**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based upon the comprehensive assessment of a resident for one of three residents (Resident #54) reviewed for quality of care. Agency LVN E failed to properly insert Resident #54's Foley catheter on 03/13/24 by inflating the balloon in the resident's urethra causing urethal trauma and significant bleeding. Resident #54 had to be transported to the hospital where a CT Scan revealed the urinary catheter balloon had been inflated in the resident's urethra causing trauma to the area. Due to the blood loss, the resident had to receive a blood transfusion to stabilize his vitals. An Immediate Jeopardy (IJ) situation was identified on 06/12/24. While the IJ was removed on 06/14/24, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for an adverse outcome to resident care or services and may also include the potential for physical and psychosocial harm. Findings include: Record review of Resident #54's, undated, admission Record reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #54 had active diagnoses which included traumatic spinal cord dysfunction, quadriplegia (paralysis below the neck), hidradenitis suppurative (chronic inflammatory skin condition), muscle weakness, neuromuscular (disorders affect nerves or muscles) disfunction of bladder and iron deficiency anemia. Record review of Resident #54's quarterly MDS, dated [DATE], reflected a BIMS score of 14, which indicated intact cognition. Section H - Bladder and Bowel reflected Resident #58 had an indwelling catheter and was always incontinent. Record review of Resident #54's Care Plan, revised 05/05/24, reflected: Problem: Category: Urinary Incontinence [Resident #58] has the Potential for complications related to indwelling urinary catheter. DX:N31.9 Neuromuscular dysfunction of bladder, unspecified. Goal: Will remain free s/sx of complications related to catheter through review date. Approach: Assess for patency and document daily. Assess for urine characteristics (volume, color, clarity, odor) and document daily. Change bag every 30 days or per facility protocol or as per MD orders. Maintain closed drainage system, with drainage bag lower that bladder level at all times. Monitor, document, notify MD PRN s/sx of complications related to catheter use, including UTI, trauma, bleeding. Record review of Resident #54 physician orders reflected: Change Catheter (16F/10cc) for leakage, blockage, or becoming dislodged. As needed. Document clinical reason for catheter change in the progress notes. Start date: 05/05/2023 - 04/02/2024 (DC Date). Observation and interview on 06/11/24 at 12:26 PM revealed Resident #54 lying in bed. The resident stated he was doing well. Resident #54 had a Foley catheter, observed catheter bag to have a privacy bag, the Foley tubing had yellowish color urine. Resident #54 denied any pain, he stated a couple of months ago he had to go to the hospital and had to get a blood transfusion. Resident #54 stated he could not recall much of the incident, but the nurse at the time attempted to change his catheter and caused bleeding. Resident #54 he stated he felt some discomfort. Resident #54 stated he could not recall the name of the nurse. Resident #54 stated he was unsure if he left to the hospital with the catheter inserted or not, he stated he could not recall as it had been a couple of months. Resident #54 stated because of that incident staff were not allowed to change his catheter. He stated he must go to the hospital to get it changed. Record review of Resident #54's progress note, dated 03/13/24 at 11:11 AM, by the PA reflected: [Recorded as Late Entry on 04/05/2024 11:11 AM] Patient Encounter Note . Encounter Date: 03/13/2024 Chief Complaint: Follow up encounter History of Present Illness: This is a [AGE] year-old Male resident of [Facility name] Nursing Home who presents for follow up and management of chronic medical problems. Interval Reports: - Per nursing, resident was found with a dislodged foley catheter without any urine return. - Nursing re-inserted foley catheter but only return bright red urine upon placement. - Resident reports severe discomfort. - Seen and examined at the bedside. - He is alert and oriented x4. - He has significant urethral injuries. Plans in place for SPT placement. - He has contractures to bilateral upper and lower extremities Dislodged Foley Catheter: Re-inserted but severe bloody urine and discomfort. - OK to send to ER for imagery and further evaluation. Record review of Resident #54 progress note, dated 03/13/24 at 18:21 [6:21 PM] by Agency LVN E, reflected: Nurse attempted to re-insert new 16 Fr. Cather using sterile technique blood return observed no urine return. Cath. [catheter] flushed only blood return.119/80, 129, 97.9, 98%, 18 RA 0/10 NP notified client own POA. NP new orders received send to ER for further treatment. Client left via medical transport on stretcher. Record review of Resident #54's EMS report reflected: Dispatch Information: Incident Date: 03/13/24 17:46 [5:46 PM] Complaint: Blood at site of catheter Compliant Type: Chief (Primary) Duration of Complaint: 10 Hours 17:59 [5:59 PM] Unit arrived on scene 18:16 [6:16 PM] Vitals: BP 97/64 P 127 18:20 [6:20 PM] Unit left scene - BP 105/69 P 127 18:37 [6:37 PM] Patient arrived at destination [hospital] Provider Impression: Primary Impression: Illness, unspecified Working Diagnosis: UTI Differential Diagnosis: Sepsis, Kidney Stones, Urethra Tear Record review of Resident #54's hospital reflected the following: Reason for visit: Chief Complaint on 03/13/24 6:44 PM: Urinary Catheter Problem (Pt from [Facility] staff attempted to insert foley, unsuccessful attempts per staff due to blood clots coming out, pt hypotensive and tachycardic upon EMS arrival) History of Present Illness 6:46 PM [Resident #54] is a 52 y.o. male with a h/o HTN, leukocytosis, and who comes to ED via EMS from [Facility] NH and c/o urinary catheter dysfunction that started today s/p multiple unsuccessful attempts. EMS denies any medical intervention en route. Pt denies feeling more fatigue than usual .Pt is quadriplegic (paralysis). 03/13/24 1853 [6:53 PM] ED Triage Vitas: BP 124/58 P 139 Physical exam: Constitutional: General: He is in acute distress (mild) Cardiovascular: Rate and Rhythm: Regular rhythm. Tachycardia present. Genitourinary: Comments: Foley in place with chronic appearing urethral tear with mild surrounding bleeding. Blood in foley tubing. 03/13/24 1914 [7:14 PM] RN Assessment: Abdominal Pain: GI Signs/Symptoms: pain; discomfort ABD Pain Location: generalized ABD Pain Character: Intermittent; Stabbing Genitourinary Assessment: Foley present upon arrival, blood cloths present PT hard stick, in process of obtaining access with sono[gram] at this time; Delay in CT scan due to pt condition and obtaining IV access at this time; 18G [gauge needle] placed in external jugular vein; Labs and blood cultures sent; CT notified pt ready 03/13/24 1922 [7:22 PM] Lab results showed HGB (Hemoglobin) of 7.9 Abnormal [Ref Range: 13.0 -17.0 g/dL] and HCT [Hematocrit] 25.6 Abnormal [Ref Range: 38.0 - 51.0%] ED Medication Administration: 03/13/24 1925 [7:25 PM] Normal Saline 1,797 mls [milliliters] as part of sepsis protocol. 03/13/24 1931 [7:31 PM] Maxipime (antibiotics) 2,000 mg IV started. 03/13/24 2013 [8:13 PM] CT abdomen and pelvis results: Impression: 1. Soft tissue attenuation in the left aspect of the urinary bladder concerning for blood clots or a soft tissue mass. Urology consultation is recommended. 2. Foley catheter present with the balloon inflated in the membranous or bulbous portion of the urethra. 3. Moderate bilateral hydronephrosis (urine is unable to drain from the kidney into the bladder) and hydroureter (abnormal enlargement of the ureter caused by any blockage that prevents urine from draining into the bladder). 4. Right nephrolithiasis (kidney stone). 03/13/24 2230 [10:30 PM] [NAME]: Discussed case w/ [Dr.], who is aware of assessment/workup in the ED and agrees to admit pt. 03/13/24 2240 [10:40 PM] ER nurse notified [Dr.] of being uncomfortable removing foley due to pt anatomy. [Dr.] notified and aware of hematuria and elevated troponin. New orders received - urology and cardiology consult Per [Dr.] ok to leave foley in at this time and wait for urology to see patient. 03/13/24 2316 [11:16 PM] Urology at bedside; Previous foley removed by urology; New foley by urology at this time 03/13/24 2344 [11:44 PM] Notified by ED monitor tech BP 66/43- reassessed BP and BP 72/44. Patient given Ringer's lactate 1 L bolus and episode resolved 03/13/24 2356 [11:56 PM] Pt states he got lightheaded when urology irrigated bladder and then BP was noted to be low. 03/14/24 0026 [12:42 AM] ICU NP @ bedside. States to change bed to cardiac PCU so pt may receive low dose levophed (raise blood pressure) if needed. Bed control notified of change. Two sono PIVs placed in R arm. Seeing how pt responds to IV bolus at this time prior to starting Levophed per NP and ER physician. Record review of Resident #54's Discharge Summary (Notes from 03/14/24 through 03/17/24 reflected: Hospital Problems: 1. Gross hematuria (blood in urine) with hydroureteronephrosis (dilation of the ureter due to obstruction of urine outflow) secondary to mispositioned Foley-resolved s/p Foley placed by cysto and CBI, follow-up with Urology. 2. Possible sepsis secondary to complicated UTI with chronic indwelling Foley - completing course of empiric antibiotics per ID recommendation, cultures negative but urine cultures collected after CBI. 3. Acute blood loss anemia-possibly secondary to hematuria, H&H remained stable after transfusion of PRBC 3/14, consider GI workup if needed, no signs of acute GI bleed during hospitalization. 4. Hypotension-resolved, related to acute issues and possible sepsis, resolved with treatment Presenting HPI: .presents to the emergency room with a history of gross blood in the Foley catheter that started yesterday. There was no history of trauma or manipulation of the Foley catheter. Patient denies any fevers or chills. Initial vital signs include a blood pressure 124/58, pulse of 139 and temperature 97.5° F . Labs significant for a high sensitivity troponin of 522 up from 377, procalcitonin of 0.14, white count of 20000, with a neutrophil count of 85%, hemoglobin of 7.9/26, down from 8.9/30 on 02/20/2024, chest x-ray that showed no acute radiographic cardiopulmonary abnormality. CT abdomen pelvis without contrast shows soft tissue attenuation in the left aspect of the urinary bladder concerning for blood clots soft tissue mass. Foley catheter present with balloon inflated in the membrane is a bulbous portion of the urethra. Moderate bilateral hydro nephrosis hydro ureter. In the emergency room patient was given cefepime 2 g (grams) IV, IV Tylenol 1000 mg, normal saline 1.8 L bolus, and is being admitted for urology consult for Foley catheter replacement and proper positioning, irrigation of bladder, empiric antibiotic therapy. During the process of Foley catheter placement, the patient had hypotensive episode with blood pressure dropped to systolic 70s. He was given a Ringer's lactate 1 L bolus and his blood pressure 96/57 from 89/52. Antibiotic therapy with extended and patient was placed on IV ampicillin 2 g. Pulmonary has been consulted, will also consult Cardiology for up trending of high sensitivity troponins. Record review of Resident #54 clinical records for the month of January 2024 and February 2024 reflected Resident #54 was not admitted to the hospital for catheter related issues. Interview on 06/12/24 at 9:43 AM by phone with Agency LVN E revealed from what he recalled Resident #54 asked for his Foley catheter to be changed because it was not draining. Agency LVN E stated he removed the old catheter and attempted to reinsert the new catheter, but he could not. He stated he was not able to get any urine return, but there was bleeding and blood clots noted. Agency LVN E said he did not recall if he had inflated the balloon or gotten any resistance. Agency LVN E stated when he tried to flush and did not get anything in return, he called the DON for assistance. He stated he obtained physician orders to send the resident to the hospital. Agency LVN E stated he could not recall if Resident #54 was sent to the hospital with the catheter inserted. Agency LVN E stated he had been trained on how to insert/change a catheter, he stated inserting a catheter was a sterile technique, and the catheter should be inserted about 4 to 6 inches and wait for urine return. Interview on 06/12/24 at 9:22 AM with LVN D revealed she assisted Agency LVN E with flushing Resident #54's Foley catheter. LVN D stated Agency Nurse E re-inserted Resident #54's Foley catheter, but he was not able to flush the catheter and caused it to bleed. LVN D said she did not attempt to re-insert the catheter since Agency Nurse E had already attempted. LVN D stated she attempted to help flush the catheter once Agency Nurse E inserted the catheter. She stated there was fresh blood coming out in the line and bag. She stated she was able to flush; however, they were just waiting for the urine to clear because it was only blood. LVN D said they monitored Resident #54 and was then sent out to the hospital. LVN D stated she was not present when Resident #54 was discharged to the hospital. LVN D stated Resident #54's penis was flayed all the way to the bottom making it tricky to insert the catheter. She stated prior to this incident they had not had any issues with inserting the catheter when it had come out. LVN D further stated after the incident (03/13/24) Resident #54 was being sent to the hospital to have his catheter replaced. Interview on 06/12/24 at 9:10 AM with CNA C revealed he had been assigned to Resident #54 on 03/13/24 and recalled the time Agency LVN E had tried to replace the catheter and the agency nurse could not get it in. He stated he was in the room with Agency Nurse E and LVN D when the incident happened. He stated Agency Nurse E had set up the catheter kit, he removed the old catheter, and he inserted the new catheter in, but it started bleeding. He stated there was blood in the tube of the catheter, it was clogged, and Agency Nurse E tried to flush it and the water got all over the bed. CNA C stated no urine was coming out, but only blood was noted in the catheter tubing. CNA C stated after the catheter was inserted, they placed the resident on observation and once they noticed it was not working, the resident was sent out to the hospital. He stated Resident #54 did not complained of any pain or distress at that time, because of his paralysis. CNA C stated in the past, Resident #54's Foley catheter had fallen out but had been replaced with no issues. Interview on 06/12/24 at 12:45 PM by phone with the previous DON B revealed she was called to Resident #54's room because Agency Nurse E was unable to insert a catheter. She stated when she went to the room, she did not try to insert the catheter because Agency Nurse E had already attempted. She stated she observed little blood on the line but because Resident #54 was having pain and there was resistance, they sent Resident #54 to the hospital. She stated Agency Nurse E had already tried to flush prior to her entering the room. She stated Resident #54 did not have the Foley inserted when he went out to the hospital, she stated Agency Nurse E had taken out the catheter and was not able to put it back in. She stated she did not think the catheter was inserted back in because they could not flush properly. She stated she could not remember what the hospital discharge summary indicated. She stated it had been some time since the incident. She stated she was unaware the catheter balloon was placed in the urethra if she had known she would have addressed it and education would have been done. She stated Resident #54 had always had trouble with his catheter, that was why the urologist changed his catheter. She stated Resident #54 required a suprapubic catheter, and if not placed resident would continue to have issues with trauma and having a large prostate. DON B stated she could not confirm or deny if the catheter was inserted, she stated she did not have any recollection of the event. She stated her expectation was for nurses to stop if they got any resistance when inserting the catheter. Interview on 06/12/24 at 9:55 AM with ADON A revealed she was not present at the time when Resident #54's catheter was changed. She stated she was brought in at the end. From what she recalled, Resident #54 said his catheter was bothering him. She stated they were going to replace the catheter because the resident felt his bladder was not emptying/draining and that was why they tried to flush it. After inserting the catheter, ADON A said Agency Nurse E attempted to flush the catheter, but he was not able to flush it. She stated there was not a lot of blood and could not tell if the catheter was in place. The DON was called and had requested to send the resident to the hospital. She stated LVN D was called in to help as well, and she was able to flush the catheter. She stated she believed the resident left to the hospital with the catheter inserted. ADON A stated hospital discharge records were reviewed and stated they should not replace the Foley catheter after this incident. She stated the Foley catheter was not placed correctly. ADON A stated Resident #54 was contracted to place a Foley catheter in a nursing home. ADON A stated if the Foley catheter balloon was inflated in the urethra, it could cause pain and bleeding. ADON A stated she was not sure if they had completed an in-service on Foley catheters after this incident. Interview on 06/12/24 at 1:11 PM with DON A revealed she had been employed at the facility since 04/23/24. She stated she was not made aware of the incident regarding Resident #54 Foley catheter until today (06/12/24). She stated her expectation was for LVNs to remove the old catheter and reinsert the new one and receive a good flow of urine. She stated they completed skill check-offs with everyone. She stated she would expect competency-based skills check-offs to be provided before getting into the field for agency nurses. She stated the agency nurses' competencies were completed by their agency. DON A stated she had not had the opportunity to review Resident #54's hospital records. She stated by inflating the catheter balloon in the urethra, it could cause trauma in the urethra. Interview on 06/12/24 at 12:33 PM with Regional Nurse Consultant revealed at the time of the incident she was not made aware of the situation with Resident #54. She stated she was made aware of the urology appointment. She stated they had a urology appointment set for Resident #54 ; however, the insurance would not cover the appointment and family would not pay out of pocket. She stated Resident #54 was recommended to get a suprapubic catheter due to how the resident's penis and urethra were. The Regional Nurse Consultant stated the Foley catheter should be inserted until it reached the Y of the catheter. She stated from what she understood Resident #54's trauma was when the nurse attempted to insert the catheter. She stated she was unaware the balloon was inflated in the urethra. She stated the previous DON was in the room at the time, but she was unaware what was done. She stated the risk of inflating the balloon in the urethra was that it could cause trauma. The Regional Nurse Consultant stated Resident #54's catheter could not be changed at the facility, the resident's catheter should be changed at the hospital due to the pre-existence trauma to his penis. Interview on 06/12/24 at 10:28 AM with PA revealed he was aware of Resident #54's catheter