthly. Thereafter, QA will monitor quarterly up to a year. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns noted, will continue to monitor as per routine facility QA Committee. Monitoring of the facility's Plan of Removal to confirm the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) included the following: Interviews were conducted on 05/19/23 starting at 5:00 p.m. and continued through 05/19/23 at 8:00 p.m. with 10 nurses, and 15 CNAs, 2 housekeepers, 3 kitchen staff, one van driver, and 4 MAs from various shifts regarding in-services with policy and procedures of abuse to include reporting any and all allegations of abuse/neglect, reporting if they witness any issues with abuse/neglect and/or customer service, to whom to report and in what timeframe to report, and location of postings that were available with numbers for whom to report. Comprehension of training would be validated by: The staff members were able to: Describe the correct process for reporting abuse and neglect. Describe the process for reporting if they witness abuse. Describe the process of customer service. Describe the process of whom to report to and timeframe to report. Describe the location of posting that are available with numbers for whom to report. Interviewed staff members and shifts were: LVN C -worked 10:00 p.m. to 6:00 a.m. LVN D-worked 6:00 a.m. to 2:00 p.m. LVN E- worked 6:00 a.m. to 2:00 p.m. LVN F- worked 6:00 a.m. to 2:00 p.m. RN G- worked 6:00 a.m. to 2:00 p.m. and 2:00 p.m. to 10:00 p.m. LVN H- worked all shifts ADON I- worked all shifts LVN J- worked 6:00 am to 2:00 p.m. LVN H - worked 10:00 p.m. to 2:00 p.m. RN I - worked 10:00 a.m. to 2:00 p.m. LVN J - worked 6:00 a.m. to 2:00 p.m. LVN K - worked 2:00 p.m. to 10:00 p.m. LVN L - worked 2:00 p.m. to 10:00 p.m. LVN M- worked the 10:00 p.m. to 6:00 a.m. MA N- worked 6:00 a.m. to 2:00 p.m. MA O- worked 2:00 p.m. to 10:00 p.m. MA P- worked 6:00 a.m. to 2:00 p.m. MA Q-worked 2:00 p.m. to 10:00 p.m. CNA R-worked 6:00 a.m. to 2:00 p.m. CNA S-worked 6:00 a.m. to 2:00 p.m. CNA T-worked 6:00 a.m. to 2:00 p.m. CNA U-worked 6:00 a.m. to 2:00 p.m. CNA V- worked 2:00 p.m. to 10:00 p.m. CNA W- worked 2:00 p.m. to 10:00 p.m. and 10:00 p.m. to 6:00 a.m. CNA X - worked 2:00 p.m. to 10:00 p.m. CNA Y - worked 2:00 p.m. to 10:00 p.m. CNA Z - worked 2:00 p.m. to 10:00 p.m. CNA AA -worked- 10:00 p.m. to 6:00 a.m. CNA BB - worked 10:00 p.m. to 6:00 a.m. CNA CC - worked all shifts CNA DD - worked 10:00 p.m. to 6:00 a.m. CNA EE - worked 6:00 a.m. to 2:00 p.m. CNA FF - worked 6:00 a.m. to 2:00 p.m. Housekeeper GG- worked 7: 00 a.m. to 3:00 p.m. Housekeeper HH - worked 7:00 a.m. to 3:00 p.m. KA II - worked 12:00 p.m. to 7: 00 p.m. Cook JJ - worked 6:00 p.m. to 2:00 p.m. KA KK- worked 11:00 a.m. to 7:00 p.m. VD LL - worked 8:00 a.m. to 5:00 p.m. An interview with the DON on 05/19/23 at 1:30 p.m. revealed going forward the facility would be following the policy and procedure for reporting abuse and neglect. She stated the staff would be monitored by the compliance testing that would be given on a month-by-month basis An interview with the Administrator on 05/19/23 at 2:00 p.m. revealed going forward the facility would be following the policy and procedure for reporting and investigating neglect. She stated she would ensure the facility completed and continued the proficiency training and testing for abuse and neglect. The Administrator was notified on 05/19/23 at 4:56 p.m., the Immediate Jeopardy was removed. While the immediacy was removed on 05/19/23, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents and supervision. The facility failed to ensure Resident #1 was provided with supervision resulting in him eloping from the facility on 03/18/23. Resident #1 was found approximately 5 miles away at a convenience store by Emergency Medical Services (EMS). The resident was taken to the hospital and required hospitalization for altered mental status and unknown infection. An Immediate Jeopardy IJ)was identified on 03/19/23 at 2:50 PM. While the (IJ) was removed on 03/22/23 at 1:30 PM, the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed all residents that are an elopement risk at risk for serious injury, harm, and/or death. Findings included: Review of Resident #1's MDS assessment, dated 01/12/23, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 9 meaning he had moderately impaired cognition. The resident required one staff assist for transferring. The resident required supervision for walking