**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #1) of 4 residents review for catheter care. The facility failed to change Resident #1's foley catheter (a medical device used to drain urine from the bladder.) as ordered monthly on 04/09/2025 and 5/9/2025. Resident #1 was sent to the local ER on [DATE] due to fever and lethargy and was diagnosed with possible sepsis (is a life-threatening condition that occurs when the body has extreme response to infection). This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/2025 at 4:19 pm and an IJ template was given. While the IJ was removed on 05/20/2025 at 7:01 pm, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for hospitalization, coma and death. Findings included: Review of Resident # 1's face sheet dated 05/18/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Autistic disorder (is a developmental disorder that affects communication, behavior and social interaction, with symptoms typically appearing in early childhood), Hypertension (HTN - High blood pressure), Urinary retention, history of Urinary Tract Infections (UTI -occurs when bacteria get in the urinary system, often through the urethra, and begin to multiply in the bladder), Diabetes Mellitus type II (a chronic condition characterized by insulin resistance and elevated blood sugar levels). Review of Resident #1's hospital discharge papers dated 4/1/2025 reflected: Urinary retention -multiple trials of foley removal without success -continue foley -continue Flomax -3/10 foley replaced by urology. replace foley monthly. Review of Resident #1's admission MDS dated [DATE] indicated he had a BIMS score of not conducted indicating severe cognitive impairment. Staff assessment of Mental Status reflected Resident #1 has short-term and long-term memory problems. Section H- Bladder and Bowel reflected Resident #1 had an indwelling catheter. Review of Resident #1's MAR/TAR reflected: CHANGE F/C 14fr 10cc Q MONTH AND PRN IF DISLOGED. one time a day starting on the 9th and ending on the 9th every month dated 04/03/2025 with start date of 04/09/2025. Provide catheter care Q-shift/PRN every shift. Review of Resident #1's Care Plan initiated 04/14/2025 reflected no plan of care for catheter, DM or Hypertension. Review of Resident #1's TAR reflected his Foley was changed on 4/9/25 by MA E. Review of Resident #1's TAR reflected his Foley was changed on 5/9/25 by MA A. Review of Resident #1's progress notes written by LVN C dated 05/17/2025 at 1:39 pm reflected: Resident transferred to ER due to difficult to arouse, decrease in urine output and low blood pressure. Review of Resident #1 current hospital records dated 5/17/2025 reflected: He was sent over from his nursing home for fever of 101, more lethargic than usual and his glucose reading was high. On arrival his serum glucose is around 478, sodium is 156, creatinine of 4. He is very lethargic and barely opens eyes. Initial work up shows likely diagnosis of DKA/ hyperosmolar diabetes (is a serious complication of diabetes, primarily occurring in individual with type 2 diabetes), possible sepsis, UTI (his foley was exchanged in ER, had brown urine with some pus in penile area), possible right lung pneumonia, with AKI. During an interview on 05/19/2025 at 10:11 am MA A stated she did not change Resident #1's foley catheter because it was outside her scope of practice. MA A stated Resident #1's foley catheter order to change was on her MAR and she accidentally signed it. MA A also stated she did not tell the nurse who worked on 5/9/2025 about the foley catheter needing to be changed. During an interview on 05/19/2025 at 11:04 am the DON stated, foley catheters were supposed to be changed once a month. The DON stated if foley catheters were not changed as ordered, the resident would get infection. The DON stated Resident #1's foley catheter was supposed to be changed around 5/09/2025 and the nurse was supposed to initial when it was changed. The DON stated staff did not document urine output because Resident #1 did not have orders to document urine output and Resident #1 did not have issues with output. The DON stated MAs cannot change foley catheters because it was not within their scope of practice. The DON reviewed Resident #1's TAR and noted that it was not changed on 4/9 and 5/9 but was initialed by MAs. The DON stated Resident #1's order for catheter change was revised on 5/10/2025 by LVN F to reflect on the nurse's TAR, according to the DON. During an interview on 05/19/2025 at 11:43 am the NP stated Resident #1 had a foley catheter due to urinary retention. The NP stated she usually did not write orders for foley catheters, and she let the urologist deal with foley catheters. The NP stated she expected the facility to keep foley catheters clean and free from infection. The NP asked to step out and call the MD, came back later and stated she would not continue with the interview unless her MD was present. During a phone interview on 05/19/2025 at 2:45 pm the MD stated, there was new evidence that indicated not to change the foley catheter monthly. The MD stated changing foley monthly, really did not make a difference in infection prevention. The MD stated the hospital may have said change the foley catheter monthly, but he disagreed with the urologist (are medical specialists who focus on the diagnosis and treatment of conditions related to the urinary tract and male reproductive system) . The MD stated Resident #1 would have to be scheduled for urology follow-up, maybe his foley catheter was difficult. During an interview on 05/19/2025 at 1:35 pm, the Interim Administrator stated not changing the foley catheter as ordered can lead to possible infection. The Interim Administrator stated the CNAs were supposed to document urine output. The interim Administrator stated if Resident #1 had the foley catheter due to urinary retentions, it was important to document urine output. Attempts was made to contact MA E on 05/19/2025 at 10:30 am but was unsuccessful. Attempts was made to contact LVN F on 05/19/2025 at 12:21 pm but was unsuccessful . Review of facility's policy titled Catheter Care; Urinary dated August 2022 reflected: Purpose The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. The VP for Operation, Interim Administrator and the DON were notified on 05/19/25 at 4:19 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 05/20/25 at 12:51 pm. F690 Immediate Jeopardy Removal Actions Taken 1. Immediate Resident Response o Resident #1 was immediately transferred to the emergency room on 5/17/2025 due to fever, lethargy, and suspected sepsis. o A full head-to-toe assessment was conducted by licensed staff prior to transfer. (No skin breakdown, foley catheter intact) o Foley catheter was replaced in the ER. The resident was diagnosed with UTI, possible sepsis, AKI, and pneumonia. o Family and physician were notified immediately. 2. Resident Safety Review o 100% audit of all residents with Foley catheters completed on [5/19/2025] by the Director of Nursing (audit tool created to monitor foley catheter orders) (DON was in-serviced prior to completing audit on 5/19/2025 by CNO) Reviewed orders for catheter care and replacement schedule. (Review of 1 resident with foley pre- discharged orders in PCC were reviewed by DON as resident #1 is in the hospital. ( No residents other than resident # 1 have a foley catheter. Verified compliance with physician orders, TAR/MAR accuracy, and documented output as needed. Any overdue changes were immediately completed by a licensed nurse. (Currently no residents in the facility with foley catheter orders) None are affected. Any discrepancies in documentation were immediately addressed and corrected. 3. Order Clarification & Physician Review o All current Foley catheter orders reviewed with attending physicians to ensure: By: CNO and DON 5/19/2025. Specific frequency for changes (monthly, prn, etc.) Whether urology follow-up is required. Clear instructions on who is responsible (facility vs. specialist). o Physician orders revised accordingly and entered into EMR (1 resident total) (DON/ designee will monitor upon admission and weekly in Standards of care meeting). 