incident; however, it was addressed by another doctor. He stated when he came on board, hospital records were reviewed but the discharge instructions did not provide much detail. The PA stated Resident #54 was recommended to get a suprapubic catheter; however, the resident refused. He stated when inserting a catheter, it could sometimes cause little trauma when inserting and cause bleeding. He stated he was not surprised the resident was sent out to the hospital due to resident's anatomy. The PA stated the process of when inserting a Foley catheter required a sterile technique, lubrication, insertion measurement, and then inserting the catheter based on the measurements and then inflating the balloon. Once urine was observed, that was an indication the catheter was in and should not proceed further than that. The PA stated nurses would need more than 4-6 inches when inserting a catheter. He stated if the catheter balloon was inserted in the urethra, it would cause excessive bleeding. The PA stated he was unaware the catheter balloon was intact at the hospital. He stated he thought it was the trauma of the penis that caused the bleeding. The PA stated if the balloon was inflated in the urethra, it could cause kidney failure and trauma. Follow-up interview on 06/14/24 at 11:16 AM by phone with the PA revealed he was aware of Resident #54 anemia. He stated the resident had an order for ferrous sulfate; however, since the resident refused the medications, the medications were discontinued. The PA stated he was aware of Resident #54's anatomy and if the resident's Foley catheter was not inflated it would have come out on its own. If the balloon was inflated, the catheter would not fall unless tampered with. Interview on 06/12/24 at 12:41 PM with the Administrator revealed at the time of the incident he was at the facility and was made aware of the incident. He stated the agency nurse attempted to insert Resident #54's catheter; however, he was not sure if the agency nurse was able to do so. The Administrator stated Resident #54 was discharged to the hospital and when Resident #54 returned he was on leave. The Administrator stated he was not aware the catheter balloon was place in Resident #54's urethra. He stated the DON and the ADON were responsible for the skills check-offs and to provide orientation to the agency nurses. Interview on 06/14/24 at 1:48 PM by phone with the Hospital RN revealed she recalled the resident very well. The Hospital RN stated the resident arrived with the urinary catheter in place. She stated she did not manipulate the catheter and most especially did not inflate the balloon. She stated the resident was there for a traumatic catheter insertion, so she was very aware of the catheter. She stated she charted/documented the resident arrived at the hospital with the Foley catheter in place. When they received the CT Report indicating the balloon was in the urethra, both she and the ER physician felt uncomfortable with removing the catheter and consulted urology. The catheter was left untouched until urology removed it and replaced it with a new catheter. Record review of EMT Statement dated 06/20/24 reflected: as an EMT for [Company Name] Mobile Healthcare on 3/13/24 responded to a call for service at [facility address]. Facility reports they attempted to reinsert patient's urinary catheter, though they are unable to and have notice blood clots coming out. [I] made contact with a black male who was identified as [Resident #54] DOB: [DATE]. Patient was moved to stretcher, moved to ambulance, transported [Hospital Name]. PT was safely moved to ED bed, report was given to facility RN and transfer of care was at 1847 hours [6:47 PM] to Hospital RN. At no time during this call did I ever removed, place, insert, deflate, inflate, or manipulate the patients foley catheter in any manner. Record review of Agency LVN E's Skills competency checklist dated 03/05/24, reflected he was Proficient/Expert/Highly skilled in the area of Catheterization/foley catheter care. Record review of the facility's Catheterization, Intermittent, Male Resident policy, revised October 2010, reflected the following: The purpose of this procedure is to provide guidelines for the aseptic insertion of an intermittent catheter .21. Insert the catheter gently into the meatus (approximately 5-7 inches) until urine begins to flow from the bladder. When urine beings to flow advance the catheter 2 inches. This was determined to be an Immediate Jeopardy (IJ) on 06/12/24 at 1:40 PM. The Administrator and Regional Nurse Consultant were notified. The Administrator was provided with the IJ template on 06/12/24 at 2:00 PM. The following Plan of Removal submitted by the facility was accepted on 06/13/24 at 9:33 AM: The facility failed to ensure nursing staff had appropriate competencies and skills sets necessary to care for resident's needs, as identified through resident assessments and described in the plan of care, when a LVN failed to properly insert a urinary catheter for a male resident resulting in the resident having to be transferred to the hospital after experiencing severe bleeding requiring a blood transfusion. On 6/12/24 The facility Administrator notified the Medical Director of immediate jeopardy. On 6/12/24 the facility DON (Director of Nursing)/designee assessed Resident #54 and all other residents in the facility with Foley Catheters that their catheters were functioning properly. On 6/12/24 the DON (Director of Nursing)/Designee, initiated Foley Catheter Insertion competencies for all nurses. These will continue until all nurses have completed their competencies before their next scheduled shift. On 6/12/24 the RNC /Designee initiated the in-servicing of all nurses including PRN and Agency nurses regarding not to perform catheter insertion unless a competency has been completed or provided. o The Foley Catheter insertion competency of the Agency nurse must be verified by the DON/designee via hand delivery or email from the Agency or Agency nurse prior to performing the skill. If a nurse that does not have competency on file is working, and the need for Foley insertion arises, the DON must be notified, and the DON/designee will come to insert the Foley catheter. o The clinical management team will discuss staffing to include new agency nurses who will be covering the floor during the morning meeting. Any changes in coverage during the day will be discussed with the DON/designee. Ad-Hoc QAPI meeting was held on 06/12/24, with the Medical Director, Regional Nurse Consultant, Director of Nursing & Assistant Director of Nursing to review the alleged deficiencies, policy and procedure and the plan of removal of immediacy. The policies pertaining to Foley Catheter insertion were reviewed on 6/12/24 by the RNC, Facility Administrator and Director of Nursing. No changes were made to the policy. The RNC will monitor for compliance on all residents with Foley Catheters weekly x 4 weeks and send any trends or issues to the ADHOC QAPI Meeting for review. The RNC (Regional Nurse Consultant) will ensure this plan is completed on 6/12/24. Monitoring of the facility's Plan of Removal included the following : Interviews on 06/12/24 from 2:00 PM-2:10 PM with Resident #5, Resident #48, and Resident #118 revealed no concerns regarding their Foley catheters. Record review of the progress notes for Resident #5, Resident #19, Resident #48, and Resident #118, who all had Foley catheters, reflected they were assessed by the DON on 06/12/24 with no concerns reported. Record review of Admit/Discharge Report, from 04/11/24-06/12/24, reflected sample residents had not been to the hospital for catheter related issues. Record review of the facility's in-services, dated 06/12/24, reflected training for Foley Insertion Competencies Completed and Suprapubic Catheter Replacement. In-services reflected all staff completed the trainings . The in-services were conducted and signed by nursing on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Nursing staff competency: Catheter, insertion of indwelling completed on 06/12/24 reflected: Performance Criteria included .22. Inserts catheter through meatus. A. Males 1) Lifts penis to position perpendicular to patient/resident's body. 23. Advance catheter 2-3 inches in females and 7-9 inches in males or until urine flows out of catheter end. 24. Inflates balloon. 25. Attaches catheter to collection device and lowers bag below level of bladder . Record review of the facility's Ad Hoc Meeting for Foley Catheters reflected the meeting was completed on 06/12/24. Interviews conducted on 04/13/24 from 2:40 PM through 6:31 PM and 04/14/24 from 9:24 AM through 10:20 AM with LVN B, LVN D, LVN F, ADON A, ADON B, LVN H, LVN I, LVN K, LVN L, RN M and DON who work the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM revealed nurses were able to verify education was provided to them, nursing staff were able to accurately summarize what to do when changing a foley catheter. Nurses indicated it was sterile technic, insert catheter until urine began to flow and advance the catheter 2 inches. If resistance when inflating the balloon they must deflate the balloon, remove the catheter, and notify the physician. DON A stated she would be responsible for ensuring PRN Nurses and Agency Nurses competency checkoffs were obtained and verified prior to working the floor and if she was on leave the ADONs would be responsible for competency checkoff were obtained and verified. The Administrator and Regional Nurse Consultant were informed the Immediate Jeopardy was removed on 06/14/2024 at 11:00 AM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents reviewed (Resident # 1) for abuse, neglect and sexual exploitation. The facility failed to properly monitor and supervise resident relationships and interactions which resulted in an incident of unwanted sexual conduct. Resident #1 reported being sexually assaulted and was sent to the hospital where a SANE exam was performed. As a result of the sexual incident, Resident #1 reported to hospital staff that she was experiencing emotional distress, pain, and no longer wanted to remain at the facility as she did not feel safe. This failure resulted in an identification of an Immediate Jeopardy on 10/20/23 at 6:40 PM. While the IJ was removed on 10/21/23 at 12:47 PM, the facility remained out of compliance at a level of isolated with actual harm due to the facility's need to complete additional education, interventions and monitoring that include counseling and psych referrals to evaluate the effectiveness of the corrective system. This failure placed residents at risk of sexual assault and mental anguish including trauma victimization. Findings included: Review of Resident #1's Face Sheet revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged on 10/20/23. Resident #1 had diagnoses that included: schizoaffective disorder (Mental Disorder of abnormal thoughts), bipolar disorder (manic depression mental disorder), Borderline Personality (emotionally unstable disorder), Major Depression Disorder (low mood), Muscle wasting, and atrophy (loss of skeletal muscle mass), and post-traumatic stress disorder (mental and behavioral from traumatic experiences). Review of Resident #1's MDS, dated [DATE], revealed she had a BIMS score of 15 indicating she was cognitively intact. Her Functional Status indicated she required extensive assistance for ADLs and independence for eating, no assistance required. Resident # 1s MDS reflected physical, verbal and other behaviors as-sociated with mood disorder. Review of Resident #1's care plan, dated 08/23/23, revealed she desired to live in room with her significant other who was a resident at the facility. She had behaviors related to schizophrenia DX AFB that includes acts of pseudo (non-genuine) seizures, (changes in brain that causes involuntary movement) or she will act non-responsive, physical altercations with staff pulling hair and striking. Resident has episodes of anxiety and was at risk of fluctuations in moods and complications related to anxiolytic (medication that reduces anxiety) use. Resident at risk of injury to self-related to suicidal ideations. Interventions include encourage to express feelings and establish trusting relationship. Resident at risk for alteration in comfort and pain. Risk of falls. Record review of Resident #1's MD orders reflected the Invega Sustenna order dated 10/20/23 syringe: 156 mg/mL; amt:1 ml; administer every 28 days to treat schizophrenia in adults. *Duloxetine 30 mg order date 10/20/23 delayed release capsule once daily for depression. *Fluphenazine 5 mg order dated 10/20/23 tablet once daily to treat schizophrenia. Record review of Resident #1's progress notes by the dated 10/19/23 at 12:28 PM reflected When resident was assisted with dressing, she complained of having something on her thigh. A wet wipe was used to clean the area. The wipe and the ADON gloves were put into the empty trash can next to resident's bed. When police officer and EMT's arrived, I made them aware of the wipe and gloves and pointed out the trash can. Police officer acknowledged the can that contained the items. Record review of Resident #1's progress note dated 10/19/23 at 12:21 PM by the ADON reflected This writer was made aware that resident had phoned her [family members] stating she had been involved in sexual encounter with a male resident. the ADON went directly to the room, ensured resident safety, then the ADM entered the room to interview this resident. the ADON said stated that she (Resident #1) and male resident (Resident #2) were kissing and then she (Resident #1) performed oral sex. Male resident then pulled her leg up in the air, she told him he was hurting her hip, so he stopped and ejaculated on her left thigh. Resident was upset and crying. Much moral support given. Pseudo seizures are displayed on and off during the interview. Exam was conducted by this nurse and RN. No bruising, redness, swelling, or bleeding are noted. She can move all extremities as normal. MD notified, police are called, EMT's are called. The ADM is an active participant in this process and RNs aware of all happenings. [family members] of resident were notified by herself, as she called them. Resident was transported to [Hospital] by EMT/stretcher. She remains at the hospital at this time. Record review of Resident #1's progress notes dated 10/20/23 at 2:48 PM by CRN reflected Resident was readmitting from [hospital] today. She stated she does not wish to remain in this facility. She was offered alternate living choices and chose another placement (HH). Resident #1 remained with CRN and the ADM in the conference room, being attended at all times. Resident #1s PO, MD, Judge, and family were notified of the move. Record review of Resident #1's progress note dated 10/20/23 at 6:29 PM by CRN Late Entry on 10/21/2023 12:36 PM reflected she spoke with the DON of receiving Nursing Home .to report sexual assault incident that occurred by male resident. In an interview with Resident #1 on 10/20/23 at 2:00 PM, at the facility while waiting to transfer to HH, she stated that she does not want to remain at the facility as she did not feel secure. She stated that Resident #2 asked her 3 months ago if she would be his girlfriend, and she said yes. She told him she loved him, and he proceeded to kiss on her hair and pushing her head down while putting his penis in her mouth. Resident #1 stated that she did not agree to any sexual encounters or touching. She told Resident 21 to stop when he was kissing her hair, and he did not. Resident #2 proceeded to pull her sock and pants off, and she told him he was hurting her leg. Resident #1 said she yelled for help, and he ejaculated on her leg near her again. Resident #2 went in the bathroom located in her room. She called FM-D and told him Resident #2 raped me. Resident #1 said it was at that time Resident #2 took the phone from her and told FM-D she was unstable. He left the room and FM-D notified the ADM. She stated that both the ADM and the ADON came immediately, she was crying and having pseudo seizures. She stated LE was called and EMS arrived and transported her to the hospital where she agreed to a sexual examination. She does not know the results of the exam. She said she felt like it was my fault for being his friend, she felt pressured to be his girlfriend and that was why she said yes. She stated that she requested to be his roommate at one point, however she no longer wanted to be in a relationship or remain at the facility after he sexually assaulted her. Resident #1 said this has never happened before while being at the facility She started to cry, and the interview ended. Resident #2 Record review of Resident #2's face sheet dated 10/20/23 reflected a [AGE] year-old male admitted to the facility on [DATE], his diagnosis includes Alzheimer's disease, Parkinson's Disease, Edema, Muscle wasting and atrophy, insomnia, cognitive communication deficit, arthritis, Schizoaffective Disorder, Bipolar Disorder, cur-rent episode of hypomanic, anxiety disorder, Review of Resident #2's MDS, dated [DATE], revealed he had a BIMS score of 15 indicating he was cognitively intact. His Functional Status indicated he independent for task requiring supervision for ADLs. Resident behaviors reflected other, for refusing medications. Record review of Resident #2's updated care plan dated 10/19/23 reflected problem: Resident has had a con-sensual relationship with female resident at facility. Resident voices God sent her to me to staff, attends activities and meals together and wants to be in her presence as much as possible. Resident #2 states no intent to have relations with any other residents and verbalizes that his relationship with this said female resident should and would be consensual. Resident will respect privacy of other resident and allow staff to intervene as needed to provide care. Record review of Resident #2's MD orders reflected the following: *an order dated 09/15/23 Document the Behavior Code and # of Episodes each shift for antipsychotic. Codes: 0=none, 1=verbal/physical aggression, 2=constant crying or yelling, 3=hallucinations (visual & auditory), 4=inappropriate sexual behavior, 5=refusal to cooperate in routine care, 6=insomnia, 7=sudden angry outburst, 8=suspicious or distrustful of others, 9=taking belongings or food item from others, 10=hoarding items, 11=withdrawn, 12=other . Order dated 09/15/23 interventions for antipsychotic: 0=none, 2=redirection, 3=offer food/snack, 4=diversion activity, 5=discuss behavior with resident, 6=quiet time, re-[NAME] noise/distraction, 7=re-orientation to current situation, 8=leave alone and re-approach, 9=clothing/bedding change, 10=problem solving with resident, 11=assisted to toilet, 12=simplified task into short steps, 13=allow time to complete tasks, 14=explain need prior to beginning, 15=other, 16=medication as needed prescription Lasix (furosemide) tablet; 20 mg; amt: tab 1; oral Once A Day. *An Order dated 05/31/23 Target Behavior: obsessive. At the end of each shift mark Frequency-how often behavior occurred & Intensity-how resident responded to redirection. Intensity Code: 0=Did Not Occur; 1=Easily Altered; 2=Difficult to Redirect. Special Instructions: Staff Note: Add Frequency & Intensity med notes to order for tracking. Every Shift Day, Night. *An Order dated 02/14/23 Anti-Psychotic Medication Use - Observe resident closely for significant side effects: Common - Sedation, Drowsiness, Dry Mouth, Constipation, Blurred Vision, Extra Pyramidal Reaction, Weight Gain, Edema, Postural Hypotension, Sweating, Loss of Appetite, Urinary Retention. Special Instructions: Special Attention For: Tardive Dyskinesia, Seizure