and locomotion on/off the unit. The resident required 1 person assist for toilet use and hygiene. The resident was occasionally incontinent of bowel and bladder. The resident did not have any behaviors. The resident's diagnoses included Wernicke's Encephalopathy (disease that leads to confusion, loss of mental activity, and loss of muscle coordination), Parkinson's Disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), and a seizure disorder . Review of Resident #1's Care Plan reflected the following: 09/26/22 Resident is exhibiting exit seeking behaviors by stating he no longer wants to live at facility. Wander guard placed on right ankle. Facility interventions included: Check resident location frequently, wandering alert bracelet to be checked by nurse every shift. If bracelet is removed, replace or place on increased monitoring of whereabouts. Observe for verbalizations of wanting to leave/go home. Review of Resident #1's Physician Orders reflected the following: 09/26/22 Wander Bracelet related to wandering/exit seeking behaviors. Nurse to check placement and function every shift including skin check under bracelet. Location of bracelet on resident: right ankle Review of Resident #1's progress notes reflected the following: 03/18/23 at 2:25 AM Late Entry: Patient (Resident #1) was not observed in his room, and on investigation, his roommate stated that patient informed him that he would be going to South Dallas to visit a friend. Patient wears an ankle wander guard bracelet, and it was noted that he has taken it off and he wrapped it up and put on top of toilet roll paper and put it in his drawer. The DON, Administrator, Physician, and Police was notified. Staff Immediately did a search of the whole building, rooms and surrounding areas, called the hospital and business, drove the streets. Patient is his own responsible person. - Weekend Supervisor. Review of Risk Elopement Assessment for Resident #1 reflected: 12/19/22 High Risk for Wandering . Review of the Police Report for Resident #1 reflected: [AGE] year-old male diagnosed with Parkinson's left the location. Male listed as missing. Male found. Reported 03/18/23 6:59 PM. Cleared 03/20/23 10:52 AM An interview with the DON on 03/19/23 at 1:00 PM, the DON revealed Resident #1 eloped from the facility on 03/18/23 . She said the resident was oriented x2 and his own responsible party. The DON said the resident was found by EMS at a convenience store approximately 5 miles away from the facility. She said she had spoken to the resident, and he said he left the facility because he needed a break and was still in the hospital. The DON said the facility did not have a secure unit but did have a wander guard system in place. The DON said Resident #1 took off his wander guard bracelet before eloping from the facility. The DON said the resident wore the wander guard because he was at risk for wandering. The DON said a little after 2:00 PM on 03/18/23 the resident left the facility, and the security doors were working at that time. He was found sometime between 5:00-6:00 AM on 03/19/23 by EMS. She said she did not know how he eloped from the facility because all the doors required a security code to exit and enter the facility . An observation on 03/19/23 at 2:25 PM, of Hall 200 with CNA A revealed there were two sets of doors that had to be opened to go to the smoking area. The 2nd door had a security code pad and CNA A entered the code to open the door. The smoking area had sidewalks and a gazebo. There was no fence or barrier to prevent residents from walking to the front of the building. CNA A said on 03/18/23 construction painters were painting the interior area with the vending machines when she arrived for her shift at 2:00 PM. She said later she saw the painters had barricaded the first door with the vending machines to paint behind them. An observation and interview on 03/20/23 at 2:30 PM, with Resident #1 revealed he was still in the hospital. He was in bed awake and alert and was oriented x2. (He knew who he was and where he was, he did not know what day it was or why he was in the hospital.) The resident was unable to recall specific events of his elopement. He did not remember being found. He said he took of his bracelet and left the facility. He said he was able to push the door (on Hall 200) open and go out the door. He said he did not have to enter a security code. He said residents frequently used that door to go outside to smoke. He said when he left the