4. Scope of Practice Enforcement o Immediate education and competency check completed on 5/19/2025 for all medication aides (MAs) clarifying: ( DON completed education. Staff that were not present we called by the DON. Staff that could not be reached must be in-serviced prior to next scheduled shift. MAs may not change Foley catheters. MAs must report Foley orders to licensed nurses immediately. MAs may not document, or initial Foley care they did not perform. o The MA involved was removed from the schedule pending retraining and counseling (In-service and posttest). ( Next scheduled shift for MA is 5/21/25 and she will not be allowed to work prior to the in-service and test for acknowledgement. 5. Documentation & Tracking System Improvements o New Foley catheter tracking log implemented for all residents with catheters ( monitored by DON/ Designee. o TARs and MARs updated to reflect accurate task assignments and responsibilities. ( DON completed the task after in-service by CNO on 5/19/2025. o DON or designee to verify completion of catheter change orders date. (This will be reviewed after admission and weekly in Standards of Care meeting) (Continuously). 6. Care Planning & Assessment o Resident #1's care plan updated by DON immediately to reflect catheter management needs. o 100% audit of care plans (foley catheter audit ) for all catheterized residents completed by DON to ensure individualized interventions for infection prevention, hydration, and output monitoring (3 resident's care plans were updated). (This will be tracked in the weekly Standards of care meeting) o Facility policy updated to require catheter care plans within 24 hours of admission. ( DON will be responsible and the CNO will provide oversight weekly X 6 weeks and then monthly. 7. Staff Education o In-service conducted for all licensed nurses and MAs by DON (in-service and posttest) on: ( DON will provide continuous training with new hires, agency, and staff who were not present to ensure compliance is met and sustained. Foley catheter management per HHSC/CMS standards. Identifying early signs of UTI and sepsis. Documentation protocols and scope of practice. o DON and ADON re-trained on oversight responsibility for order reconciliation, scope of practice enforcement, and task delegation (in-service by CNO) ( By verbal and written acknowledgement of training. 8. Quality Assurance and Monitoring o Daily (clinical morning meeting) review for 14 days (continuously in weekly Standards of care meeting) of: Catheter care orders. Documentation of changes. Correct scope of task completion. o QA team to review catheter log weekly and monitor compliance during rounds. (Monthly in QAPI meeting indefinitely-as long as there are residents with foley catheters) o Findings reviewed in monthly QAPI meetings. 9. Leadership Accountability o MA involved received documented disciplinary counseling. (DON via phone on 5/20/25) All MAs and nurses have been in-serviced by DON via in person or phone. ( Post test was sent via phone after in-service by DON to the staff who were not present at the time of the in-person training. All staff will be required to acknowledge the education was given by presenting the signed posttest prior to the next scheduled shift. o DON received education on catheter care orders, identifying signs of UTI and sepsis, and documentation protocols and scope of practice. Chief Nursing Officer providing oversight (5/19/25 daily X 10 days in person, then weekly X 4 remotely, and then monthly remotely and prn to ensure continued compliance with the plan. The Surveyor monitored the POR on 05/20/2025 from 1:00 pm to 7:00 pm as follows: During interviews on 05/20/2025 from 1:00 pm -7:00 pm, three LVNs (LVN B, C and D), 1 RN (RN D) from all shifts stated they had been in-serviced by the DON and the Interim Administrator/ CNO During interviews on 05/20/2025 from 1:00 pm -7:00 pm, two MAs (MA A and B), from all shifts, they both stated they had been in-serviced by the DON and the Interim Administrator/ CNO that MAs and Nurses were responsible for documenting on the MAR. They stated MAs were responsible for documenting in the MAR non-nursing responsibilities. Nurses were responsible for documenting in the MAR nursing responsibilities, such as catheter care. They were trained on MAR documentation. They learned to notify the charge nurse or DON if they observed incorrect entries or nursing responsibilities in the MAR. They stated if they accidentally checked off performing nursing responsibilities, such as ointment, on the MAR, they would strike out and notify nurse on duty. They stated they knew it was important to notify the nurse whenever they observe nursing responsibilities on the MA's MAR. They stated It's important because it could be abuse or neglect. Resident won't get attention they need as ordered from the doctor. Resident needs to get their treatment. Residents won't get what they need, such as wound care or ointment. Residents could not receive a medication or treatment if the MAR was checked off as received but they did not receive. During an interview on 05/20/2025 at 3:40 pm the DON stated she was in-serviced on 05/19/25 by the CNO. She learned about the types of orders, expectations, what to look for when reviewing orders, admissions/readmissions process, new procedures, scope of practices for MAs and nurses, following orders, and reviewing and revising care plans. She also reviewed orders for catheter care and replacement schedule on 05/19/25 and found there were no residents other than Resident #1 who had a foley catheter. She reviewed Resident #1's EHR and verified compliance with physician orders, TAR/MAR accuracy, and urinary output documentation on 05/19/25. There were no overdue changes that immediately needed to be completed by a licensed nurse during review and verification. She also did not identify any discrepancies in documentation. Attending physicians, her and the CNO reviewed all current foley catheter orders on 05/19/25 for frequency for changes in output, urology follow-up, and who was responsible for changing. MD became oversight for ensuring urinary output documented, urology follow-ups were made, and foley catheters were changed according to orders. She started and completed the audit of all residents with foley catheters on 05/19/25 and found there were no residents with foley pre-discharged orders in EHR other than Resident #1. Resident #1's physician orders were revised and entered in EHR on 05/19/25 . She provided immediate education and competency checks by phone and in-person to the MAs on 05/19/25 regarding MAs not changing foley catheters, reporting foley orders to licensed nurses immediately, and not documenting or initialing foley care they did not perform. All MAs have been reached by in-person or phone before their next scheduled shift. MA involved was removed from the schedule. She reached out to the MA involved and the MA was scheduled to visit the facility to receive counseling and retraining on 05/21/25. She initiated and was monitoring a new foley catheter tracking log on 05/19/25. No discrepancies and errors observed. She updated Resident #1's TAR/MAR to reflect task assignments and responsibilities after being trained by the CNO on 05/19/25. There were no other residents. She was to start verifying completion of catheter change orders date and review after Resident #1's readmission and weekly. She updated Resident #1's care plan to reflect catheter management needs on 05/20/25. She completed an audit of all catheterized residents' care plans to ensure interventions were included and implemented and was tracking weekly. The DON stated the CNO updated the facility's policy to reflect requiring catheter care plans within 24 hours of admission and overseeing weekly for next 6 weeks and then monthly thereafter. She in-serviced all licensed nurses and MAs and gave post-tests to them regarding foley catheter management, documentation protocols, and identifying early signs of UTI and sepsis. CNO retrained her and had her sign written acknowledgment on oversight responsibility for order