Disorder, Chronic Constipation, Glaucoma, Diabetes, Skin Pigmentation, Jaundice. Every Shifts. *An Order date 02/14/23 Hypnotic/Sedative/Tranquilizer Medication Use - Observe resident closely for significant side effects: Common - Sedation, Drowsiness, Morning Hangover, Ataxia (drunk walk). Special Instructions: Special Attention: If given with other sedatives, hypnotics, or alcohol. Special Instructions: Special Attention: In use with other CNS depressant drugs or residents who develop fever blood dyscrasias. Every Shift Orders . Geodon (ziprasidone hcl) capsule; 20 mg; 1 tablet; oral Special Instructions: give one cap po twice daily Twice a Day 09:00, 21:00 1 of 5 Linked Orders 05/31/23. Record review of Resident #2's Psychiatric visit; dated 10/21/23 12:46 PM reflected was asked to see for psychiatric evaluation and psychotropic medication management. The patient was last seen on October 16, 2023. History of Present Illness: The patient is a [AGE] year-old African American with diagnosis of anxiety, major depressive disorder, schizoaffective disorder, insomnia, and anxiety disorder. Was notified by staff that the patient had a sexual encounter with a female resident. The patient is alert and oriented to time and place. He denies any anxiety or depressive symptoms. He denies any suicidal ideation. He stated that he has been in a relationship with the female residents for 3 months now. That they have kissed but never had any sexual intercourse .That she did not take her medications which caused her to have increased depression. The patient verbalized that on that they kissed but he never had any sexual encounter with a female resident. CARE PLAN / ASSESSMENT ICD (international classification of Disease) 10 or DX (Diagnosis) : 1. Major depressive disorder, single episode, mild, Primary insomnia, anxiety disorder due to known physiological condition, schizoaffective disorder, bipolar type, Alzheimer's disease, unspecified the patient is not a threat to other residents or staff at this moment Continue Trazadone 50mg at bedtime. Zoloft 100mg daily. Depakote 375mg at bedtime for aggressive behavior. Geodon 20 mg twice daily Restoril 7.5 mg at bedtime Xanax 0.25 milligrams at bedtime Continue supportive non-pharmacological interventions Assess for pain during periods of agitation. -Reorient as needed. -Gentle redirection as needed. Maintain daily routine as much as possible. -Communicate simply about aspects of care/activities/changes -Keep familiar or favorite objects/pictures around. -Behavior monitoring and documentation. Record review of Resident #2's progress note dated 10/21/23 at 11:46 AM from the ADM reflected on 10/20/2023, this writer educated resident to notify staff if he has any desire to start consensual relationships with other residents. Record Review of Resident #2's progress note reflected a note from the ADM. Resident acknowledged the ADM 10/19/23 at 12:35 PM. This writer and ADM spoke with resident (Resident # 2) regarding alleged event that took place immediately prior. Fellow female resident (Resident #1) alleges this resident and herself had a sexual encounter. Allegation includes kissing, oral sex and pulling her leg up in the air. Female resident told him he was hurting her, and he stopped, then ejaculated on her left thigh. This resident admits to having con-sensual sex with the female resident. He also states she said he was hurting her hip and he stopped. When asked what else took place, resident states nothing. One on one began immediately. Police were notified and resident was located to front office while police questioned him about the female resident. After questioning both residents, the police officer stated they did not have reason to arrest anyone based on the interview results. Resident responsible party was notified, MD was notified CRN was aware of the situation. Record review of the ADM progress note Resident #2's dated 10/19/23 at 8:05 PM reflected This ADM spoke with resident with facility RN in the room as well. Discussion was held regarding alleged event today regarding he and a female resident. Resident stated that he would speak to the other resident upon her return, this writer advised resident to gain that residents approval before he attempted to speak to her. One on one observations halted at this time. This took place at 4:20 pm. Resident has voiced no concerns. An observation of Resident #2 on 10/20/23 at 11:30 AM revealed he was not in his room. Further search observed him in the dining room with other residents in an activity of Karaoke. He was sitting at the table with another male, no reactions or engagement with others at the time. In a second attempted interview on 10/20/23 at 3:28 PM revealed Resident #2 in his room. Resident # 2 denied having any sexual interactions with Resident #1 during their 3-month consensual boyfriend and girl-friend relationships. Resident #2 stated that it was Resident #1 that asked if he would be her boyfriend and he said yes. He said, I love her. He maintained he was not involved in a sexual interaction with the Resident #1 on 10/19/23. He denied reporting that he and the resident had sex in her room to the ADM. He stated he was placed on 1 on 1 supervision by the ADM on 10/19/23 but could not remember the time. He said he was inter-viewed by LE and told him that he has not had any sexual interactions with Resident #1. In an interview with Resident #2 on 10/21/23 at 3:28 PM he said he felt safe and told the ADM that he did not want to move to a new facility last night because this was his home. Resident #2 denied having sex interactions with Resident #1. He said several leadership staff have met with him on 10/19/23 and 10/20/23, and he has provided the same information to the ADM, the CRN, and the RDO. He was currently on 1 on 1 supervision. Resident #1 has never asked him for sex, and he has not spoken to her. He denied telling FM-D that he stated, I didn't stick it in her he ejaculated on her leg. Interview on 10/20/23 at 9:28 AM with the ADM, the ADON, and the CRN revealed they were covering the roles of the DON and SW until a new hire was located. In an interview on 10/20/23 at 9:30 AM with the ADON revealed she and the ADM arrived at Resident #1's room she was crying hysterically and yelling get me dressed first. Once the ADON cleaned the thick liquid substance off the Resident's thigh, she called the ADM to enter and interview. The ADON said Resident #1 reported she and Resident #2 were kissing and then she performed oral sex on him. Resident #2 then pulled her legs up in the air, she told him that he was hurting her hip, so he stopped and ejaculated on her left thigh. The Resident was observed crying, pseudo seizures on and off. Moral support provided to resident. The ADON RN D conducted an exam and there was no bruising, redness, swelling, or bleeding noted, and she was able to move all extremities. The MD was notified, police, and EMT initially. Resident notified her family member herself. She said Resident #2 was placed on 1 on 1 by the ADM. Law enforcement arrived and resident was transported to hospital for a consented the SANE exam. In an interview with the ADM on 10/20/23 at 9:40 AM revealed he received a call from Resident #1's family member around on 10/19/23 at 12:20 PM stating that she called and reported Resident #2 had raped her. The ADM said he and the ADON went immediately to ensure resident safety. Resident #2 was standing in the hall outside the door. The ADM then placed Resident #2 on 1 on 1 supervision with RN D while he spoke with Resident #1. The ADM said Resident #1 reported she and her boyfriend (Resident #2) had a sexual encounter today with Resident #1. She said the resident tried to have oral sex with her, and then he pulled her leg up in the air. Resident #1 said he was hurting her and asked Resident #2 to stop. The ADM said Resident #2 said he stopped when she made the request and ejaculated on her thigh. The ADM said Resident #2 admit-ted to having consensual sex with Resident #1. The ADM said the resident had no more information, so the interview ended, Resident #1 was placed on 1-on-1 monitoring immediately with RN D. Police were notified. Resident was interviewed by law enforcement, then released from supervision after LE reported that based on his interviews and investigation he would not be making an arrest. He said the report would be available in 10 business days and provided the report # and his badge number. In an interview with VA on 10/21/23 at 11:38 AM revealed she was the victims advocate that met with Resident #1 on 10/19/23. Resident #1 reported that her boyfriend came to the nursing home and sexually assaulted her in her room. VA said Resident #1 refused the sane exam 2 times as she was very emotional and crying. The SANE nurse was notified and would attempt again later. Resident was provided and advocate so she would not be alone. VA provided contact information for the SANE nurse to be contacted. In an interview with hospital the SANE RN J on 10/24/23 at 4:03 PM, she said a forensic exam was conducted on 10/20/23 at 10:12 AM on Resident #1. Resident #1 told the SANE nurse P that they were kissing, and he was pressing down on her and put his penis in her mouth. She said the notes stated that they were making out and proceeded to pull down her pants, fondled her breast and her vagina with his finger, attempted to insert his penis, when she said no, and it felt like he ejaculated on her vagina. Resident #1 said he Resident #2 did not penetrate her vagina with his penis. After ejaculating he went into the restroom, and she called a family member to report she was raped because she was afraid. Resident #1 consented to a physical exam that yield no injuries; however, she refused the speculum exam (tool used to investigate body orifices (an opening or tube, in body). She said evidence was collected and sent to crime lab. The SANE exam does not confirm or deny sexual assault, the victim reports what occurred and the nurse documents. In an interview with SANE RN-P on 10/25/23 at 11:09 AM revealed Resident # 1 presented to ER on [DATE] at 1:05 PM with chief complaints of chronic hip pain and sexual assault. Resident #1 refused sexual exam examination upon arriving on 10/19/23, as she was crying and very and yelling that she wanted to be left alone. would not consent to exam. The SANE RN-P said Resident #1 agreed to sexual assault exam kit on mid-morning. Resident #1 was examined with a rape kit, physical and with labs and swabs. Due to pain and distress with the speculum exam she refused after attempts were made. 10/20/23 agreed to sexual assault ex-am without a speculum. All evidence was collected in the sexual assault kit and sent to the crime lab. Resident #1 reported that she was in her room at the facility feeling sick when Resident #2 entered and proceeded to kiss all over her face and hair. Resident #1. She said Resident #2 was her like her best friend. She told Resident #2 don't touch me. Resident #2 put his penis in her mouth. Resident #2 removed penis from her mouth, removed her pants, and climbed top of her in bed trying to put his penis inside of her vagina. She said no! Resident #1 said Resident #2 pulled back his penis and ejaculated on outside of her vagina. Resident #1 said he did not penetrate the vagina. She said she tried to fight but she had no energy. She yelled for help, but no one heard. Resident #1 called FM-D and Resident #2 told him she had a mental health outburst. SANE RN P conducted the sexual exam kit and crime lab determines the conclusion of rape. She said based on her professional rape assault experience, Resident #1's behaviors, labs, and physical exam was consistent with sexual assault. In an interview on 10/24/23 at 4:09 PM, with LE revealed Resident # 1 stated that she and Resident #2 had been dating for 3 months. On 10/19/23 Resident #2 entered her room, they were making out kissing and rubbing became more aggressive. Resident #2 pulled his penis out, and she performed oral sex on him. Resident #1 reported that she consented to the oral sex. As Resident #2 started to undress her, she said no, and he stopped and ejaculated on her foot. LE said when Resident #2 complied when she withdrew consent it was not a sexual assault/rape. LE consulted with a sex crimes investigator with findings from his interviews with the residents and staff and concluded that the interaction was consensual. He did not collect any evidence be-cause the nurse cleaned a clear sticky substance off the resident's leg with a chemical wipe, therefore, damaging the evidence. LE said Resident #2 confirmed that he and Resident #1 had been in a relationship for 3 months, and he denied any sexual encounter with Resident #1 today and in the 3 months period. Record review of the online LE Report on 10/25/23 at 7:30 AM. Resulted in a report with demographics of Resident #1 and unlawful sexual assault. There was no documentation in the summary section addressing the incident Status (empty) .victim summary (empty) .Resident #1 demographics. In an attempted follow-up interview with LE on 10/25/23 at 8:05 AM to confirm the time of the incident on the online report was initiated and a detailed message to return surveyors call. On 10/20//23 at 6:45 PM, the ADM was notified an Immediate Jeopardy Situation and an IJ template was provided. The facility's Plan of Removal was accepted on 10/21/23 at 12:2 PM and included: Plan to remove immediate jeopardy. Facility failed to properly monitor and supervise resident relationships and interactions that resulted in an incident of unwanted sexual misconduct that led up to allegations of sexual assault. F689 On 10/20/2023 the ADM and the ADON notifies Medical Director of immediate jeopardy. On 10/20/2023 Resident #2 was assessed by the ADON and the ADM. Resident #2 denies any desire to be with other residents in the facility and no inappropriate sexual behavior was noted toward other residents or staff, Medical Director and Responsible Party updated. Behavioral services evaluated patient for any signs or symptoms of inappropriate sexual behaviors or desire to have sex with any other residents in the facility - no findings. Resident #2 will be seen by psychiatric/counseling services weekly x 4 weeks and if stable, will have visits as needed after this. Resident #2 is alert and oriented x 3 without behavioral disturbances. Resident was educated by the ADM to notify staff if he has any desire to start consensual relationships with other residents and verbalized understanding importance to respect other resident's rights. This was completed on 10/20/23. One on one supervision was initiated at the time of the allegation and restarted again on 10/20/23 at 6pm. Will continue with one-on-one monitoring for 72 hours to ascertain if there is a pattern of behaviors. If no behavioral disturbance patterns are observed, IDT team will discuss with Medical Director to discharge on e on one supervision. IDT will continue to monitor this resident and any other resident for behavioral disturbances with daily rounds. The ADM will oversight this task completion. On 10/20/2023 all residents in the facilities were assessed by the Assistant Director of Nursing/Designee for any allegations unwanted sexual misconduct or sexual assault. Four other residents were identified to be in consensual relationships without allegations of unwanted sexual behaviors or not feeling safe, plan of care reviewed and is appropriate. All residents feel safe, and no allegations were reported or identified, findings were communicated to the Medical Director. On 10/20/2023 the RDO completed 1:1 in-service on Abuse/Neglect, including unwanted sexual misconduct, and appropriate interventions with the ADM and the Assistant Director of Nursing. Starting on 10/20/2023 the ADM/Designee will initiate in-services with staff on prevention of abuse and neglect, including unwanted sexual misconduct, and reporting to Abuse Coordinator (ADM). All staff, including new hire, PRN, and Agency will be in-service prior to start work. The ADM will oversight this completion by 10/21/2023. Ad-Hoc QAPI meeting was held on 10/20/2023, with the Medical Director, NHA (Nursing Home ADM), RDO (Regional Director of Operations), RNC (Regional Nurse Consultant), and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. Starting on 10/20/2023, IDT (Interdisciplinary team), including the ADM, the Assistant the Director of Nursing, and the MDS Coordinator will review any allegations or sexual behaviors daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if sexual relationships is consensual, timely notification of any allegations or grievances, timely investigation and reporting allegation of abuse timely. The findings will be immediately brought up to the ADM for further action, if necessary. On 10/20/2023 the RDO (Regional Director of Operations) will start reviewing grievance log and IDT notes for any identified sexual relationships between residents for validation of thorough review of consensual relationships, person-centered plan of care for both involved parties, safety and mental wellbeing, timely identification of allegation of abuse weekly for four (4) weeks followed by monthly x 2 months. 10/20/2023 the RDO will provide physical oversight at facility weekly x4 weeks and then monthly x 2 months. The ADM/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks. This was initiated on 10/20/2023. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The ADM will be responsible for ensuring this plan is completed on 10/20/2023. The RDO will provide oversight of the ADM to ensure that the items on the plan of removal are reviewed and completed. Monitoring plan of Removal continued and included interviews with staff on both day and night shifts. In an interview with the ADM and the ADON on 10/21/23 at 3:30 PM revealed they had completed training and in-servicing of all staff on 1:1 supervision of Resident #2, Abuse/Neglect, including unwanted sexual misconduct, and appropriate interventions with the ADM and the Assistant Director of Nursing. That would include inquiring if the resident felt safe in the relationship, notifying ADM and nurse of consensual and non-consensual interactions to be further assessed and educated on relationships. The ADM stated staff were asked to give examples of interactions, for example, if a resident was touching another resident leg affectionately, intervene and ask the receiving resident if they agreed to the interactions. The ADON stated staff that were not at work were contacted via phone for education. The ADON stated it was her expectation for staff to report resident relationships as well as observe and report concerns to the abuse coordinator immediately to assess safety of the relationships. She said the ADM starting on 10/20/2023 the ADM/Designee will initiate in-services with staff on prevention of abuse and neglect, including unwanted sexual misconduct, and reporting to Abuse Coordinator Interview on 10/21/23 at 2:56 PM RN A stated she received training on 10/20/23 at 4:00 PM. The training reviewed abuse and neglect again, reporting, what to report: abuse, neglected financial, sexual. If the resident feels any unwanted or undesired touching statements report to the administration. She stated the aides and residents were educated to report to the nurse. Interview on 10/21/23 at3:03 PM the HSK attended training today about 8 am, The HSK stated when they saw resident PDA ask the resident if they are comfortable and notify the ADM immediately to assess for safety. Interview on 10/21/23 at 3:07 PM with the DC stated that she does know the residents and they were in a relationship. No reports of sexual. DC stated that she learned in the training to monitor physical resident interactions and confirm consensual interactions for safety and report to administrator resident relationships. Interviews on 10/21/23 at 3:24 PM CNA M stated she attended in-services 10/21/23 at 10:00 AM on abuse and neglect. She said she was to communicate with the residents and make sure they feel safe in the relation-ship and report abuse and neglect to the abuse coordinator when observed and communicating all forms of abuse and sexual misconduct. She said if the ADM was not available report to designee or the ADON. Interviews on 10/21/23 at 3:19 PM AD revealed she had been in-serviced by the ADM on abuse, neglect, and sexual incidents or touching of residents. If a resident reported that contact was not consensual, fear, or further concerns, notify the ADM or designee, separate residents and remain with residents until the ADM arrive to take over. Interviews on 10/21/23 at 3:48 PM with CNA A revealed he attended an in-service on 10/21/23 at 2:30 PM today. The training reflected information on reporting abuse, neglect, and sexual harassment and touching. He said all concerns with relationships or touching and interactions the ADM should be notified immediately. Interviews on 10/21/23 at 3:52 PM revealed he CNA J (agency staff) was in-serviced today at 2:45 PM and was educated about reporting abuse, neglect, sexual abuse, and harassment. Observe residents and engage in a conversation to determine that both

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview and record review the facility failed to ensure the rights to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 had his communication device when he was temporarily transferred to another room. While in the room Resident#1 yelled for help, and Resident #1 was sexually assaulted. An Immediate Jeopardy (IJ) situation was identified on 08/23/23. While the IJ was removed on 8/24/2023 at 1:54 AM, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for psychosocial and physical harm. The findings were: A record review of Resident #1's Continuity of Care Document, dated 08/24/23, revealed a [AGE] year-old male. Resident #1 was admitted to the facility on [DATE]. His diagnoses included Amyotrophic lateral sclerosis (a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord), Atelectasis (the collapse of part or all of a lung), and Quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down). A record review of Resident #1's Quarterly MDS, dated [DATE], reflected a BIMS of 15, which indicated he was cognitively intact. Resident #1 was totally dependent on staff to help with activities of daily living. Resident #1's walk-in room and walk-in corridor did not occur. Record review of Resident #1's care plan, last edited 07/18/23, revealed the resident required extensive total staff assistance. Resident #1 had impaired expressive or receptive communication related to Amyotrophic lateral sclerosis (ALS). Resident #1 will have his communication device with him at all times to communicate effectively with staff and others . A record review of Resident #1's progress note, dated 08/21/23 at 4:05 PM, reflected (Resident #1) stated he was in a temporary room and was inappropriately touched by his roommate. The resident was interviewed about the incident via the communication device. Resident #1 stated he felt safe at the time of the interview. Resident #1 stated he was not physically hurt, but was emotionally hurt. The resident was offered counseling and psychiatric services. The resident denied wanting the services, completed by a sister facility administrator. An observation and interview on 08/22/23 at 9:34 AM with Resident#1's RP, revealed Resident #1 had used his communication device on 08/21/23 to inform her via text message, Resident#1 was moved to another room and was molested by another resident. An observation of the RP's cellular phone reflected the message was received at 1:09 p.m. on 08/21/23. Resident #1 revealed he was okay following the attack. However, the male resident had tried to jack me off and rubbing on my thigh. An interview with LVN A on 08/22/23 at 10:04 AM revealed she was the primary nurse for Resident #1 on 08/21/23. Resident #1 was placed in another room after the wound care nurse requested Resident #1 be placed in a bed. Resident #1 did not have a bed inside of his room, per the resident and family's request. Resident #1 stayed in his electric wheelchair. Resident #1 was taken into another room with a resident and placed into a bed. Resident #1 was placed into the bed, however, his communication device was not included in the temporary room change. Resident #1 was taken into the room by CNA B. After the assessment from the wound care physician, she was informed the resident needed to be moved back to his room because the assessment was complete. LVN A revealed she did not know how long Resident #1 was left alone in the room. LVN A revealed there was no reason why Resident #1 was placed in the room with another resident, instead of any other room with a bed. An observation and interview with the Scheduler/CNA C on 08/22/23 at 10:28 AM revealed she received a text message on 08/21/23 at 12:16 PM from Resident #1. An observation of the text messages provided by the Scheduler/CNA C revealed (Resident #1) when he was in the room after the doctor came and looked at his back. The male resident in the room came over and started messing with his catheter bag, and then started pulling on the tube. The resident pulled on his right leg, thigh and rubbed on his penis. After she received the text message she went down to the Resident #1 room. Resident #1 had returned to his original room. Resident #1 was being interviewed by several unknown management staff members about the incident. He did not have his communication device while in the temporary room. An interview with CNA B on 08/22/23 at 11:09 AM revealed she was the assigned aide for Resident #1 on 08/21/23. CNA B revealed she had temporarily moved Resident #1 into another room, following the request from the wound treatment nurse. CNA B stated Resident #1 was taken into another room without his communication device . CNA B stated without his communication device, it was impossible to understand or communicate with Resident #1. She was alerted by a nurse on 08/21/23 that the resident had been sexually assaulted by the resident in the temporary room. When she entered the room, she noticed Resident #1 condom catheter was lying on the floor. An interview or communication on 08/22/23 at 1:49 PM with Resident #1 using a communication device, Resident #1 communicated he was sexually assaulted by the resident in the room . An aide entered the room as he was being assaulted, however, because he didn't have his communication device he was unable to tell what happened. An interview with CNA R on 08/22/23 at 2:28 PM revealed she entered the room on 08/21/23 with Resident #1 and the temporary roommate to retrieve a Hoyer lift. Upon entering the room, she saw the roommate at the foot of Resident #1 bed, rolling back to his side of the bed. Resident #1 was trying to mumble something however she could not understand the resident because he did not have his communication device. She left the room and informed a nurse. An interview with the COO on 08/22/23 at 2:41 PM was revealed at the time of the incident, the facility did not have a DON or Administrator. The sister facility administrator was called to interview Resident #1 following the incident. The COO revealed the facility did not have a policy for ensuring residents always had their communication devices. However, the staff had been educated on 08/21/23 regarding that matter. This was determined to be an Immediate Jeopardy (IJ) on 08/22/23 at 9:00 p.m. The COO was notified. The COO was provided with the IJ template on 08/23/23 at 3:36 PM. The following Plan of Removal submitted by the facility was accepted on 08/24/23 at 1:54 PM: Immediate Action taken On 8/23/2023 the COO (Chief Operation Officer) notified Medical Director of immediate jeopardy. On 8/23/2023 The Regional Quality Consultant, RN/Designee assessed Resident #1 for any changes in condition - no findings noted, MD notified, and the Responsible Party updated on the patient's stable condition. On 8/23/2023 the Regional Quality Nurse/Designee completed Safe Surveys with all residents in the facility for any s/s of abuse and any other residents to utilize communication devices. No residents had any concerns or grievances regarding the identified citation. All residents in the facility were negative for s/s of abuse during the Safe Survey, The Medical Director updated on the Safe Survey results and plan of care for residents in the facility who utilize communication devices. Three other residents identified to have communication deficits were assessed by RQC RN/Designee on 8/23/2023 for any changes in condition and the plan of care was reviewed to make sure appropriate interventions were in place for communication, including communication devices if appropriate and monitoring for any changes in condition. Speech therapy assessed all residents and interventions in place. On 8/23/2023 the COO completed 1:1 in-service on abuse prevention and residents who utilize communication devices, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the resident's goals and preferences with IDT (intra-disciplinary team), which includes Assistance Director of Nursing, MDS Coordinator, Business Office Director, RDO, RQC, Activity Director, HR , and Maintenance Director. Starting on 8/23/2023 the Regional Quality Consultant/Designee will initiate in-service with staff on abuse prevention and communication with residents who utilize communication devices, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences. The training was initiated on 8/23/2023 and will be completed on 8/23/2023. Staff will not be allowed to work until they receive training. Ad-Hoc QAPI meeting was held on 8/23/2023, with the Medical Director, COO, RDO (Regional Director of Operations), Regional Quality Consultant, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policies about Abuse/neglect and communication were reviewed on 8/23/2023 by the COO, RQC, and Medical Director. Starting on 8/23/2023, IDT (Interdisciplinary team), including the Assistant Director of Nursing, MDS Coordinator, Business Office Director, HR, and Activity Director will meet with all residents daily Monday to Friday, and the Manager on Duty Saturday and Sunday to determine if any allegations of abuse arise and any residents with communication devices have changes in condition, including review of new admissions who utilize communication devices for 4 weeks, then PRN . The findings will be brought up to the RDO for further action within 24 hours if necessary. Grievances and new admissions who need communication devices will be reviewed during the morning meetings with RDO and IDT team members for any follow-up needed starting 8/23/2023 as an on-going process. On 8/23/2023 the RDO will start reviewing the Grievance log, new admissions with the need for communication devices and plan of care, and investigation forms weekly for four (4) weeks followed by monthly reviews after this will be ongoing. The RDO/designee will monitor compliance by completing an audit of ten (5) residents per week for four (4) weeks. This was initiated on 8/23/2023. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The RDO will be responsible for ensuring this plan is completed on 8/23/2023. The COO will provide oversight of RDO to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the POR included the following: Interviews with staff members on 08/24/23 from 12:15 PM to 2:30 PM with LVN A. CNA B, CNA C, CNA E, LVN F, RN G, LVN H. who worked different shifts at the facility (6 AM-6 PM or 6 PM to 6 AM). The staff members revealed they had received education regarding making sure residents were provided with their communication devices at all times . An interview with the COO on 08/24/23 at 2:41 p.m. revealed she completed 1:1 education with CNA B regarding ensuring residents were provided with their communication devices. On 08/23/23 an Ad-Hoc QAPI meeting, with the Medical Director, COO, RDO (Regional Director of Operations), Regional Quality Consultant, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. Record review of In-service education revealed all staff members were educated on 08/22/23 regarding ensuring residents with communication devices had them at all times. Record reviews of safe surveys were completed starting on 08/22/23 with residents of the facility. No resident reported any issues with not having their device. The COO was informed the Immediate Jeopardy was removed on 08/24/23 at 2:47 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 5 residents (Resident #1 ) reviewed for abuse and neglect. The facility failed to ensure Resident #1 was not sexually assaulted by Resident #2 when he was temporarily relocated to another room. An Immediate Jeopardy (IJ) situation was identified on 08/23/23. While the IJ was removed on 8/24/2023 at 1:54 AM, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings include: A record review of Resident #1's Continuity of Care Document dated 08/24/23 revealed a [AGE] year-old male. Resident #1 was admitted to the facility on [DATE]. His diagnoses included Amyotrophic lateral sclerosis (a progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord), Atelectasis (the collapse of part or all of a lung), and Quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down). A record review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS of 15, indicating cognitively intact. Resident #1 was totally dependent on staff to help with activities of daily living. Resident #1's walk-in room and walk-in corridor did not occur. Record Review of Resident #1's care plan last edited 07/18/23 revealed the resident required extensive total staff assistance. Resident #1 had impaired expressive or receptive communication related to Amyotrophic lateral sclerosis (ALS). Resident #1 will have his communication device with him at all times to communicate effectively with staff and others. A record Review of Resident #1's progress note dated 08/21/23 at 4:05 pm reflected [Resident #1] states he was in a temporary room and was inappropriately touched by his roommate. A resident was interviewed about the incident via the communication device. Resident #1 stated he felt safe at the time of the interview. Resident stated he was not physically hurt, but was emotionally hurt. The resident was offered counseling and psychiatric service, resident denied wanting the services, completed by a sister facility administrator. A record review of Resident #2's Continuity of Care Document dated 08/23/23 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included Parkinson Disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), Cognitive Communication deficit (difficulty with thinking and how someone uses language), and Dysphagia (swallowing difficulties). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed a BIMS of 14, which indicated the resident was cognitively intact. Resident #2 required limited assistance of one person with activities of daily living. A record review of Resident #2 care plan with the problem date of 04/27/2022, revealed Resident #2 had behavioral symptoms. Resident #2 behavioral problems related to the potential for self-harm due to the resident potentially inserting clothes hangers into the perineal area or rectum. The facility approach included intervening as needed to protect the rights and safety of others. Remove from the situation and take to another location as needed. Resident #2 was witnessed by staff watching porn on his phone. A record review of an event report dated 08/21/23 at 2:00 PM, for Resident #2 revealed Reported by a temporary roommate that resident sexually inappropriate touched him. Resident denies touching roommate. Moved the roommate out of the room immediately. Notified the physician, family, and management, New orders for psych evaluation. Completed by LVN A. An interview with LVN A on 08/22/23 at 10:04 AM revealed she was the primary nurse for Resident #1 on 08/21/23. Resident #1 was placed in another room after the wound care nurse requested Resident #1 be placed in a bed. Resident #1 did not have a bed inside of his room, per the resident and family's request. Resident #1 stayed in his electric wheelchair. Resident #1 was taken into another room with a resident and placed into a bed. Resident #1 was placed into the bed, however, his communication device was included in the temporary room change. Resident #1 was taken into the room by CNA B. After the assessment from the wound care physician, she informed the resident needed to be moved back to his room because the assessment was complete. LVN A revealed she did not know how long Resident #1 was left alone in the room. LVN A revealed there was no reason why Resident #1 was placed in the room with another resident, instead of any other room with a bed. When she entered the room Resident #1's condom catheter was on the floor. Resident #1 did not have the ability to remove the catheter. An observation and interview with the Scheduler/CNA C on 08/22/23 at 10:28 AM revealed she received a text message on 08/21/23 at 12:16 PM from Resident #1. An observation of the text messages provided by the Scheduler/CNA C revealed (Resident #1) when he was in the room after the doctor came and looked at his back. The male resident in the room came over and started messing with his catheter bag, and then started pulling on the tube. The resident pulled on his right leg, thigh and rubbed on his penis. After she received the text message she went down to Resident #1's room. Resident #1 had returned to his original room. Resident #1 was being interviewed by several unknown management staff members about the incident. He did not have his communication device while in the temporary room. She heard Resident #2 would touch himself inappropriately, however, she had not seen any evidence of the behavior. An interview with CNA B on 08/22/23 at 11:09 AM revealed she was the assigned aide for Resident #1 on 08/21/23. CNA B revealed she had temporarily moved Resident #1 into another room, following the request from the wound treatment nurse. CNA B stated Resident #1 was taken into another room without his communication device . CNA B stated without his communication device, it was impossible to understand or communicate with Resident #1. She was alerted by a nurse on 08/21/23 that the resident had been sexually assaulted by Resident #2 in the temporary room. When she entered the room, she noticed Resident #1 condom catheter was lying on the floor . An interview or communication on 08/22/23 at 1:49 PM. with Resident #1 using a communication device. Resident #1 communicated he was sexually assaulted by the resident in the room. An aide entered the room as he was being assaulted, however, because he didn't have his communication device he was unable to tell what happened. An interview with CNA R on 08/22/23 at 2:28 PM revealed she entered the room on 08/21/23 with Resident #1 and Resident #2 to retrieve a Hoyer lift. Upon entering the room, she saw Resident #2 at the foot of Resident #1's bed, rolling back to his side of the bed. Resident #1 was trying to mumble something, however she could not understand the resident because he did not have his communication device. She left the room and informed LVN A. An interview with the Chief Operating Officer (COO) on 08/22/23 at 2:41 PM revealed at the time of the incident, the facility did not have a DON or Administrator. The sister facility administrator was called to interview