facility he wanted to go to South Dallas, get his government money and get his own place, but did not know how to do it. He said he did not know where he was going when he left the hospital, but did not want to go back to the facility because he did not like it. An interview on 03/20/23 at 2:40 PM, the Hospital RN assigned to Resident #1 reflected the resident was in the hospital for altered mental status and an infection (the nurse did not say what the infection type was). She said she did not know when or where the resident was going to be discharged to. She said the resident was alert and oriented x2. An interview on 03/19/23 at 2:30 PM with Resident #2 revealed he was awake, alert, and oriented x4. He said he saw Resident #1 go out the Hall 200 door on 03/18/23 after lunch while he was sitting outside. He said there were no staff outside and no one let Resident #1 out of the facility and no one followed him out of the facility. He said Resident #1 exited the facility by himself. Resident #2 said he was able to go out of the Hall 200 door by entering a security code to leave and another security code to re-enter. He said he saw Resident #1 with his coat and hat on and knew he was not supposed to be outside. He said he saw him go around the edge of the facility in his wheelchair. Resident #2 said he was seated in the smoking area at the gazebo in front of the laundry department . Resident #2 said he did not tell anyone he saw the resident. An interview on 03/22/23 at 12:50 PM, CNA A revealed she was assigned to Resident #1 on the 2:00 PM - 10:00 PM shift on 03/18/23. She said she did rounds after starting her shift at 2:00 PM, but she did not see him. She said she thought the resident was in the front room of the facility. She said at dinner time (approximately 4:30 PM-5:00 PM), she put his tray in his room as she did every day. She said she went to pick up the tray and realized he had not eaten it. She notified LVN B at that time that she could not find Resident #1. She said staff started searching for him. An interview on 03/22/23 at 1:15 PM with LVN B revealed she was assigned to Resident #1 during the day and evening shift. She said she had checked his Wander guard and said it was in place before and after lunch (did not know exact times) on 03/18/23. She said the last time she saw the resident was after lunch. She said she identified he was missing when CNA A said he did not eat dinner (did not know exact time). LVN B said staff looked in all the rooms inside and outside the facility looking for the resident but could not find him. She said she notified the Weekend Supervisor. LVN B said Resident #1's roommate, unknown time, told him he was going to South Dallas to visit a friend. An interview on 03/19/23 at 1:45 PM with the Weekend Supervisor revealed on 03/18/23 she saw Resident #1 at around 10:00 AM and he was in his room. She said at lunch time (did not know exact time) she saw Resident #1 at the nurse's station. She said around 4:30-5:00 PM CNA A reported she went to pick up the residents tray and noticed the resident was gone. The Weekend Supervisor said staff started searching the facility for him. She said Resident #1 had a wander guard, and while searching his room, they found it in his drawer. She said when staff could not find him, they called the police. She said the resident did not have a history of removing his wander guard. She said someone might have let the resident out of the Hall 200 door when they were going out to smoke. She said smoking residents knew the code to enter and exit the facility to smoke. She said the smoking area was not fenced and anyone could walk around the building. She said he told his roommate and had told residents before he wanted to go to South Dallas. An interview on 03/20/23 at 11:25 AM, with the Administrator revealed she had video footage showing Resident #1 outside of the building on 03/18/23. The video did not have a time stamp. The video showed Resident #1 in the courtyard. She said she spoke to Resident #3 and said he let Resident #1 out even though Resident #2 said no one followed or opened the door for Resident #1. The camera footage showed Resident #3 was outside. She said she did not know how Resident #1 eloped. An interview on 03/20/23 at 11:35 AM, Resident #3 revealed he was awake, alert, and oriented x3. The resident said he did not let Resident #1 out of the door and did not know why facility staff said he did. An interview on 03/20/23 at 11:40 AM with the [NAME] reflected he said they did not prop the Hall 200 door open while painting. An interview on 03/22/23 at 10:00 AM, the Administrator and DON revealed Resident #1 was still in the hospital. They said the facility should not be held responsible for the actions of Resident #1 because even though he had a BIMs score of 9 and had moderately impaired cognition the resident made a plan and executed it when he removed his wander guard. Record review of the facility policy, Wanderer Management, Monitoring System, and Resident Elopement Protocol, dated 01/17/18, reflected: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible . This failure resulted in an identification of an (IJ) Immediate Jeopardy on 03/19/23 at 2:50 PM, the administrator was notified The IJ template was provided to the Administrator on 03/19/23 at 3:00 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: Resident #1 admitted to the facility on [DATE]. When he admitted , he made verbal statements about wishing to maintain his homeless lifestyle and go back to South Dallas (where he was from). As a result, a wander guard bracelet was provided as a precautionary measure. He willingly and knowingly created a plan to exit the building on 03/18/23. He intentionally cut his wander guard bracelet off, hid it in a toilet paper roll and placed it in the drawer to prevent it from being found. He also verbalized to his roommate that he planned to visit a friend in Dallas. In addition, he took a jacket and a hat to prepare for the weather. Our investigation also revealed that Resident #3 inadvertently let Resident #1 out while he was re-entering the facility. We have all our doors secured. Residents at elopement risk have wander guard bracelets which alarm when an elopement is attempted. The bracelet is checked every shift by nurses for placement and function. The door functions are checked weekly by the Maintenance Director. The Interdisciplinary team discusses our at-risk residents weekly to identify any changes in behavior that may be indicators of added risk . The Plan of Removal was accepted on 3/21/23 at 1:53 PM. Monitoring of the plan of removal included: Observations and interviews were conducted on 03/21/23 starting at 2:10 PM and continued through 03/22/23 at 1:15 PM with 9 staff from various shifts regarding in-services which included elopement and monitoring of residents with a wander guard. The staff members were able to: identify the residents with a wander guard, their responsibility for their monitoring, and what to do if they did have a resident who eloped. Interviewed staff members and shifts were: ADON C - worked all shifts ADON D - worked all shifts LVN E - worked 6:00 AM to 2:00 PM LVN F - worked 6:00 AM to 2:00 PM CNA A - worked 2:00 PM to 10:00 PM LVN B - worked 2:00 PM to 10:00 PM LVN G - worked 6:00 AM to 2:00 PM and worked 2:00 PM to 10:00 PM CNA H - worked 6:00 AM to 2:00 PM and worked 2:00 PM to 10:00 PM CNA I - worked 6:00 AM to 2:00 PM and worked 2:00 PM to 10:00 PM. Smoking signage observed in the smoking area said to notify staff to access the smoking area and to not share security codes. Three residents with wander guards were observed wearing them. An interview on 03/22/23 at 12:40 PM with the DON revealed there were three residents who wore a wander guard, and they were assessed every shift to make sure they were wearing the wander guard. The door codes had been changed, and the facility doors were routinely checked to make sure the wander guard system was working. She said the facility systems in place to prevent elopement were the Wander guard system and the facility doors required a passcode to enter and exit. The DON said Resident #1 was not returning to the facility. An interview on 03/22/23 at 12:55 PM with the Administrator revealed three residents who wore a Wander guard. He said there were multiple assessments completed by the different departments. He said the nurses checked residents every shift to make sure they were wearing the Wander guard ankle bracelet. He said maintenance performed weekly checks on the doors and that all doors required a security code to enter and exit. He said that on-going monitoring would include interdisciplinary team meetings and weekend supervision. The administrator was informed the Immediate Jeopardy was removed on 03/22/23 at 1:30 PM. While the IJ was removed the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated, due to the facility still monitoring the effectiveness of their Plan of Removal.