reconciliation, scope of practice enforcement, and task delegation on 05/19/25. QA was reviewing daily for 14 days and then weekly on catheter care orders, documentation of changes, and correct scope of task completion. QA team also reviewing catheter log weekly to monitor compliance during rounds and findings monthly in QAPI meeting. CNO was overseeing from 05/19/25, daily for the next 10 days in person, weekly for the next four weeks, and then monthly remotely and as needed to ensure compliance. During an interview on 05/20/2025 at 5:18pm Interim Administrator/CNO stated she in-serviced the DON on 05/19/25 regarding order reconciliation, ensuring orders were in nurses' MAR, ensuring orders for foley care and monitoring were in place, ensuring MAs notifying nurses of any orders in their MAR, and DON reviewing and tracking any discrepancies and errors and correcting. The Interim Administrator/CNO stated the DON signed an acknowledgement of receiving the in-service before performing the audit of residents with foley catheters. The Interim Administrator/CNO stated she, the DON, and MD reviewed current residents' foley catheter orders on 05/19/25 and found no other discrepancies and errors. The Interim Administrator/CNO stated she and the DON discussed with the MD the IJs as well. The Interim Administrator/CNO stated she in-serviced the DON on updating TARs and MARs to reflect accurate task assignments and responsibilities on 05/19/25 before the DON updated the TARs and MARs. DON signed an acknowledgement of receiving the in-service before updating the TARs and MARs. She was overseeing weekly for the next 6 weeks to ensure facility policy was updated and followed regarding catheter care plans were required within 24 hours of admission. She in-serviced the DON on oversight responsibility for order reconciliation, scope of practice enforcement, and task delegation. DON signed an acknowledgement of receiving the in-service before initiating oversight responsibility for order reconciliation, scope of practice enforcement, and task delegation. She oversaw to ensure processes completed daily for the next 10 days in person, then weekly for four weeks remotely, and then monthly remotely and as needed to ensure continued compliance. Review of facility's in-services dated 05/19/2025 reflected the following: Facility had an ADHOC QAAC for identification of deficient practice. DON: Foley Catheter Review: Foley Catheter Policy presented by the Interim Administrator/CNO and signed by the DON. Nurses: Foley catheter, Foley catheter management/policy and procedure, identify early signs of UTI and sepsis, documentation presented by the Interim Administrator/CNO and the DON; signed by LVN B and LVN F and via phone for LVN C and RN D. Medication Aides: Foley Catheter: MAs may not change foley catheter, MAs must report foley catheter orders to nurse, MAs may not document or initial on foley catheter, presented by the Interim Administrator/CNO and the DON; signed by MA A, MA E via phone. Education to Physician/NP on MARs/TARs on new/readmissions. Weekly Review of high-risk residents regardless of payer. LOA residents require same level of care as skilled. MD stated and acknowledged understanding of medication process and foley catheter orders to be specified if would like catheter changed monthly. Nursing: Scope of Practice/ Medication Administration presented by the DON via phone for MA F. Foley Catheter test completed on 05/19/2025 by Nurses including the DON, LVN B, LVN C via phone, RN D via phone, MA E via phone, LVN F Review of facility's in-services dated 05/20/2025 reflected the following: Foley Catheter management, notification of change in condition to nurse, where to document output dated 05/20/2025 presented by the DON signed by CNAs . Review of Facility's Indwelling (Foley) Catheter Insertion policy, revised 05/19/25, reflected the policy was updated to required care plan updates with foley catheter within 24 hours of admission, verify resident specific output orders related to diagnosis for foley catheter insertion, and verify resident specific foley change orders with physician monthly or PRN for occlusions and dislodgement. DON audit of all residents with foley catheters, completed on 05/19/25, reflected Resident #1 was the only resident. Orders for catheter care and replacement schedule were reviewed and present. Foley change frequency was ordered. Foley changed as ordered. Care plan reflected foley use. Tracking log was used for foley catheter care residents. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/2025 at 4:19 pm and an IJ template was given. While the IJ was removed on 05/20/2025 at 7:01 pm, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 4 residents review for pharmacy services. The facility failed to carry out Resident #1's orders from the hospital for insulin to control his blood glucose. Resident #1 was sent to the local ER on [DATE] due to fever and lethargy and was diagnosed with Diabetes Ketone Acidosis (DKA-Diabetes Ketone Acidosis is serious and can be life threatening. DKA is when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy (with a blood serum level of 478. Normal blood serum glucose levels: Fasting blood glucose 70 to 99 mg/dL. Random blood glucose: generally, it should be 125 mg/dL.) . This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/2025 at 4:19 pm and an IJ template was given. While the IJ was removed on 05/20/2025 at 7:01pm, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for high blood glucose, hospitalization, coma and death. Findings included: Review of Resident # 1's face sheet dated 05/18/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Autistic disorder (is a developmental disorder that affects communication, behavior and social interaction, with symptoms typically appearing in early childhood), Hypertension (HTN - High blood pressure), Urinary retention, history of Urinary Tract Infections (UTI -occurs when bacteria get in the urinary system, often through the urethra, and begin to multiply in the bladder), Diabetes Mellitus type II (a chronic condition characterized by insulin resistance and elevated blood sugar levels). Review of Resident #1's hospital discharge orders dated 4/1/2025 reflected: Insulin NPH Hum/Reg 70/30 (Trade name: Novolin 70/30) 15 Units Subcutaneous before Breakfast and Dinner Review of Resident #1's hospital discharge papers dated 4/1/2025 reflected: Type 2 diabetes mellitus uncontrolled with hyperglycemia (high blood sugar level), A1c 7.5% - Home regimen; NPH 70/30 15 units b.i.d. - continue at l0u BID due to hypoglycemia - sliding scale insulin, monitor for hypoglycemia Review of Resident #1's admission MDS dated [DATE] indicated he had a BIMS score of not conducted indicating severe cognitive impairment. Staff assessment of Mental Status reflected Resident #1 has short-term and long-term memory problems. Section I- Active Diagnoses reflected Resident #1 had Diabetes Mellitus. Section N- Medications did not indicate Resident #1 was on insulin. Review of Resident #1's initial physician/NP narrative note written by the MD dated 05/04/2025 reflected: Type 2 Diabetes Mellitus with Foot Ulcer Continue insulin regimen as prescribed. Monitor glucose levels and foot ulcer healing. Review of Resident #1's Care Plan initiated 04/14/2025 reflected no plan of care for a catheter, DM. Review of Resident #1's progress notes written by NP dated 05/04/2025 reflected: Type 2 Diabetes Mellitus with Foot Ulcer Continue insulin regimen as prescribed. Monitor glucose levels and foot ulcer healing. Chief Complaint Management of chronic medical conditions including the ones listed above. Review of Resident #1's MAR/TAR reflected no orders for Insulin or blood sugar checks for the months of April and May 2025. Review of Resident #1's progress notes written by LVN C dated 05/17/2025 at 1:39 pm reflected: Resident transferred to ER due to difficult to arouse, decrease in urine output and low blood pressure. Review of Resident #1's current hospital records dated 5/17/2025 reflected: He was sent over from his nursing home for fever of 101, more lethargic than usual and his glucose