Resident #1 following the incident. The COO revealed the facility did not have a policy for ensuring residents always had their communication devices. However, the staff had been educated on 08/21/23 regarding that matter. This was determined to be an Immediate Jeopardy (IJ) on 08/22/23 at 9:00 p.m. The COO was notified. The COO was provided with the IJ template on 08/23/23 at 3:36 PM . The following Plan of Removal submitted by the facility was accepted on 08/24/23 at 1:54 p.m. : Immediate Action taken On 8/23/2023 the COO (Chief Operation Officer) notified Medical Director of immediate jeopardy. On 8/23/2023 The Regional Quality Consultant, RN/Designee assessed Resident #1 for any changes in condition - no findings noted, MD notified, and Responsible Party updated on patient stable condition. On 8/23/2023 the Regional Quality Nurse/Designee completed Safe Surveys with all residents in the facility for any s/s of abuse. No residents had any concerns or grievances regarding the identified citation. All residents in the facility were negative for s/s of abuse during the Safe Survey, Medical Director updated on the Safe Surveys results. On 8/23/2023 the COO completed 1:1 in-service on abuse prevention, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences with IDT (intra-disciplinary team), which includes Assistance Director of Nursing, MDS Coordinator, Business Office Director, RDO (Regional Director of Operations), RQC (Regional Quality Consultant), Activity Director, HR, and Maintenance Director. Starting on 8/23/2023 the Regional Quality Consultant/Designee will initiate in-service with all staff on abuse prevention, to ensure that each resident receives the services consistent with the professional standards of practice, comprehensive person-centered care plan and the residents' goals and preferences. The training was initiated on 8/23/2023 and will be completed on 8/23/2023. Staff will not be allowed to work until they receive training. Ad-Hoc QAPI meeting was held on 8/23/2023, with the Medical Director, COO, RDO (Regional Director of Operations), Regional Quality Consultant, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policies pertaining to Abuse/neglect were reviewed on 8/23/2023 by the COO, RQC, and Medical Director. Starting on 8/23/2023, IDT (Interdisciplinary team), including Assistant Director of Nursing, MDS Coordinator, Business Office Director, HR, and Activity Director will meet with all residents daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any allegations of abuse arise for 4 weeks, then PRN . The findings will be brought up to the RDO for further action within 24 hours if necessary. Grievances will be reviewed during the morning meetings with RDO and IDT team members for any follow-up needed. All grievances will be entered into the Grievance log by RDO starting 8/23/2023 and the investigation form will be filled out by RDO accordingly as an on-going process. On 8/23/2023 the RDO will start reviewing the Grievance log and investigation forms weekly for four (4) weeks followed by monthly reviews after this will be ongoing. The RDO/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks. This was initiated on 8/23/2023. Any identified concern will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The RDO will be responsible for ensuring this plan is completed on 8/23/2023. The COO will provide oversight of RDO to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the POR included the following: Interviews with staff members on 08/24/23 from 12:15 pm to 2:30 pm with LVN A, CNA B,, CNA C, CNA E, LVN F. RN G, LVN H. who worked different shifts at the facility (6 am-6 pm or 6 pm to 6 am). The staff members revealed they received education regarding abuse. Staff were instructed to report any sexual behaviors to the nursing staff and abuse coordinator. An interview with the COO on 08/24/23 at 2:41 p.m. revealed she had completed 1:1 education with CNA B regarding ensuring residents were provided with their communication devices. On 08/23/23 an Ad-Hoc QAPI meeting, with the Medical Director, COO, RDO (Regional Director of Operations), Regional Quality Consultant, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. Record review of Inservice education revealed all staff members were educated on 08/22/23 abuse and neglect. Record reviews of safe surveys were completed starting on 08/22/23 with residents of the facility. No resident reported any issues with not having their device. The COO was informed the Immediate Jeopardy was removed on 08/24/23 at 2:47 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision for 1 (Resident #1) of 5 residents reviewed for accidents. The facility failed to supervise Resident #1 to prevent him from eloping from the facility, allowing him to walk out the front door undetected. The resident was missing for three days without his medications. This failure resulted in an identification of an Immediate Jeopardy on 07/17/23. While the IJ was removed on 07/18/23, the facility remained out of compliance at a Immediate Jeopardy and a scope identified as isolated due to the facility's need to completed in-services training and evaluate the effectiveness of the corrective system. This failure placed residents at risk of eloping, serious injury, hospitalization, or death. Findings included: Review of Resident #1's Face Sheet revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and discharged on 07/03/23. Resident #1 had diagnoses that included stroke affecting swallowing, high blood pressure, and diabetes. Review of Resident #1's MDS, dated [DATE], revealed he had a BIMS score of 8 indicating severe cognitive impairment. His Functional Status indicated he required minimal assistance with all of his ADLs except eating which required total dependence. The resident received nothing by mouth, all nutrition and medications were received via gastric tube. Review of Resident #1's EHR revealed on 07/03/23 his BIMS was recalculated to 13, indicating he was cognitively intact. Review of Resident #1's care plan, dated 06/13/23, revealed he was high risk for choking on food and drink, related to stroke. He was at risk for social isolation related to refusing to socialize, He was at risk for falls related to stroke. He had behavioral issues, refusing gastric tube feedings and demanding regular food. The care plan interventions were not available. Interview on 07/18/23 at 2:20 PM with CNA K revealed on 07/03/23 Resident #1 asked her to make his bed and get him some ice. CNA K stated the resident told her he was going to go out to the courtyard for a while. Around 8:00 PM, the resident was not in his room, and she asked LVN B if she had seen him. LVN B told her Resident #1 had gone out-on-pass. CNA K stated she checked the sign-out book and the resident was not signed out. On 07/05/23, CNA K stated when she came into work, she noticed Resident #1 was still not there. When she pulled up her list of residents, Resident #1 was still green and unassigned. She stated when residents were on leave, they were grayed out and you can't chart on them. She stated she asked LVN C if Resident #1 was on leave, and she said he was. CNA K stated she thought it was odd but let it go. Interview on 07/17/23 at 3:00 PM with the family member of Resident #1 stated she had been contacted on 07/06/23 by the Administrator asking her when Resident #1 would be returning to the facility. She informed the Administrator that Resident #1 was not with her or any family member. She was notified that the resident had left the faciity on the evening of 07/03/23 on pass with family. The family member stated the resident had not left the facility with family and was not with any family; his location was unknown. The family member stated she was able to make contact with Resident #1 on 07/07/23 and learned he was hiding from them at a friend's house because he did not want to go back. She stated he did not have his medications from the facility and had not taken his medications in the time he had been gone from the facility. Interview on 07/17/23 at 3:25 PM via phone with Resident #1 revealed he did not leave the facility on pass, did not leave with his family, did not take anything with him, including his medications, did not tell anyone he was leaving, and did not sign anything. He stated he waited until the office staff was gone for the day, called his friend to pick him up, and walked out the front door. Interview on 07/17/23 at 4:37 PM with the Administrator revealed she was made aware that Resident #1 was not in the facility during thier morning meeting, the ADON stated he had gone out on pass on 07/03/23 and had not returned. The Administrator contacted the family of Resident #1 to inquire as to when Resident #1 would return and was advised they had not taken him out of the facility, and he was not with any of the family; they did not know where he was. The Administrator stated staff had been under the assumption Resident #1 was out on leave, not that he had eloped. The Administrator stated she had interviewed the two nurses who worked on 07/03/23 and received conflicting stories. LVN B stated she had been told by LVN C that Resident #1 was going out-on-pass with his family. LVN C stated she had not told LVN B that Resident #1 was going out-on-pass; there was another resident that was going out-on-pass she had told her about. On 07/17/23 at 5:45 PM, the Administrator was notified an Immediate Jeopardy in the area of Quality of Care was identified. The facility's Plan of Removal was accepted on 07/18/23 at 1:26 PM and included: Plan to remove immediate jeopardy. The facility failed to ensure a resident was provided with adequate supervision to prevent a resident from leaving the facility. F689 On 7/17/2023 the Administrator and Director of Nurses notifies Medical Director of immediate jeopardy. On 7/17/2023 the head count of all residents currently residing in the facility was completed by the Administrator. All residents are present. Starting on 7/17/2023 the Director of Nursing/Designee will initiate in-service on adequate supervision to prevent a resident from leaving the facility, including policies on elopement/missing resident, resident out on pass, timely notification of RP/Family of residents who are on pass without his/her legal representative. Ad-Hoc QAPI meeting was held on 7/17/2023, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations), Director of Nursing, and Assistant Director of Nursing to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy. Starting on 7/17/2023, IDT (Interdisciplinary team), including Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator will review headcount of all residents residing in the facility daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any residents went out on pass, and if on pass with not his/her legal representative - timely notification was completed to his/her legal representative. The findings will be immediately brought up to the Administrator for further action, if necessary. Starting on 7/18/2023, The Administrator/designee will contact law enforcement any time a resident is known to be missing. On 7/18/2023 the RDO (Regional Director of Operations) will start reviewing leave of pass binder for any resident who left facility on pass for validation of timely notification of RP weekly for four (4) weeks followed by monthly x 2 months. 7/17/2023 RDO will provide physical oversight at facility weekly x4 weeks and then monthly x 2 months. The Administrator/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks who are at risk of Elopement and left on pass with or without RP, timely notification of RP if left without legal representative. This was initiated on 7/17/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. The Administrator will be responsible for ensuring this plan is completed on 7/17/2023. The DON was unavailable for interview during POR monitoring. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the Plan of Removal continued and included interviews with staff on both day and night shifts. Interview on 07/18/23 at 2:40 PM with the Administrator revealed their Social Worker quit on 07/17/23 and she was in the process of setting up interviews. She and the DON would cover her roles until a replacement could be found. Resident #3 had eloped on 06/22/23, he went out the front door and down the sidewalk. CNA had noted him outside when she was coming into work, and he was brought back inside. He did not leave the property. Lab work showed he had a UTI, he was started on antibiotics and was now back to his baseline. No previous elopement attempts by this resident. The alarm on the front door was replaced with the current loud alarm after Resident #1 eloped form the building. She stated Resident #1 was not reported to family or HHSC because the belief was that he was out on leave. It was not until he did not return after 48 hours that they became concerned. Any resident with decreased mental capacity is considered an elopement if they left the facility. Resident #1 had a BIMS of 13. Residents received an Elopement Risk evaluation on admission, quarterly, and with any significant change. Elopement risks evaluations were put in a binder that was located at each nurses' station and at the receptionist's desk. The receptionist's desk was not manned since pandemic restrictions were lifted. They had a bid to install a keypad lock on the front door, no date for completion had been set. Interview on 07/18/23 at 3:20 PM with LVN D revealed she had been in-serviced by the Administrator on elopement/missing residents, residents on pass, and timely reporting to the responsible party/family if a resident eloped. When sending a resident out-on-pass, they were to notify the Administrator or DON, provide medications needed and educate on when to take them, have the resident and whomever they were leaving with sign the sign-out book with an estimate of when they would return. Interview on 07/18//23 at 3:27 PM with CNA E revealed she had been in-serviced by the Administrator on elopement/missing residents and what to do if a resident eloped. If a resident was suspected of eloping, she was to report to the nurse immediately, search the facility and then the grounds for the resident. Interview on 07/1823 at 3:29 PM with CNA F revealed she had been in-serviced by the Administrator on elopement/missing residents. She knew to familiarize herself with the binder that had the high-risk residents in it and keep an eye on them. If a resident was missing to search the facility and then the grounds, report to the nurse if they were missing. Interview on 07/18/23 at 3:31 PM with CNA G revealed she had been in-serviced by the Administrator on elopement/missing residents, and residents on pass. She knew to look at the binder so she knew who the high risk residents were and to keep an eye on them. If a resident could not be located, they were supposed to check the facility and grounds immediately and help with the head count. Interview on 07/18/23 at 3:34 PM with the ADON O revealed she had been in-serviced by the Administrator on elopement/missing residents and residents on pass. She stated there was a binder with the high risk residents in it so they knew who to keep an eye out for. If a resident went out on pass, they were supposed to notify the DON. ADON O stated they were supposed to send any medications with the resident they might need, have them sign out with an estimate of when they would return, and create a note so everyone knew about the resident. Interview on 07/18/23 at 3:37 PM with MA H revealed she had been in-serviced by the Administrator about elopement, She knew to look at the binder for the high risk residents. If a resident was suspected of being missing, they were supposed to check the facility and grounds to locate them and notify the nurse if not found. Interview on 07/18/23 at 3:45 PM with LVN I revealed she had been in-serviced by the Administrator on missing residents and elopements. LVN I stated they were supposed to be aware of the high risk residents in the binder, search for anyone thought to be missing and notify the DON if not found. She stated the process of sending residents on pass was also covered. Interview on 07/18/23 at 3:50 PM with LVN J revealed she had been in-serviced by the Administrator on elopement and missing residents. If anyone was missing, they were supposed to check the premises and report to the DON if not located. If residents were leaving on pass, the residents needed to sign out with an ETA of their return. LVN J stated they were also supposed to send all medications with the resident that they would need. An Immediate Jeopardy was identified on 07/17/23. While the IJ was removed on 07/18/23, the facility remained out of compliance at a scope of isolated and a severity level of Immediate Threat because all staff had not been trained on elopement, residents on pass and timely reporting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 (Resident #1) of 5 residents reviewed for medication errors. The facility failed to ensure Resident #1's critical medications were sent with him and failed to notify the family that the resident left the facility without his medications when the facility believed Resident #1 had left on pass. An Immediate Jeopardy was identified on 08/01/23. While the IJ was removed on 08/02/23 the facility remained out of compliance at a scope of Isolated and a severity level of Immediate Threat because all staff had not been trained on sending medications with residents on pass. This failure led to Resident #1 being without his medications for three days and placed him at risk of a hypertensive crisis, diabetic ketoacidosis, hospitalization, or death. Findings included: Review of Resident #1's Face Sheet revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] and discharged on 07/03/23. Resident #1 had diagnoses that included stroke affecting swallowing, high blood pressure, and diabetes. Review of Resident #1's MDS, dated [DATE], revealed he had a BIMS score of 8 indicating severe cognitive impairment. His Functional Status indicated he required minimal assistance with all of his ADLs except eating which required total dependence. The resident received nothing by mouth, all nutrition and medications were received via gastric tube. Review of Resident #1's EHR revealed on 07/03/23 his BIMS was recalculated to 13, indicating he was cognitively intact. Review of Resident #1's care plan, dated 06/13/23, revealed he was high risk for choking on food and drink, related to stroke. He was at risk for social isolation related to refusing to socialize, He was at risk for falls related to stroke. He had behavioral issues, refusing gastric tube feedings and demanding regular food. Review of Resident #1's physician orders revealed he was prescribed Coreg and diltiazem for blood pressure control, Eliquis as a blood thinner for an irregular heart rhythm, and Insulin and Jardiance for his blood sugar control. Resident #1 required his blood glucose level to be checked before each meal and his insulin dosage was determined by his glucose levels. Interview on 08/01/23 at 8:00 AM with ADON O revealed she had noted Resident #1's medications were still in the cart on 07/5/23 but assumed he had been sent with everything he needed while he was on pass. She stated she had assumed the nurse had dispensed the number of pills he would need while on pass, and left the medication cards in the cart. Interview on 08/01/23 at 11:56 AM with LVN D revealed she had noticed Resident #1's medications were still in the cart on 07/06/23 which prompted her to call the family of Resident #1 to inquire about him having his medications; resulting in discovering he was not on pass but had eloped. Interview on 08/01/23 at 9:25 AM with the family member of Resident #1 revealed the resident left the facility without his medications, and he had not returned to the facility for his medications. She did not know how he managed his medical problems without his medications. She stated the facility assumed Resident #1 left the faciity on pass with his family on 07/03/23, when in fact, he had eloped with a friend. Resident #1 was not discovered to have eloped until 07/06/23 when she was contacted about his whereabouts. Interview on 08/01/23 at 12:04 PM with LVN B revealed she had noticed Resident #1's medication in the cart on 7/03/23, but had assumed LVN C sent the pills that Resident #1 would need while he was on pass. She stated she did not feel a need to contact the family to follow up. Interview on 08/01/23 at 10:50 AM with LVN L revealed the process of sending a resident out-on-pass included sending any medications they might need, along with them. Interview on 08/01/23 at 11:00 AM with LVN M revealed the process of sending a resident out-on-pass was to send their medications with them, usually the whole card of pills so they did not get lost, mixed up, etc If a resident's medications were still in the cart, when they were supposed to be out of the facility, the DON had to be contacted. Interview on 07/18/23 at 10:46 AM with the Physician revealed the initial concern for Resident #1 being without his medications was a seizure. The Physician sstated a person could start to have seizures after missing their medication for only one day. The next concern would be his blood pressure, being without his medication could cause his blood pressure to rise and possibly cause a hypertensive crisis (uncontrolled extremely high blood pressure). The final concern would be the resident's diabetes, not having his insulin could cause his blood sugar to rise and lead to diabetic ketoacidosis (diabetic coma). Review of the facility's Dispensing Medications to Residents on Leave/Pass policy, dated April 2007, reflected: .Policy Statement- The facility shall provide residents with necessary when they leave the facility temporarily. 1. Residents who are away from the facility during medication passes will be given scheduled and PRN medications to take with them. 2. The Charge nurse will provide verbal and written directions to the resident and/or the person signing out the resident regarding any dispensed medications. 3. The nursing staff will document the resident's absence from the facility on the resident's MAR if the resident is absent during one or more medication passes On 08/01/23 at 6:00 PM, the Regional Director of Operations was notified an Immediate Jeopardy, in the area of Pharmaceutical Services was identified. The facility's Plan of Removal was accepted on 08//02/23 at 1:24 PM and included: Plan to remove immediate jeopardy. The facility failed to ensure a resident was free of significant medication errors. The resident left the facility without medication from facility causing a significant medication error. This failure is likely to result in serious harm if immediate action is not taken to prevent residents out on pass have all prescribed medications. F760 On 8/1/2023 at 18:00 the Director of Nurses notified Medical Director of immediate jeopardy. On 8/1/2023 the head count of all residents currently residing in the facility was completed by the Director of Nursing. All residents are present. On 8/1/2023 Regional Nurse Consultant completed 1:1 in-service with Director of Nursing on Signing residents out with medication policy and procedure. Starting on 8/1/2023 the Director of Nursing/Designee will initiate in-service with licensed nurses on Signing Resident out with medications on 8/1/23. Ad-Hoc QAPI meeting was held on 8/1/2023, with the Medical Director, RDO (Regional Director of Operations), Regional Nurse Consultant (RNC), [NAME] President of Clinical Services (VPCS), Chief Operation Officer (COO), Director of Nursing, and Assistant Director of Nursing to review the alleged deficiency, policy and procedure, and the plan for removal of immediacy. Starting on 8/1/2023, IDT (Interdisciplinary team), including Director of Nursing, Assistant Director of Nursing, and MDS Coordinator will review headcount of all residents residing in the facility daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if any residents went out on pass with Medications, and if on pass with not his/her legal representative. The findings will be immediately brought up to the Director of Nursing for further action, if necessary. On 8/1/2023 the Director of Nursing will start reviewing out on pass binder for any resident who left facility on pass for validation of medications were given as needed while on pass. The audit will be completed weekly for four (4) weeks followed by monthly x 2 months. 8/1/2023 RDO will provide physical oversight at facility weekly x 4 weeks and then monthly x 2 months. The Regional Nurse Consultant (RNC) will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks who left on pass with or without medications. This was initiated on 8/2/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. The Director of Nursing will be responsible for ensuring this plan is completed on 8/1/2023. The RDO will provide oversight of Director of Nursing to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the Immediate Jeopardy continued with interviews of nursing staff and administration. Interview on 08/02/23 at 1:35 PM with LVN L revealed she had been in-serviced by the VP of Clinical Services on the process of sending residents out-on-pass, which included sending residents out-on-pass with their medications, and what to do if a resident's medications were still in the cart when they were out-on-pass. Interview on 08/02/23 at 1:40 PM with ADON P revealed she had been in-serviced by the VP of Clinical Services on the process of sending residents out-on-pass, which included sending their medications with them and what to do if a resident out-on-pass was discovered to have left their medications behind. Interview on 08/02/23 at 1:45 PM with RN N revealed she had been in-serviced by the VP of Clinical Services on the process of sending esidents out on pass. She stated all medications, including controlled substances, that the resident would need while out of the facility had to be sent with them along with directions on when and how to take them. All medications would be checked back in when they returned. During medication pass, if the medications for a resident out-on-pass were discovered still in the cart the DON was to be notified immediately. An Immediate Jeopardy was identified on 08/01/23. While the IJ was removed on 08/02/23 the facility remained out of compliance at a scope of Isolated and a severity level of Immediate Threat because all staff had not been trained on sending residents out on pass.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to immediately inform the physician and the resident's representative when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for one (Resident #1) of five residents reviewed for physician notification. The facility failed to ensure LVN A notified the physician when Resident #1 suffered a fall with injury that resulted in the resident developing a subdural hematoma which ultimately resulted in her death on [DATE]. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of and a severity level of Immediate Jeopardy because all staff had not been trained on change in condition, timely assessments, physician notification, and treatments based on physician orders. This failure placed residents at risk of a delay in treatment, and a worsening of their condition. Findings included: Review of Resident #1's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included stroke, dementia, difficulty swallowing, and difficulty speaking. Review of Resident #1's admission MDS assessment, dated [DATE] revealed her BIMS score was not calculated due to her medical condition. Her Functional Status indicated she required limited assistance with her ADLs, including walking on the unit. Review of Resident #1's care plan, dated [DATE], revealed she was at risk for falls related to previous history of falls, alteration in bleeding related to anticoagulant use, and stroke related to previous stroke. Review of facility's Accident & Injury report for [DATE] revealed Resident #1 had suffered two falls on [DATE] and was transported to the hospital on [DATE] with stroke-like symptoms. Review of nursing progress notes revealed LVN A documented a fall on [DATE] at 9:30 AM and again at 9:50 AM, both resulted in no injury to the resident. There was no documentation of notification made to the physician or the resident's representative. Review of nursing progress notes revealed LVN B documented on [DATE] at 10:00 AM Resident #1 was demonstrating stroke-like symptoms with a left facial droop, left-sided gaze, and a decrease in her level of responsiveness. Resident #1 was assessed by the ADON and the NP, and 911 was called. Review of Nurse Practitioner notes on [DATE] revealed he assessed the resident as Unlike her baseline, she is non-verbal and non-engaging. Physical examination remarkable for edema to the right face and upper lip concerning for fall. Review of the EMS report revealed they transported Resident #1 on [DATE] at 10:55 AM to the hospital. The Paramedic assessment revealed the resident had presence of facial droop and swelling to the right upper lip. Review of hospital records for Resident #1's admission, dated [DATE], revealed the ER physician documented swelling to right upper lip, laceration to the inner aspect of the lip, swelling to right cheek, and decreased responsiveness. Review of MRI results for Resident #1 revealed the resident had a hematoma to the back of her head, a left-sided subdural hematoma that was expanding and causing swelling in her brain. Interview on [DATE] at 2:20 PM with the family member of Resident #1 revealed they had not been informed of any events with Resident #1 until they were notified on [DATE] that the resident was being transported to the hospital with stroke-like symptoms. They stated Resident #1 had swelling to her right upper lip, right cheek, and the back of her head when they saw her in the ER. The resident was admitted to the hospital with bleeding and swelling of the brain. They were told there was nothing that could be done at that point to evacuate the bleeding from the brain as she would continue to bleed. The family opted to transfer her to hospice. The family member submitted three photos to the surveyor's phone revealing swelling to the right upper lip, bruising to the inner lip, and swelling to right cheek. A text message on [DATE] at 11:49 AM from the family member of Resident #1 stated the resident continued to deteriorate in hospice and had passed away on the evening of [DATE]. Interview on [DATE] at 12:00 PM LVN B stated Resident #1 would try to stand up from her wheelchair occasionally, but usually just moved around the unit using her feet to propel the wheelchair. LVN B stated her assessment of Resident #1's capabilities were that if she fell to the floor she would not be able to get herself up, making it unlikely that Resident #1 could have fallen without anyone knowing. LVN B stated she entered Resident #1's room on [DATE] around 10:00 AM to give her morning medications and she noted the resident was not responding to her and the resident had a left sided facial droop. She called the ADON and the NP to the bedside and they confirmed the resident appeared to be suffering a stroke. 911 was called and the resident was transported to the hospital. LVN B stated she thought there was swelling to the upper lip, but she was not sure because of the facial distortion caused by the facial droop. Interview on [DATE] at 1:00 PM CNA C stated on [DATE] at 9:30 AM she found Resident #1 face down on the floor in front of her wheelchair. She stated she called LVN A to the room, and they were able to get Resident #1 into her wheelchair again. She did not notice any swelling to the resident's face at that time. CNA C stated she was called back to the room at 9:50 AM by LVN A who stated Resident #1 had started to get up from her wheelchair, but she was able to grab her and lower the resident to the floor. Resident #1 was again lying face down on the floor. LVN A, CNA C and CNA D were able to get the resident into bed after the second fall. CNA C stated she noted swelling to the resident's upper lip, The three of them left Resident #1's room together and CNA C stated she did not see LVN A perform any type of assessment on the resident. CNA C stated Resident #1 remained in bed the rest of the shift, did not want lunch or dinner when they were offered; all of which was abnormal for Resident #1. Interview on [DATE] at 1:25 PM, via phone, LVN A stated Resident #1 had suffered no injury after both falls. Therefore there was not a reason to call the physician. LVN A stated she did a head-to -toe assessment and found no injury. She was sure the resident did not hit her head on the second fall because she had lowered the resident to the ground. She was not able to document the events immediately because the facility internet was down. LVN A returned the next afternoon to document the event. Interview on [DATE] at 2:25 PM via phone, LVN A again stated she had performed a head-to-toe assessment on Resident #1 after both falls and denied any injury. She denied seeing any swelling to the lip after the second fall. LVN A stated she started to do neuro checks on Resident #1 but did not follow through because she got busy. Interview on [DATE] at 2:45 PM CNA D stated she was called to Resident #1's room to help get her up after a fall. When she entered the room she noted the resident was face down on the floor. She stated she, CNA C and LVN A were able to get the resident up an into bed. CNA D stated there was swelling to Resident #1's upper lip and her right cheek was red. CNA D stated the three of them left the room together and she did not observe LVN-A assess the resident. CNA D had never worked with Resident #1 before so she was unable to state if the resident was acting normal. Interview on [DATE] at 3:35 PM the Administrator stated she had been made aware of Resident #1 being transported to the hospital with a stroke, and she was aware of the two falls the previous day but no one had reported any injuries to her. The Administrator stated she had been told the swelling to Resident #1's lip was likely due to her biting her lip during the night according to the ADON. She stated she felt there was no further action needed based on what she had been told. She stated she was aware of the requirement to report injuries to HHSC. Interview on [DATE] at 8:30 AM the Physician stated he was notified after Resident #1 had been sent to the hospital for stroke like symptoms. He had not been made aware of the swelling to the lip until the Administrator called him on [DATE]. He stated if he had been notified he would have advised the nurse to hold the resident's anticoagulation medications, monitor her neurological status for 24 hours and report any changes to him. The Physician stated had he be been made aware of Resident #1's injuries he would have deferred treatment to the hospice physician about transporting her to the hospital because there were no medications to reverse her anticoagulants and likely would not have altered the resident's outcome. On [DATE] at 10:30 AM the Administrator was notified that an Immediate Jeopardy in the area of Resident Rights. The facility submitted the following acceptable Plan of Removal on [DATE] at 3:03 PM: F580 - The facility failed to notify the physician of a change in condition after a resident fell and sustained injuries, which resulted in the resident sustaining a subdural hematoma and her subsequent death on [DATE]. On [DATE] the Administrator and Director of Nurses notifies Medical Director of immediate jeopardy. On [DATE] the Director of Nurses suspended Nurse who responded to the fall on [DATE] but didn't report any injury and failed to conduct a thorough assessment of neurological checks to assess the resident for injuries to include head trauma. On [DATE] all residents in the facility will be assessed by the Director of Nursing/Designee for any changes in condition. Any findings will be communicated to the Medical Director for further interventions. orders. Starting on [DATE] the Director of Nursing/Designee will initiate in-service with nurses on changes in condition, including timely assessment, physician notification, and treatment as ordered by physician. Ad-Hoc QAPI meeting was held on [DATE], with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations), Director of Nursing, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policy pertaining to Change in condition and timely reporting was reviewed on [DATE] by the NHA (Nursing Home Administrator), Director of Nursing, RDO (Regional Director of Operations), and Medical Director. Starting on [DATE], IDT (Interdisciplinary Team), including Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker will review any changes in condition and events daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if timely notification and assessment was completed due to changes in condition. The findings will be immediately brought up to Administrator for further action, if necessary. On [DATE] the RNC (Regional Nurse Consultant) will start reviewing Events/Changes in Condition for validation of thorough assessment and timely notification weekly for four (4) weeks followed by monthly x 2 months. On [DATE] RDO will provide physical oversight at facility weekly x 4 weeks and then monthly x 2 months. The Administrator/designee will monitor compliance by completing audit of ten (10) residents per week for four (4) weeks. This was initiated on [DATE]. Any identified concern will be addressed immediately and if trends and patters are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. Administrator will be responsible for ensuring this plan is completed on [DATE]. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the Plan of Removal continued and included interviews with staff on both day and night shifts. Interview on [DATE] at 6:00 AM with LVN E, she stated she had been in-serviced by the DON, covering falls, reporting of falls, and fall procedures. She stated she had to assess the resident for injuries before moving them. If the resident had any injuries she was to contact the physician and follow his orders. Interview on [DATE] at 6:10 AM with RN F, he stated he had been in-serviced by the DON at the beginning of his shift. The in-service covered falls, fall protocols, and notifications. In the event of a fall he would assess the resident for any injuries and notify the physician. If there was an obvious injury that would need to be treated at the hospital, he would call 911 and then notify the physician and DON. Interview on [DATE] at 6:18 AM with LVN G, she stated she had been in-serviced by the DON prior to starting her shift. The in-service covered falls, neglect, and fall protocols. She stated if a resident had a fall she would assess them before moving them to determine if there were any injuries. After rescuing the resident, she would notify the physician and see what his orders were. If neuro checks were ordered, they would continue for 72 hours. Interview on [DATE] at 9:20 AM with RN H she stated she had been in-serviced by the DON this morning. They covered abuse and neglect, fall prevention and reporting, and fall protocols. In the event of a fall, she is supposed to assess the resident for injuries and determine if they can be picked up off the floor safely. If there are obvious injuries that are not critical, she calls the physician and follows his orders. If there are critical injuries, they can call 911 prior to contacting the physician. Monitoring of neuro status is usually for 72 hours after the fall to monitor for any changes in condition. Interview on [DATE] at 9:30 AM with RN I, she stated she had been in-serviced by the DON yesterday. The in-service covered reporting falls, documentation of falls, and post-fall procedures. In the event of a resident fall she is to notify the DON and the physician once she has assessed the resident for injuries. After contacting the physician, she would follow his orders, including starting neuro checks. She reports the incident to the on-coming shift via verbal report as well as the 24-hour log. Interview on [DATE] at 9:42 AM with RN J, she was in-serviced by the DON yesterday. The In-service covered abuse, neglect, and exploitation and falls. In the event of a resident falling, she will assess them for any injuries before getting them off the floor. Un-witnessed falls and falls with injuries have to be reported to DON and physician. Review of facility Ad-Hoc QAPI meeting agenda, held on [DATE], had the Administrator; the DON; the Medical Director; the ADON; and the RDO in attendance. Review of residents assessed by the DON and ADON for changes in condition revealed all 62 residents had been assessed, with one resident found with a change in condition related to abnormal labs and the physician had been contacted. Resident was sent to the hospital for abnormal lab. An Immediate Jeopardy (IJ) was identified on [DATE] at 10:30 AM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems/ plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review. the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #1) of five residents reviewed for quality of care. The facility failed to ensure LVN A performed an assessment of Resident #1 after she suffered two falls that resulted in in the resident developing a subdural hematoma, resulting in the resident dying on 06/05/23. An IJ was identified on 06/07/23. While the IJ was removed on 06/08/23, the facility remained out of compliance at a scope of Isolated and a severity level of actual harm because all staff had not been trained on change in condition, timely assessments, physician notification, and treatments based on physician orders. This failure placed the resident at risk of an unreported injury and worsening of her condition. Findings included: Review of Resident #1's admission Record revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included stroke, dementia, difficulty swallowing, and difficulty speaking. Review of Resident #1's admission MDS assessment, dated 02/28/23 revealed her BIMS score was not calculated due to her medical condition. Her Functional Status indicated she required limited assistance with her ADLs, including walking on the unit. Review of Resident #1's care plan, dated 04/22/23, revealed she was at risk for falls related to previous history of falls, alteration in bleeding related to anticoagulant use, and stroke relate to previous stroke. Review of facility's Accident & Injury report for May 2023 revealed Resident #1 had suffered two falls on 05/21/23 and was transported to the hospital on [DATE] with stroke like symptoms. Review of nursing progress notes revealed LVN A documented a fall on 05/21/23 at 9:30 AM and again at 9:50 AM, both resulted in no injury to the resident. There was no documentation of notification made to the physician or the resident's representative. Review of nursing progress notes revealed LVN B documented on 05/22/23 at 10:00 AM Resident #1 was demonstrating stroke like symptoms with a left facial droop, left sided gaze, and decrease in level of responsiveness. Resident was assessed by the ADON and the NP, and 911 was called. Review of Nurse Practitioner notes on 05/22/23 revealed he assessed the resident as Unlike her baseline, she is non-verbal and non-engaging. Physical examination remarkable for edema to the right face and upper lip concerning for fall. Review of EMS report revealed they transported Resident #1 on 05/22/23 at 10:55 AM to the hospital. Paramedic assessment revealed presence of facial droop and swelling to the right upper lip. Review of hospital records for Resident #1's admission revealed the ER physician documented swelling to right upper lip, laceration to the inner aspect of the lip, swelling to right cheek, and decreased responsiveness. Review of MRI results for Resident #1 revealed the resident had a hematoma to the back of her head, a left sided subdural hematoma that was expanding and causing swelling in the brain. Interview on 06/05/23 at 2:20 PM with the family member of Resident #1 stated they had not been informed of any events with Resident #1 until they were notified on 05/22/23 that the resident was being transported to the hospital with stroke like symptoms. They stated Resident #1 had swelling to her right upper lip, right cheek, and the back of her head when they saw her in the ER. The resident was admitted to the hospital with bleeding and swelling of the brain. They were told there was nothing that could be done at that point to evacuate the bleeding from the brain as she would continue to bleed. The family opted to transfer her to hospice. The family member submitted three photos to the surveyor's phone revealing swelling to the right upper lip, bruising to the inner lip, and swelling to right cheek. A text message on 06/06/23 at 11:49 AM from the family member of Resident #1 stated the resident continued to deteriorate in hospice and had passed away on the evening of 06/05/23. Interview on 06/06/23 at 1:25 PM, via phone, LVN A stated Resident #1 had suffered no injury after both falls, therefor there was not a reason to call the physician. LVN A stated she did a head-to -toe assessment and found no injury. She was sure the resident did not hit her head on the second fall because she had lowered the resident to the ground. Follow up interview on 06/06/23 at 2:25 PM via phone, LVN A again stated she had performed a head-to-toe assessment on Resident #1 after both falls and denied any injury. She denied seeing any swelling to the lip after the second fall. LVN A stated she started to do neuro checks on Resident #1 but did not follow through because she got busy. On 06/07/23 at 10:30 AM the Administrator was notified that an Immediate Jeopardy, Immediate Threat, and Substandard Quality of Care in the areas of Resident Rights and Facility Practice and Resident Behavior. The facility submitted the following acceptable Plan of Removal on 06/07/23 at 3:03 PM: On 06/07/20223 the Administrator and Director of Nurses notifies Medical Director of immediate jeopardy. On 06/07/2023 the Director of Nurses suspended Nurse who responded to the fall on 05/21/22023 but didn't report any injury and failed to conduct a thorough assessment of neurological checks to assess the resident for injuries to include head trauma. On 06/07/2023 all residents in the facility will be assessed by the Director of Nursing/Designee for any changes in condition. Any findings will be communicated to the Medical Director for further interventions. orders. Starting on 06/07/2023 the Director of Nursing/Designee will initiate in-service with nurses on changes in condition, including timely assessment, to include neurological checks and physician notification, for changes of condition or serious injury following a fall to prevent serious injury, harm, impairment or death. On 6/7/2023 the RDO completed 1:1 in-service on Abuse/Neglect, investigation of any allegations, timely reporting, and appropriate interventions with Administratoor, Director of Nursing, Social Worker, and Assistant Director of Nursing. Ad-Hoc QAPI meeting was held on 06/07/2023, with the Medical Director, NHA (Nursing Home Administrator), RDO (Regional Director of Operations), Director of Nursing, and Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan for removal of immediacy. The policy pertaining to Abuse/Neglect, change in condition, fall management, and Timely reporting was reviewed on 6/7/2023 by the NHA (Nursing Home Administrator), Director of Nursing, RDO (Regional Director of Operations), and Medical Director. Starting on 6/7/2023, IDT (Interdisciplinary Team), including Administrator, Director of Nursing, Assistant Director of Nursing, MDS Coordinator, Social Worker will review any changes in condition and events daily Monday to Friday, and Manager on Duty Saturday and Sunday to determine if timely notification and assessment was completed due to changes in condition. The findings will be immediately brought up to Administrator for further action, if necessary. On 6/7/2023 the RNC (Regional Nurse Consultant) will start reviewing Events/Changes in Condition for validation of thorough assessment and timely notification weekly for four (4) weeks followed by monthly x 2 months. On 6/7/2023 RDO will provide physical oversight at facility weekly x 4 weeks and then monthly x 2 months. The Administrator/designee will monitor compliance by completing audit of ten (10) residents per week for four (4) weeks. This was initiated on 6/7/2023. Any identified concern will be addressed immediately and if trends and patters are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. Administrator will be responsible for ensuring this plan is completed on 6/7/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the Plan of Removal continued and included interviews with staff on both day and night shifts. Interview on 06/08/23 at 6:00 AM with LVN E, she stated she had been in-serviced by the DON, covering falls, reporting of falls, and fall procedures. She stated she had to assess the resident for injuries before moving them. If the resident had any injuries she was to contact the physician and follow his orders. Interview on 06/08/23 at 6:10 AM with RN F, he stated he had been in-serviced by the DON at the beginning of his shift. The in-service covered falls, fall protocols, and notifications. In the event of a fall he would assess the resident for any injuries and notify the physician. If there was an obvious injury that would need to be treated at the hospital, he would call 911 and then notify the physician and DON. Interview on 06/08/23 at 6:18 AM with LVN G, she stated she had been in-serviced by the DON prior to starting her shift. The in-service covered falls, neglect, and fall protocols. She stated if a resident had a fall she would assess them before moving them to determine if there were any injuries. After rescuing the resident, she would notify the physician and see what his orders were. If neuro checks were ordered, they would continue for 72 hours. Interview on 06/08/23 at 9:20 AM with RN H she stated she had been in-serviced by the DON this morning. They covered abuse and neglect, fall prevention and reporting, and fall protocols. In the event of a fall, she is supposed to assess the resident for injuries and determine if they can be picked up off the floor safely. If there are obvious injuries that are not critical, she calls the physician and follows his orders. If there are critical injuries, they can call 911 prior to contacting the physician. Monitoring of neuro status is usually for 72 hours after the fall to monitor for any changes in condition. Interview on 06/08/23 at 9:30 AM with RN I, she stated she had been in-serviced by the DON yesterday. The in-service covered reporting falls, documentation of falls, and post-fall procedures. In the event of a resident fall she is to notify the DON and the physician once she has assessed the resident for injuries. After contacting the physician, she would follow his orders, including starting neuro checks. She reports the incident to the on-coming shift via verbal report as well as the 24-hour log. Interview on 06/08/23 at 9:42 AM with RN J, she was in-serviced by the DON yesterday. The In-service covered abuse, neglect, and exploitation and falls. In the event of a resident falling, she will assess them for any injuries before getting them off the floor. Un-witnessed falls and falls with injuries have to be reported to DON and physician. Review of facility Ad-Hoc QAPI meeting agenda, held on 06/07/23, had the Administrator; DON; Medical Director; ADON; and RDO in attendance. Review of residents assessed by the DON and ADON for changes in condition revealed all 62 residents had been assessed, with one resident found with a change in condition related to abnormal labs and the physician had been contacted. Resident was sent to the hospital for abnormal lab. An Immediate Jeopardy (IJ) was identified on 06/07/23 at 10:30 AM. While the IJ was removed on 06/08/23, the facility remained out of compliance at a scope of isolated and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective systems/ plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services to prevent neglect for 1 of 5 residents (Resident #1) reviewed for neglect. Resident #1 had an elopement attempt on 10/15/22 where he sat on the facility side street and when found he voiced that he wanted to go home and he had a decrease in his BIMS on 11/10/22 from 13 to 11. The facility failed to address the concerns, assess for elopement, or revise care plan. Resident #1 eloped from the facility on 2/16/23 and his location was unknown for 4 days during freezing temperatures with lows of 27 degrees. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 02/20/23. While the IJ was removed on 02/22/23, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm, and a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for continued neglect, undetected neglect and/or decline in feelings of safety and well-being, and psychosocial harm. Findings included: Review of the facility's undated Abuse Prevention program policy revealed the residents have the right to be from abuse, neglect. Neglect is defined as a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of Resident #1's progress note dated 10/15/22 at 8:40 AM completed by Nurse O revealed [Resident #1] was seen sitting on the side of the street by someone in the kitchen. Upon observation the resident was seen with a sweater and hat on stating he was wanting to go home to Mississippi Completed head to toe assessment. The resident does not have any skin issues and does not complain of pain.[Resident #1] stated he is ready to go home. Educated [Resident #1] on the proper procedure for signing out when wanting to go outside. [Resident #1] verbalized understanding. Will monitor the resident. Review of an event report dated 02/16/23 for Resident #1 completed by LVN H revealed On 2/16/23 at approximately 6:00 AM nurse identified that resident was not in his room. Nurse alerted other staff members and a search was conducted throughout the facility, facility grounds and outside areas surrounding facility. Staff unable to locate resident. Nurse notified DON and DON notified Administrator. At approximately 7:00 AM police and family were notified. Resident was last seen by nurse at 4:30 AM in his room in bed and then again at 4:45 AM heading toward the break room to go get himself a drink. Record review of Resident #1's electronic Face Sheet revealed a [AGE] year-old male who admitted to the facility 04/18/22 with diagnoses that included Cerebral infarction(Stroke), Seizures, Drug induced tremor and schizoaffective disorder(a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania) and Muscle Wasting and Atrophy (the shrinking of muscle or nerve tissue). Resident #1 discharged from the facility on 02/16/23. Record review of Resident #1's MDS dated [DATE] revealed Resident#1's BIMS score was 10 (scores 8 to 12 suggests moderately impaired).The resident required supervision or limited assistance with activities of daily living. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS of 13 (A score of 13 to 15 suggests the resident was cognitively intact). Review of Resident #1's MDS dated [DATE] revealed a BIMS of 11, indication of being moderately impaired with cognition. Record review of Resident #1's care plan dated 04/18/22 did not address Resident #1's cognition change. Resident #1's care plan revealed no information regarding the resident being at risk for elopement. Record review of Resident #1 electronic health record revealed no elopement assessment had been completed until 02/16/23 after Resident #1 had eloped from the facility. There was no evidence an elopement assessment had been completed prior. Record review of the facility resident sign out binder on 02/17/23 revealed Resident #1 had not sign out of the facility prior to leaving the facility on 02/16/23. Record review of Resident #1's Continuity of care document dated 02/21/23 revealed Resident #1 was prescribed Depakote 250 mg tablet, once a day, with the start date of 04/18/22 for seizures, the medication was last administered on 02/15/23 at 9:28 PM. Resident #1's was prescribed Depakote 500 mg tablet, at bedtime with the start date of 04/18/22 for seizures, the medication was last administered on 02/15/23 at 9:28 PM. Resident #1 was prescribed oxcarbazepine 150 mg, once a day with the start date of 04/18/22 for seizures, last administered on 02/15/23 at 9:28 PM. Resident #1 was missing due to elopement on 02/16/23. Record review of Resident #1's February 2023 Medication Administration Record revealed Depakote 250 mg tablet, once a day, with the start date of 04/18/22 for seizures, the medication was last administered on 02/15/23. Resident #1's was prescribed Depakote 500 mg tablet, at bedtime with the start date of 04/18/22 for seizures, the medication was last administered on 02/15/23. Resident #1 was prescribed oxcarbazepine 150 mg, once a day with the start date of 04/18/22 for seizures, last administered on 02/15/23. Review of all staff education revealed Elopement training was completed on 05/29/22 and again on 02/16/23 after Resident #1 had eloped. An interview with the ADM in 02/17/23 at 1:23 PM revealed Resident #1 had eloped from the facility the morning of 02/16/23 . The ADM stated LVN H had observed Resident #1 at 4:45 am. The ADM did not know where Resident #1 may have traveled. The ADM had contacted Resident #1's family member, the family member would contact the facility if Resident #1 had contact them. The local police department was notified. The ADM was not aware of Resident #1 eloping from the facility previously. The ADM stated Resident #1 walked around the facility freely. She revealed Resident #1 did not have an elopement assessment completed. The ADM stated the MDS coordinator, or the charge nurse should have completed the elopement assessment and updated Resident #1 care plan. The ADM stated facility had not provided education to the facility staff after the 10/15/22 incident .The ADM was told the Resident #1 did not leave the facility premises and was an elopement. The ADM stated when Resident #1 had change in cognition, an elopement assessment should have been completed before allowing the resident to walk throughout the facility without supervision. An interview with the DON on 02/17/23 at 1:44 PM revealed Resident #1's care plan had not been updated to reflect the resident was at risk for elopement . Resident #1 was allowed to go in and out of the facility. Resident #1 was allowed to sit on the front covered outside of the building and was able to sit out on the courtyard. The DON stated he was aware of Resident #1 leaving the facility on 10/15/22 and being located by a kitchen staff. The DON stated his understanding was Resident #1 had not traveled outside of the premises of the facility . The had not completed an elopement assessment following the incident. He had not educated staff regarding Resident #1 being located sitting on the side of the street. Resident #1's care plan was not updated. An interview with LVN A on 02/17/23 at 1:58 PM revealed she worked with Resident #1 since his admission to the facility. Resident #1 was allowed to go out of the facility and sit under the covered patio. Resident #1 was allowed to sit in the courtyard area of the facility. Resident #1 would usually come back inside the faculty after 30 minutes. She was not aware of an elopement assessment not being completed for Resident #1. Resident #1 was not asked to sign out, each time he went outside the facility. An interview with the MDS Coordinator on 02/20/23 at 1:24 PM revealed it was his responsibility to update residents care plans. He worked with the nursing team to come up with interventions. He was responsible for ensuring the elopement assessments were completed. He stated Resident #1's care plan had not been updated since his admission. Resident #1 had a change in cognition since first arriving at the facility. However was not documented on the care plan. He stated following Resident #1 being found sitting on street on 10/15/22, no elopement assessment was completed, no care plan was updated, no staff education regarding Resident #1 change in cognition and his attempted elopement. Review of the Care plan, Comprehensive Person Centered policy dated 12/16 revealed 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents condition change. Review of facility's Wandering, Unsafe resident policy dated 08/14 revealed The residents care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. The Administrator was notified on 02/20/23 at 12:50 PM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 02/20/23 at 12:51 PM . The facility's Plan of Removal was accepted on 02/22/23 at 9:42 am and included: 2/17/23 All residents were assessed for elopement risk/potential by LVN MDS Coordinator and reviewed by RN Quality Nurse. All residents identified as a risk were immediately added to elopement book by LVN MDS Coordinator. 