reading was high. On arrival his serum glucose is around 478, sodium is 156, creatinine of 4. He is very lethargic and barely opens eyes. Initial work up shows likely diagnosis of DKA/ hyperosmolar diabetes ( is a serious complication of diabetes, primarily occurring in individual with type 2 diabetes), possible sepsis (is a life threatening condition that occurs when the body has extreme response to infection), UTI (his foley (foley- a medical device that helps drain urine from the bladder when you can't pee on your own) was exchanged in ER), had brown urine with some pus in penile area, possible right lung pneumonia, with AKI. Normal blood serum glucose levels: Fasting blood glucose 70 to 99 mg/dL Random blood glucose: generally, it should be 125 mg/dL. Medlineplus https://medlineplus.gov.ency/article During an interview on 05/19/2025 at 10:01 am LVN B stated he was not aware of Resident #1 needing accu checks (accu check refer to the use of a glucometer to test a patient's blood sugar level) or insulin. During an interview on 05/19/2025 at 11:04 am the DON stated, she knew Resident #1 was diabetic from his referral papers that were faxed over. The DON stated she reviewed Resident #1's admission papers and she didn't see Resident #1 was on Insulin. The DON stated she participated in Resident #1's admission assessments and reviewed his orders from the referral papers sent in February 2025. The DON stated she did not put Resident #1's orders in Point Click Care (PCC- a web based EHR that helps long-term care provider manage the complete lifecycle of a resident care). The DON stated Resident #1 was admitted to the facility with only 2 pieces of paper. The DON stated she called the local hospital for Resident #1's hospital records and was told the records would be faxed over. The DON stated she did not follow up to find out if Resident #1's hospital records were faxed or document that she had called for the hospital records. The DON stated she did not see Resident #1 showing signs or symptoms of Hypo (low) or Hyperglycemia (high blood glucose). The DON stated if a Resident was supposed to get insulin and did not get the insulin, the resident would have hyperglycemia which can lead to DKA and coma. During an interview on 05/19/2025 at 11:43 am the NP stated, Resident #1 was seen once a month because he was non-funded ( no Payal source). The NP stated she had seen Resident #1 twice since he was admitted to the facility. The NP stated she visited with Resident #1 on 5/17/2025. She said he was not responding well, he was unresponsive, and she ordered for him to be sent to the ER for further evaluation. The NP stated she documented on 05/04/2025 that Resident #1 should continue insulin regimen as prescribed, monitor glucose levels and foot ulcer healing based on the MD's previous documentation and Resident #1's hospital records. The NP stated she did not review Resident #1's MAR/TAR for his glucose reading during her visits. The NP stated she did not have access to PCC to put in orders. The NP stated if a resident was ordered insulin and did not get the insulin as ordered, the resident can go into DKA or hyperosmolarity (blood is more concentrated than normal due to dehydration). The NP stated, generally, you want the serum blood glucose around 80 and not more than 200, and 400 plus serum blood glucose can indicate uncontrol diabetes/blood sugar. The NP stated she ordered labs on 5/4/2025 but was not able to get the lab done due to Resident #1's funding. The NP stated she gave the lab ordered sheet to the DON and spoke with the MD regarding that. The NP stated, if the insulin was ordered from the hospital for Resident #1, Resident #1 should have gotten the insulin as ordered. During a phone interview on 05/19/2025 at 12:15 pm RN D stated he worked with Resident #1 but could not remember putting Resident #1's orders in the EMR upon admission. RN D stated he did not recall Resident #1 having orders for accu checks or insulin. RN D stated he had never given Resident #1 insulin or checked his blood glucose level. During an interview on 05/19/2025 at about 12:41 pm, the DON stated the NP gave her a sheet with orders for labs for Resident #1, but the labs were not completed due to Resident's payment source (LOA-Letter of Agreement). The DON stated Resident #1 contract with the hospital only pay for room and boarding only. During an interview on 05/19/2025 at 1:35 pm, the Interim Administrator stated when a resident is being admitted from the hospital, the admitting nurse was responsible to call the hospital for clarification of orders. She stated, if the Resident was transported to the facility without hospital papers, the admitting nurse is responsible to contact the hospital for discharge papers and follow up on the papers. The Interim Administrator stated the DON was responsible to ensure the nurses were following all orders. The Interim Administrator stated for a resident who was ordered insulin and did not get the insulin, the resident's blood glucose would be high. The Interim Administrator stated the facility missed the insulin order for Resident #1, it was a mistake, and they were working on fixing the problem. The Interim Administrator stated for a Resident with LOA funding, the facility gets paid a flat rate per day through the hospital contract. The Interim Administrator also stated the facility would pay for labs because the Resident had to be taken care of. The Interim Administrator stated that was a misunderstanding. The Interim Administrator stated the MD should be able to see and treat every Resident regardless of their payment source. During a phone interview on 05/19/2025 at 2:45 pm the MD stated he had just reviewed Resident #1's chart and the insulin and accu checks were an error on their part. He stated it was an oversight not looking for the accu check and the insulin administration. The MD stated his office should have realized that Resident #1's insulin was held. The MD stated he was told by the NP that the DON said the insulin was discontinued due to insurance problem/ LOA. The MD stated the facility should have continued with Resident #1's accu checks and stopped the 70/30 insulin when the blood glucose was stable. The MD stated his NP should have asked the facility to monitor Resident #1's blood glucose reading regardless of payment source. The MD stated DKA was considered life threatening, but we can bring the Resident/Patient back from it. He stated DKA can also be triggered by acute infection, but again, the blood glucose should have been monitored before the facility can decide on keeping Resident #1 on the insulin or not. Review of Resident #1's Letter of Agreement dated 04/01/2025 reflected the following: Obligations of Facility a. Facility shall provide quality service to patient without discriminating of the basis of source of payment, gender, nationality, ethnicity, age, or handicap. b. Facility shall invoice Hospital by the 15th of each month for services to patient. An itemized statement will accompany each invoice. c. Facility agrees to provide the following services to the Patient: i. Nursing Care ii. Physical Therapy iii. Speech Therapy iv. Occupation Therapy d. Facility agrees to provide the medications prescribed by transferring physician. A list of the prescribed medications is located in Exhibit A and is included by reference herein. Review of facility's policy titled Reconciliation of Medications on admission dated July 2017 reflected: Purpose The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Preparation 1. Gather the information needed to reconcile the medication list: a. Approved medication reconciliation form. b. Discharge summary from referring facility. c. admission order sheet. d. All prescription and supplement information obtained from the resident/family during the medication history; and e. Most recent medication administration record (MAR), if this is a readmission. 2. Find a quiet place that is free from distractions. General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. 