2/18/23 All residents identified as an elopement risk/potential had care plans updated by LVN MDS Coordinator and reviewed by Director of Nursing. Any resident identified unsafe, and wandering will be placed on one on one supervision until transferred to a more secure facility. On 2/20/23 one resident was identified as an elopement risk, one on one was initiated from nursing staff and the resident was transferred on 2/20/23 to a secured facility. MD notified. Family in agreement of transfer to secured facility. 2/20/23 Chief Operating Officer educated Administrator, DON, and Wound Care LVN on Abuse and Neglect Policy and Procedure and responsibilities of Abuse Coordinator. 2/20/23 Chief Operating Officer educated Administrator on reporting potential allegations of Abuse and Neglect. 2/20/23 Chief Operation Officer educated Administrator on notifying Regional Director of Operations if there is any question regarding reporting Abuse and Neglect. 2/20/23 Chief Operating Officer educated Licensed Social Worker educated on reporting of incidents to Nursing, DON, or Administrator. 2/20/23 LVN, Wound care nurse educated all staff on Abuse and Neglect which was initiated at approximately 1pm for all staff as well as where to find the elopement binder accessible to all nursing staff members. 2/20/23 LVN, Wound Care nurse educated all staff on reporting responsibilities and who and how to report Abuse and Neglect as well as who the Abuse Coordinator is at Trail Lake Nursing and Rehab. 2/20/23 All residents were provided a copy of who the Abuse Coordinator is and to whom to report allegations This was provided by the Administrator and the Activity Director. If a resident is determined that a resident is an elopement risk, the resident will be placed on 1 on 1 until a more secure facility can be obtained for the resident. Family and MD will be notified. Staff will not be allowed to take an assignment until in-services are completed. Monitoring: Administrator/DON will review all new admits, readmits and any resident with a significant change to ensure that an elopement risk assessment and care plan is completed. Administrator/MDS will review all residents quarterly to ensure an elopement risk assessment and care plan is completed. Any negative findings will be reported to monthly QAPI meeting for further recommendation and review. On 02/22/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of sampled residents health records, revealed care plans and elopement assessments were completed and or updated for all residents. Review of education dated 02/20/23 Abuse and Neglect revealed the ADM was educated on notifying Regional Director of Operations if there was any question regarding reporting Abuse and Neglect presented by the Director of Operations. Review of education dated 02/20/23 completed by the CEO revealed the Administrator was educated on reporting potential allegations of Abuse and Neglect. Review of the Inservice education Abuse and Neglect Policy and Procedure, dated 02/20/23 reveled the ADM, DON was in serviced on Elopement. Both the ADM and DON sign in attendance. An interview with Resident #2 on 02/22/23 at 9:45 am revealed he had been educated on reporting neglect. Record review of the Inservice education Abuse and Neglect Policy and Procedure, dated 02/22/23 revealed staff had been educated regarding neglect. How to report abuse and neglect and to who to report. An interview with facility staff members on 02/22/23 from 10:00 AM to 12:00 PM LVN A, LVN D, HSK Z, HSK Y, LVN B, CNA C, CNA F, CNA G, LVN H, CNA I, HR L and AD M. Each revealed they had been educated regarding neglect. Each were able to articulate with examples of neglect. All allegations of neglect must be reported to the abuse coordinator. An interview with the DON on 02/22/23 at 10:38 AM revealed he had been in serviced regarding reporting of elopements by the ADM. The DON was educated regarding neglect. He explained that failing to provide residents with goods and services was neglect. All nursing staff were responsible for reporting neglect to the abuse coordinator. An interview with the MDS Coordinator on 02/20/23 at 12:29 PM revealed he had been educated regarding resident care plans being updated after a change in condition. He was required to report neglect to the ADM. An interview with the ADM on 02/22/23 at 12:45 PM revealed the facility had implemented that the charge nurses would ensure each resident had an elopement assessment completed upon admission, quarterly and after a change in condition. All staff had been educated regarding neglect and reporting. She had been educated by the CEO on investigating neglect and reporting neglect. On 02/22/23 at 1:10 PM the ADM was notified the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate their corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for elopement. The facility failed to provide interventions and supervision for Resident #1 from eloping from the facility on 10/15/22 and 02/16/23. Resident#1's location was unknown for 4 days. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 02/20/23. While the IJ was removed on 02/22/23, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm, and a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures put residents at risk of serious injury, hospitalization, or even death related to elopements Findings included: Record review of Resident #1's electronic Face Sheet revealed a [AGE] year-old male who admitted to the facility 04/18/22 with diagnoses that included Cerebral infarction(Stroke), Seizures, Drug induced tremor and schizoaffective disorder and Muscle Wasting and Atrophy (the shrinking of muscle or nerve tissue). Resident #1 eloped from the facility on 02/16/23. Record review of Resident #1's MDS dated [DATE] revealed Resident#1's BIMS score was 10 (scores 8 to 12 suggests moderately impaired).The resident required supervision or limited assistance with activities of daily living. Review of Resident #1's admission MDS dated [DATE] revealed a BIMS of 13 (A score of 13 to 15 suggests the resident was cognitively intact). Review of Resident #1's MDS dated [DATE] revealed a BIMS of 11, indication moderately impaired. Record review of Resident #1's care plan dated 04/18/22 reflected no information about Residents #1 cognition change. Resident #1's care plan revealed no information regarding the resident being at risk for elopement. Record review of Resident #1's progress note dated 10/15/22 at 8:40 AM revealed [Resident #1] was seen sitting on the side of the street by someone in the kitchen. Upon observation the resident was seen with a sweater and hat on stating he was wanting to go home to MS. Completed head to toe assessment. The resident does not have any skin issues and does not complain of pain.[Resident #1] stated he is ready to go home. Educated [Resident #1] on the proper procedure for signing out when wanting to go outside. [Resident #1] verbalized understanding. Will monitor the resident. Record review of Resident #1 electronic health record revealed no elopement assessment had been completed until 02/16/23 after Resident #1 had eloped from the facility. There was evidence a elopement assessment had been completed prior. Resident #1 had not sign out of the facility prior to leaving the facility on 02/16/23. Record review of an event report dated 02/16/23 for Resident #1 revealed On 2/16/23 at approximately 6:00 AM nurse identified that resident was not in his room. Nurse alerted other staff members and a search was conducted throughout the facility, facility grounds and outside areas surrounding facility. Staff unable to locate resident. Nurse notified DON and DON notified Administrator. At approximately 7:00 AM police and family were notified. Resident was last seen by nurse at 4:30 AM in his room in bed and then again at 4:45 AM heading toward the break room to go get himself a drink. Review of Resident #1's Continuity of care document dated 02/21/23 revealed Resident #1 was prescribed Depakote 250 mg tablet, once a day, with the start date of 04/18/22 for seizures, the medication was last administered on 02/15/23 at 9:28 PM. Resident #1's was prescribed Depakote 500 mg tablet, at bedtime with the start date of 04/18/22 for seizures, the medication was last administered on 02/15/23 at 9:28 PM. Resident #1 was prescribed oxcarbazepine 150 mg, once a day with the start date of 04/18/22 for seizures, last administered on 02/15/23 at 9:28 PM. Resident #1 was missing due to elopement on 02/16/23. An interview with the ADM in 02/17/23 at 1:23 PM revealed Resident #1 had eloped from the facility the morning of 02/16/23. The ADM did not know where Resident #1 may have traveled. The ADM had contacted Resident #1's family member, the family member would contact the facility if Resident #1 had contact them. The local police department was notified. The ADM was not aware of Resident #1 eloping from the facility previously. The ADM stated Resident #1 walked around the facility freely. She revealed Resident #1 did not have an elopement assessment completed. The ADM stated the MDS Coordinator or the charge nurse should have completed the elopement assessment and updated Resident #1 care plan. The ADM revealed the document incident with Resident #1 dated on 10/15/22 had not investigated as an elopement , because she was told the resident remained on the premises. An interview with the DON on 02/17/23 at 1:44 PM revealed Resident #1's care plan had not been updated to reflect the resident was at risk for elopement . Resident #1 was allowed to go in and out of the facility. Resident #1 was allowed to sit on the front covered outside of the building and was able to sit out on the courtyard. The DON stated he was aware of Resident #1 leaving the facility on 10/15/22 and being located by a kitchen staff. The DON stated his understanding was Resident #1 had not traveled outside of the premises of the facility. The had not completed an elopement assessment following the incident. He had not educated staff regarding Resident #1 being located sitting on the side of the street. Resident #1 care plan had not being updated. An interview with LVN A on 02/17/23 at 1:58 PM revealed she worked with Resident #1 since his admission to the facility. Resident #1 was allowed to go out of the facility and sit under the covered patio. Resident #1 was allowed to sit in the courtyard area of the facility. Resident #1 would usually come back inside the facility after 30 minutes. She was not aware of an elopement assessment not being completed for Resident #1. Resident #1 was not asked to sign out, each time he went outside the facility. An additional interview with the ADM on 02/20/23 at 10:11 AM revealed she had spoken with Resident #1's family member and revealed on 02/17/23 at 5:00 PM Resident #1 had traveled to the family members home and was turned away. The address of the family member home was approximately 10 miles from the facility. Review of Google maps on 02/20/23 revealed the address of the family member from the facility was 9.7 miles away and would take to 3 hours to walk. An interview with the MD on 02/21/23 at 2:23 PM revealed Resident #1 required seizure medication. Resident #1 had eloped from the facility on 02/16/23, it could be very dangerous for Resident #1 to go 4 days without his seizure medication. The MD stated he was told by the facility that Resident #1 had left the faciity on [DATE], however he was not told the resident had eloped. Record review of the weather. com website revealed the low temperature on 02/16/23 was 37 degrees. On 02/17/23 the temperature low was 29 degrees. Review of the Care plan, Comprehensive Person Centered policy dated 12/16 revealed 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents condition change. Review of facility's Wandering, Unsafe resident policy dated 08/14 revealed The residents care plan will indicate the resident is at risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included. The Administrator was notified on 02/20/23 at 12:50 PM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 02/20/23 at 12:51 PM . The facility's Plan of Removal was accepted on 02/22/23 at 9:42 AM and included: 2/17/23 All residents were assessed for elopement risk/potential by LVN MDS Coordinator and verified by Director of Nursing. All residents identified as a risk were immediately added to elopement book by Administrator and Activity Director. 2/18/23 All residents identified as an elopement risk/potential had care plans updated by the MDS coordinator and reviewed by DON. Any resident identified unsafe, and wandering will be transferred to a more secure facility. On 2/20/23 one resident was identified as an elopement risk, one on one was initiated from nursing staff and the resident was transferred on 2/20/23 to a secured facility. MD notified. Family in agreement of transfer to secured facility. 2/20/23 Chief Operating Officer in serviced Administrator, DON, and Wound Care LVN on Elopement Policy and Procedure, elopement assessment and frequency, and elopement binder and location. 2/20/23 Director of Quality, RN in serviced LVN MDS Coordinator on elopement assessments and frequency of assessment as well as updating care plans. 2/20/23 LVN, Wound Care Nurse Educated staff on Elopement Risk and assessment which were initiated at approximately 1pm for all staff as well as where to find the elopement binder. 2/20/23 LVN, Wound Care Nurse educated all staff on reporting responsibilities and who and how to report. Staff will not be allowed to take an assignment until in-services are completed. Monitoring: Administrator/DON will review all new admits, readmits and any resident with a significant change to ensure that an elopement risk assessment and care plan is completed. Administrator/MDS will review all residents quarterly to ensure an elopement risk assessment and care plan is completed. Any negative findings will be reported to monthly QAPI meeting for further recommendation and review. On 02/22/22 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Review of sampled residents health records, revealed care plans and elopement assessments were completed and or updated for all residents. Review of education dated 02/20/23 Elopement Risk and assessments signed by the facility staff Review of education dated 02/20/23 completed by the Director of Quality, educated provided to the MDS coordinator, his signature was documented. Review of the Inservice education Elopement Policy and Procedure, dated 02/20/23 reveled the ADM, DON and LVN D was in serviced on Elopement. Both the ADM and DON sign in attendance. Review of the resident roster revealed one resident was discharged to another facility on 02/20/23 after being identified at risk for elopement. An interview with facility staff members on 02/22/23 from 10:00 AM to 12:00 PM LVN A, LVN D, HSK Z, HSK Y, LVN B, CNA C, CNA F, CNA G, LVN H, CNA I, HR L and AD M. Each revealed they had been educated regarding elopements. The charge nurses would ensure each resident had an elopement assessment completed upon admission, quarterly and after a change in condition. If a resident was seen outside, the charge nurse must be notified. Each resident must sign out before leaving outside the facility if there was no or little risk for elopement. An interview with LVN D on 02/22/23 at 12:10 PM revealed she had completed education with staff regarding the elopement policy and procedure. The facility had implemented elopement binders at each nurses station and one binder at the front desk. The residents face sheet and picture was located in each binder, residents in the binders were not allowed to leave the facility without supervision. Observation on 02/20/23 of one binder at the north nurses station and one binder at the south nurses' station and one binder was located at the front desk. An interview with the DON on 02/22/23 at 10:38 AM revealed he had been in serviced regarding reporting of elopements by the ADM. The facility had implemented elopement binders at each nurses station and one binder at the front desk. The residents face sheet and picture was located in each binder, residents in the binders were not allowed to leave the facility without supervision. The facility had implemented that the charge nurses would ensure each resident had an elopement assessment completed upon admission, quarterly and after a change in condition. If a resident was seen outside, the charge nurse must be notified. Each resident must sign out before leaving outside the facility if there was no or little risk for elopement. An interview with the MDS Coordinator on 02/20/23 at 12:29 PM revealed he had been educated regarding resident care plans being updated after a change in condition. He must ensure all residents had an elopement assessment completed upon admission, quarterly and after a change in condition. An interview with the ADM on 02/22/23 at 12:45 PM revealed the facility had implemented that the charge nurses would ensure each resident had an elopement assessment completed upon admission, quarterly and after a change in condition. If a resident was seen outside, the charge nurse must be notified. Each resident must sign out before leaving outside the facility if there was no or little risk for elopement. She had been educated by the CEO regarding reporting and investigating elopements. Resident #1 had been located on 02/21/23 at 3:00 PM. Resident #1 did not want to return to the facility. On 02/22/23 at 1:10 PM the ADM was notified the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility's need to evaluate their corrective actions.