3. Medication reconciliation helps to ensure that all medications, routes and dosages on the list are appropriate for the resident and his/her condition, and do not interact in a negative way with other medications/supplements on the list. 4. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Steps in the Procedure 3. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources). 4. List the dose, route and frequency for all medications. 5. Review the list carefully to determine if there are discrepancies/conflicts. c. There is a medication listed on the discharge summary for which there is no diagnosis or condition to support the use of the medication. 6. If there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriate action to resolve the discrepancy. For example: a. Contact the nurse from the referring facility. b. Contact the physician from the referring facility. c. Discuss with the resident or family. d. Contact the resident's primary physician in the community. e. Contact the resident's secondary physician(s) in the community. f. Contact the community pharmacy used by the resident; or g. Contact the admitting and/or Attending Physician. The VP for Operation, Interim Administrator and the DON were notified on 05/19/25 at 4:19 pm that an IJ had been identified and an IJ template was provided. The following POR was approved on 05/20/25 at 12:51 pm. F755 Immediate Jeopardy Removal Actions Taken 1. Immediate Clinical Response o Resident #1 was immediately transferred to the hospital upon identification of altered mental status and signs of sepsis and hyperglycemia on 5/17/2025. o Full head-to-toe nursing assessment completed and documented prior to transfer. o Family and physician were notified promptly. 2. Resident Review & Safety Measures o 100% audit of all current residents with diabetes diagnoses was conducted on [5/19/2025] by Director of Nursing. (Documented on audit tool developed for new admit medication reconciliation) DON was in-serviced before completing audit by Chief Nursing Officer. o Review included MAR/TAR, physician orders, care plans, and hospital discharge records for insulin, glucose monitoring, or diabetic care needs. o Any missing or incorrect orders were immediately clarified with the physician and implemented. (1 resident) o Any residents found without current diabetic monitoring or medication orders received immediate physician review. (All medications for non-funded residents will be ordered through the pharmacy and charged in the same manner as a skilled resident, facility's responsibility). (All care plans were audited, with 2 updates made to care plans ) 3. Hospital Discharge Order Reconciliation o A new protocol was implemented effective immediately: A licensed nurse and the DON or designee will review all hospital discharge papers at time of admission or return to ensure all orders are entered correctly into the EMR (PCC). (Medication reconciliation form ) The receiving nurse must confirm medication orders, follow-up appointments, and labs on all new and readmitted resident. (This will be tracked daily in the clinical morning meeting by the DON/Designee) Any additional education will be provided to the DON if there are any discrepancies.) Orders will be reviewed by the DON or designee on all admission and noted as reviewed in the EMR. (Within 24 hours after admission) 4. Physician/Nurse Practitioner Notification and Oversight o The facility's Medical Director and NP were re-educated by the Chief Nurse Officer 5/19/25 on the responsibility to review MAR/TAR and hospital discharge notes on every visit. o The facility implemented a process that requires weekly NP review of high-risk residents, including diabetic and non-funded residents. (Medications will be ordered from the pharmacy and cost occurred outside of LOA will be supported by the facility. NP review will be monitored by use of change of condition form) ( Change of condition forms on PCC will be reviewed daily in clinical stand up by DON / Designee to ensure compliance. 5. Education and Training o Emergency in-service conducted on May 19th, 2025, by Director of Nurses to all licensed nursing staff on: ( DON was provided training prior to in-servicing others by CNO. Importance of following hospital discharge orders. Recognizing signs/symptoms of hypo/hyperglycemia. Diabetic care management and documentation requirements. Immediate reporting of missing or unclear orders. (in-service and posttest) o Re-education for DON and ADON on responsibilities during admission/re-admission. (By: CNO) 5/19/25) 6. Monitoring and Quality Assurance o Indefinite Daily audits of all new admissions and re-admissions to ensure: Hospital discharge orders are obtained, reviewed, and implemented timely. Daily review in clinical morning meeting). Medication orders are entered into the EMR correctly. o All audits are reviewed by the Administrator or Regional Nurse Consultant daily. o Ongoing Monthly QA audits will be conducted thereafter and tracked via QAPI. 7. Accountability and Leadership Oversight o DON educated on policy and procedure. ( By: CNO policy reviewed, and DON acknowledged understanding with verbal and written acknowledgment. o Additional coverage and oversight by Chief Nursing Officer ( Weekly X 6 weeks then monthly. The Surveyor monitored the POR on 05/20/2025 from 1:00pm to 7:00 pm as follows: During interviews on 05/20/2025 from 1:00 pm -7:00 pm, three LVNs ( LVN B, C and D), 1 RN (RN D) from all shifts stated they had been in-serviced by the DON and the Interim Administrator/ CNO and they learned about the types of orders, expectations, what to look for when reviewing orders, admissions/readmissions process, new procedures, scope of practices for MAs and nurses, following orders, review residents EHR and verified compliance with physician orders, review MAR/TAR, physician orders, care plans, and hospital discharge records for insulin, glucose monitoring, or diabetic care needs. They all stated the DON would review orders on all admissions and comparing to EHR to ensure completed within 24 hours of admission. During an interview on 05/20/2025 at 3:40 pm the DON stated she completed a full audit of all current residents with diabetes diagnoses on 05/19/25. Review included MAR/TAR, physician orders, care plans, and hospital discharge records for insulin, glucose monitoring, or diabetic care needs. The DON stated the CNO in-serviced her before completing the audit on 05/19/25. The DON stated Resident #1 was identified as the only resident with missing or incorrect orders that was immediately clarified with the physician on 05/19/25. The DON stated there were no residents identified as requiring immediate physician review because none were without current diabetic monitoring and medication orders. New protocol immediately implemented by her and licensed nurses on 05/19/25 on reviewing all hospital discharge papers at the time of admission and readmission. The DON stated there were no new admissions nor readmissions since 05/19/25. The DON stated she was conducting daily tracking to ensure receiving nurse confirmed receiving discharge papers and orders at time of admission and readmission. The DON stated she was also reviewing orders on all admissions and comparing to EHR to ensure completed within 24 hours of admission. The DON stated the MD and NP were re-educated by the CNO on 05/19/25 to review MAR/TAR and hospital discharge notes on every visit. The facility also started having NP review weekly high-risk residents on 05/19/25. The DON stated she immediately in-serviced and gave post-tests on all licensed nursing staff on 05/19/25 on importance of following hospital discharge orders, recognizing signs/symptoms of hypo/hyperglycemia, diabetic care management and documentation requirements, and immediate reporting of missing or unclear orders. She was also trained before the in-service by the CNO on 05/19/25. The DON stated the CNO re-educated her on admission/readmission process on 05/19/25. Indefinite daily audits of all new admissions and re-admissions to ensure hospital discharge orders are obtained, reviewed, and implemented timely and medication orders are entered into the EHR correctly. QAPI was conducting monthly reviews thereafter. The DON stated she was educated by the CNO and signed an acknowledgement of the policies and procedures regarding medication administration, physician orders for diabetic's process, and admission/readmission process. CNO would oversee weekly for the next six weeks and then monthly. During an interview on 05/20/2025 at 5:18pm Interim Administrator/CNO stated she in-serviced the DON on the importance of admission/readmission process and responsibilities, following hospital discharge orders, recognizing signs/symptoms of hypo/hyperglycemia, diabetic care management and documentation requirements, immediate reporting of missing or unclear orders on 05/19/25. The Interim Administrator/CNO stated the DON also signed an acknowledgement on 05/19/25 before in-servicing the remainder of staff on 05/19/25. The Interim Administrator/CNO stated she reviewed the policy and DON signed acknowledging policy and procedure reviewed on processes. The Interim Administrator/CNO stated she oversaw to ensure processes completed weekly for the next 6 weeks and then monthly. Review of facility's in-services dated 05/19/2025 reflected the following: Facility had an ADHOC QAAC for identification of deficient practice. DON: Review Medication orders on admission: following hospital discharge orders, recognizing symptoms of hypo/hyperglycemia, Diabetes care/ management, reporting missing/unclear orders presented by the Interim Administrator/CNO and signed by the DON. Nurses: Medication Administration: following hospital discharge orders, recognizing symptoms of hypo/hyperglycemia, Diabetes care/ management, reporting missing/unclear orders presented by the Interim Administrator/CNO and the DON; signed by LVN B and LVN F and via phone for LVN C and RN D. Education to Physician/NP on MARs/TARs on new/readmissions. Weekly Review of high-risk residents regardless of payer. LOA residents require same level of care as skilled. MD stated and acknowledged understanding of medication process, missed dosage of medication due to transcription error presented by the Interim Administrator and the DON signed by Interim Administrator and the DON on behalf of the MD and the NP . Abuse, Neglect and Physician Orders quiz completed by Nurses including the DON, LVN B, LVN C via phone, RN D via phone, MA E via phone, LVN F Administering Medications policy, revised April 2019, reflected DON was reeducated on policy. Abuse, neglect and physician's orders post-tests were completed by licensed nurses. DON audit of all residents with diabetes diagnoses, conducted 05/19/25, reflected the DON reviewed MAR/TAR reflecting accurate orders, ensured medication reconciliation, diagnosis of diabetes, physician orders, care plans reflect diabetes, glucose monitoring and diabetic care needs, hospital discharge orders reviewed, and insulin ordered and administered as ordered. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/2025 at 4:19 pm and an IJ template was given. While the IJ was removed on 05/20/2025 at 7:01pm, the facility remained out of compliance at a severity of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident# 25) reviewed for elopement and failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 1 shower rooms reviewed for quality of care. A) The facility failed to ensure Resident #25 was monitored for wandering and elopement. Resident #25 eloped from the facility on 05/14/2024 without facility knowledge and was found at the convenience store 0.4 miles away. An immediate Jeopardy (IJ) situation was identified on 05/29/2024 at 1:22 PM. While the IJ was removed on 05/31/2024 at 1:00 PM, the facility remained out of compliance because of the facility's need to evaluate the effectiveness of its corrective systems. This failure places residents at risk for elopement, accidents, and heat exhaustion due to lake of supervision. B) The facility failed to ensure two spray bottles containing a degreaser and a disinfectant were not left in an unlocked shower room. This failure could lead to unintentional ingestion, inhalation or eye contact with chemicals leading to injury and hospitalization. Findings included: A) Review of Resident #25's Face sheet dated 05/28/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Vertigo (A sense of spinning experienced even when someone is perfectly still.), anxiety disorder, (Fear characterized by behavioral disturbances) and lack of coordination. Review of Resident #25 Annual MDS dated [DATE] reflected he was assessed to have a BIMS score of 7 indicating moderate cognitive impairment. Resident #25 was assessed to not have wandering behavior during the assessment period. Resident #25 was assessed to require moderate assist with ADLs. Review of Resident #25's Comprehensive care plan reflected a focus area dated 09/23/22 Resident #25 has impaired cognitive function/dementia or impaired thought processes r/t Dementia, impaired decision making. Further review reflected a focus area dated 01/10/0223 Resident #25 has vertigo related to dizziness. And a focus area dated 07/26/2022 Resident #25 is a wanderer r/t Disoriented to place. He has ideations of wanting to go home and believes he has a vehicle at the community that he can get in and drive. Goals included: The resident's safety will be maintained through the review date and the resident will not leave facility unattended through the review date. Interventions included: Assess for fall risk. Date Initiated: 07/26/2022; Disguise exits; cover door knobs and handles, tape floor. Date Initiated: 07/26/202, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Date Initiated: 07/26/2022, Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 07/26/2022; Monitor for fatigue and weight loss. Date Initiated: 07/26/2022. Review of Resident #25's nursing progress notes reflected an entry dated 05/13/2024 At approx. 6:25 PM, Resident #25 asked to walk to store, stating they let me do it all the time, I just sign out. This charge nurse verified request with Administrator. This charge nurse was informed that resident cannot leave residence unattended due to being observed breaking the smoking policy and smoking unattended while walking to store on a previous occasion. Resident was mildly argumentative but agreed and verbalized understanding. Further review reflected an entry dated 05/14/2024 at 8:30 PM This resident was observed walking from the facility toward the neighborhood store. Resident stated he went to store to buy candies This charge nurse informed CNA to pick up resident from store due to the fatigue from the walk. The CNA brought resident back to facility. This charge nurse did head to toe assessment. No skin issues noted. Resident denies pain or discomfort at this time. This charge nurse asked resident if he would cooperate with a physical search to make, he doesn't have any unpopular items. Resident refused physical search of himself. Assessed vitals: B/P 124/71, P78, R18, T 98.0. Q 15 min checks initiated. Review of the weather channel website reflected the sunset at the facility on 5/14/2024 was indicated to be at 8:14 PM and the average temperature to be between 82 and 88 degrees Fahrenheit. Review of Google Maps dated 05/14/24 revealed the speed limit on the road Resident #25 walked to be 30 miles per hour and the distance to the store to be 0.4 miles. In an interview on 05/28/2024 at 3:02 PM the Administrator stated the incident with Resident #25 was not reported to the state. She stated he did leave the facility and he did not sign out and the facility did not know where he was. She stated it was not an elopement he just went to the store unattended he likes to get cigarettes. She stated again it was not an elopement, but a behavior and we discourage him from going. Administrator stated she did not know if he was his own responsible party. In an interview on 05/28/2024 at 3:10 PM the DON stated she did not do an investigation of Resident #25's elopement just what was in the nursing notes she stated he had some confusion, but he was pretty much with it. Review of Resident #25's consolidated physician orders reflected an order dated 05/11/2024 Hydrocodone-Acetaminophen 10-325mg by mouth four times daily for low back pain. Further review reflected an order dated 12/05/2022 Meclizine HCL 12.5mg one tablet every 6 hours for vertigo. Review of Resident #25's Behavioral Health care note dated 05/17/2024 This is a follow-up visit and the staff reports that the patient continues to have occasional mood swings and depression. Staff stated that the patient left and went to the store without permission. He started yelling at caregivers and refused to be checked when he came back .Patient stated that he went to the store to buy cigarettes. He denied yelling at staff though and stated that he is a grown man and can do whatever he wants . In an interview on 05/28/2024 at 3:18 PM CNA E she stated that Resident #25 wanders, but she has never seen him leave she stated she was told if he tries to leave, and we caught him that we are to put him on 15 min checks. She stated he was pretty much with it. In an interview on 05/28/2024 at 3:20 PM Resident #25 stated he feels comfortable going out by himself stated he likes to go get M&Ms. He stated, They won't take me, so I just take off, It's only a quarter of mile. Observation on 05/28/2024 at 3:36 PM revealed both the front and back exit doors without locks and an alarm that was barely audible. In an interview on 05/28/2024 at 10:32 AM the DON stated Resident #25 did not elope she stated he was alert. When asked if anyone knew he was gone, she stated no. She further stated he has had an increase in narcotic use due to a fall and complaints of hip pain. She stated she has heard of his behaviors of confusion and wandering but has not seen any. She did not know what the facility's policy was regarding elopement. She stated the nurses could not see the front door from the nurse's station and they could not hear the door alarms from there. Review of Resident #25's EMR reflected an elopement assessment dated [DATE] (no previous elopement assessments were done.) Review of the elopement assessment reflected Resident #25 was assessed to have a 12-elopement risk score indicating he was at risk for elopement. In an interview on 05/29/2024 at 10:38 AM LVN A stated she had been here for about 2 weeks; she stated Resident #25 was alert and knows what is going on. She stated she was told he likes to go to the store, but he was not supposed to go. LVN A stated she cannot see the doors or hear the alarms. She further stated she did not think it was safe for Resident #25 to go to the store alone. In an interview on 05/29/2024 at 11:20 AM Resident #25's facility Physician stated regarding Resident #25's cognitive status It depends she stated she was aware he has left in the past and has had a recent increase in his pain medication. She stated sometimes he is confused and not aware of his safety needs and other times he is aware of his needs. In an interview on 05/29/2024 at 11:42 AM the facility RN C stated an elopement was when someone would leave the facility and does not come back. She stated resident #25 was found at the store and he did not sign out, but he knows where he is going, she stated the facility did not report the incident because they did not feel like it was an elopement because they figured he went to the store. When asked if the facility knew when he left or how long he was gone the RN C stated they did not. In an interview on 05/29/2024 at 11:50 AM Resident #25's RP stated his dad should definitely be supervised and should not walk all the way to the store on his own. He stated Resident #25 did not handle the heat very well. He stated he has episodes of confusion and states he wants to go home sometimes. He stated sometimes he is fine but should definitely be supervised. In an interview on 05/29/2024 at 2:39 PM CNA G stated he was working when Resident #25 left the faciity on [DATE]. He stated he took the residents out on their last smoke break around 6:00 PM or 6:30 PM and he stated Resident #25 stayed outside on the back porch after the break. CNA G stated he was ok to be outside by himself just not to smoke. He stated the RN charge nurse told him she thought Resident #25 had left the facility because a resident told her she saw him leave and to go get him. CNA G stated he left to go get him after he finished the shower he was giving. CNA G stated Resident #25 was at the railroad tracks coming back to the facility. He stated it was still daylight. CNA G stated he was not sure what time it was he stated Resident #25 told him he wanted candy and that was why he left the building. CNA G stated Resident #25 came back without issues. In an interview on 05/30/2024 at 1:53 PM the DON stated regarding Resident #25's elopement and updating his care plan to include his behavior, she stated Well that is questionable when asked why she stated, I did not think he eloped. The DON stated care plans should be updated after changes in condition or behavior and failure to do so could cause staff to overlook something that could affect the resident's care. Attempts to contact RN Charge Nurse on 05/28/2024 at 3:25 PM, 05/29/2024 at 2:00 PM and 5/30/2024 at 10:30 AM were unsuccessful. B) Observation on 05/29/2024 at 1:15 PM in the unlocked shower room revealed two spray bottles hanging from hooks on the wall above the linen cart and approximately 6 feet from the floor. The linen cart was located in a indented area of the wall. One bottle was labeled Non-acid Restroom Cleaner Disinfectant, and the other bottle was labeled a Degreaser. Both bottle labels were from the same chemical company. Both bottles stated Warning: causes eye irritation. Avoid contact with eyes, skin, and clothing. Wash hands and affected area thoroughly after handing. First aid: If in eyes: rinse cautiously with water for several minutes. Continue rinsing for 15 minutes. If eye irritation persists, get medical attention. If on skin: Wash with plenty of water, if skin irritation persists, get medical attention. See label on original container for complete direction for use and additional information. Keep out of reach of children. Review of the product Material Safety Data Sheet for the Non-Acid Restroom Cleaner Disinfectant found online at the manufacturer's website reflected If swallowed, rinse mouth. Do not induce vomiting without medical advice. If conscious, dilute by drinking up to a cupful of milk or water as tolerated. If inhaled, move the person to fresh air and keep comfortable for breathing. Start first aid. Immediately call a poison control center or physician. Classification: eye damage, skin irritation and acute toxicity. Hazard statements: Causes serious eye damage and skin irritation. Harmful if swallowed. In an observation and interview on 05/29/2024 at 3:25 PM in the shower room, the ADM stated the chemicals in the spray bottles were not a brand that the facility used. She opened one bottle, sniffed it, and stated it's just vinegar. Observation in the shower room on 05/29/2024 at 4:40 PM revealed the spray bottles had been removed. In an interview on 05/30/2024 at 3:37 PM the DON stated her expectation was that chemicals should be locked up as the potential risk to the resident could be their skin might break out. She stated she had removed them from the shower room when informed by the ADM that they were in there. In an interview on 05/30/2024 at 4:25 PM the ADM stated chemicals should be locked up and the risk to the resident depends on the chemical. She again stated the chemicals she observed in the shower room were not a brand that the facility used. She had no further comment. Review of an undated facility policy and procedure titled Material Safety Data Sheet reflected Policy Statement: A current Material Safety Data Sheet (MSDS) will be obtained and kept on file for each hazardous chemical stored or used in our facility. The program coordinator is responsible for receiving and reviewing all material safety data sheets (MSDSs) before chemicals are used by employees. Review of the MSDS book for the facility did not include the Material Safety Data Sheets for the two spray bottles found in the shower room. Review of an undated facility policy and procedure titled Location of Hazardous Chemicals reflected Hazardous chemicals and/or materials are maintained in the following locations: housekeeping closet, maintenance closet, maintenance office, kitchen, dietary storage, storage shed. B) Observation on 05/29/2024 at 1:15 PM in the unlocked shower room revealed two spray bottles hanging from hooks on the wall above the linen cart and approximately 6 feet from the floor. The linen cart was located in a indented area of the wall. One bottle was labeled Non-acid Restroom Cleaner Disinfectant, and the other bottle was labeled a Degreaser. Both bottle labels were from the same chemical company. Both bottles stated Warning: causes eye irritation. Avoid contact with eyes, skin, and clothing. Wash hands and affected area thoroughly after handing. First aid: If in eyes: rinse cautiously with water for several minutes. Continue rinsing for 15 minutes. If eye irritation persists, get medical attention. If on skin: Wash with plenty of water, if skin irritation persists, get medical attention. See label on original container for complete direction for use and additional information. Keep out of reach of children. Review of the product Material Safety Data Sheet for the Non-Acid Restroom Cleaner Disinfectant found online at the manufacturer's website reflected If swallowed, rinse mouth. Do not induce vomiting without medical advice. If conscious, dilute by drinking up to a cupful of milk or water as tolerated. If inhaled, move the person to fresh air and keep comfortable for breathing. Start first aid. Immediately call a poison control center or physician. Classification: eye damage, skin irritation and acute toxicity. Hazard statements: Causes serious eye damage and skin irritation. Harmful if swallowed. In an observation and interview on 05/29/2024 at 3:25 PM in the shower room, the ADM stated the chemicals in the spray bottles were not a brand that the facility used. She opened one bottle, sniffed it, and stated it's just vinegar. Observation in the shower room on 05/29/2024 at 4:40 PM revealed the spray bottles had been removed. In an interview on 05/30/2024 at 3:37 PM the DON stated her expectation was that chemicals should be locked up as the potential risk to the resident could be their skin might break out. She stated she had removed them from the shower room when informed by the ADM that they were in there. In an interview on 05/30/2024 at 4:25 PM the ADM stated chemicals should be locked up and the risk to the resident depends on the chemical. She again stated the chemicals she observed in the shower room were not a brand that the facility used. She had no further comment. Review of an undated facility policy and procedure titled Material Safety Data Sheet reflected Policy Statement: A current Material Safety Data Sheet (MSDS) will be obtained and kept on file for each hazardous chemical stored or used in our facility. The program coordinator is responsible for receiving and reviewing all material safety data sheets (MSDSs) before chemicals are used by employees. Review of the MSDS book for the facility did not include the Material Safety Data Sheets for the two spray bottles found in the shower room. Review of an undated facility policy and procedure titled Location of Hazardous Chemicals reflected Hazardous chemicals and/or materials are maintained in the following locations: housekeeping closet, maintenance closet, maintenance office, kitchen, dietary storage, storage shed. Review of the facility's policy Elopements (not dated) reflected Staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing . 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. The Administrator was notified on 05/29/2024 at 1:22 PM, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 05/30/2024 at 5:01 PM: PLAN OF REMOVAL OF IMMEDIATE JEOPARDY F689 On 05/29/2024 at approximately 1:20 PM, the facility was notified by an HHSC employee the facility was in Immediate Jeopardy (IJ) with allegations of Supervision (F689) noncompliance. The surveyor provided an Immediate Jeopardy (IJ) Template notification via email that the Regulatory Services has determined that Immediate action is required to ensure residents are safety. Action: o On 5/29/24 R25 was immediately placed on every 15 min checks Nurse or designee will be assigned to do the monitoring and documentation on paper indicated q 15 min visual checks, Director Of Nursing or Nurse manager will oversee to make sure it's being completed, until the facility can transfer R25 to another facility with secure unit, waiting on approval from facility that has a secure unit, clinicals were sent. o On 5/29/24 Director of Nursing/nurse managers Immediately reviewed residents with Dementia diagnosis or wandering behaviors for elopement risk, all resident's elopement risk assessment was completed to determine risk level, 1 Resident #R25 was only identified to be at risk for elopement at this time. Elopement assessments will be completed on admission and if changes in mental cognition, and yearly. o On 5/29/24 Regional Director of Clinical Operations in-service Administrator/Director of Nursing on Provider Letter for investigation and reporting Elopement to the state. Administrator/ or designee Immediately in-service all staff Full time, Part- Time and PRN, in person and those not present were in-service via phone, 100% completion on elopement policy, exit seeking behaviors per policy, safety and supervision. New employees will be trained as part of their orientation. o On 5/29/24 Maintenance inspected the Alarms at the door entrance and exits for proper functioning, he identified the volume was low and was able to increase volume for staff to hear if someone was exiting. Door locking mechanisms were inspected for both front and dining room doors and were found to be in working order, doors will be locked after visiting hours between 10pm and 6am. o On 5/29/24 MDS nurse reviewed all residents who have diagnosis of Dementia, to make sure interventions and correct supervision were in place for the nursing staff to be able to see in the electronic health record (EHR). Director of Nursing in-service the Nursing staff in person, and the nursing staff not present were in-service via phone on where to find in the information in the care plan and [NAME] (nurse to nurse communication form). o Please review and accept this Plan of Removal. All items above have been completed with completion date and time May 30,20024 The Survey Team monitored the POR on 05/29/2024 through 5/31/2024 as followed: Review of nursing notes dated 05/29/2024 reflected an entry at 12:56 PM the DON spoke with resident's RP, notified him that resident will need to be transferred to locked unit and there is a room available at another facility, we will be sending records to them. He expressed understanding. Review of the facility's 24-hour 1:1 Monitoring and Safety check for Resident #25 reflected the monitoring started 05/29/2024 at 11:15 AM and ongoing. In an interview on 05/31/2024 at 10:58 AM the DON stated she was checking the sheet two times per shift to make sure it was done. Review of the 1:1 in-service for Administrator and DON reflected in-services were conducted on 05/29/2024 regarding elopement, and the provider letter safety/ supervision. The in-service was signed by the RNC as the trainer and the Administrator and DON as the recipients of the training. In an interview on 05/31/2024 at 11:10 AM the Administrator stated she was provided a 1:1 in-service from the RNC and was given instruction on elopements, starting to lock the doors at night, activate alarms and replaced broken alarms and purchasing a door bell. Administrator stated was instructed to report elopements as soon as it is reported to her. In an interview on 05/31/2024 at 11:11 AM the DON stated she was instructed on elopement. She stated when an elopement occurs staff should try to stop the resident from leaving and place them on every 15 min checks. She was also instructed that the incident should be reported the State. She stated, I think the confusion came from us not thinking his leaving was an elopement. She stated she was aware now that it was considered an elopement if the resident leaves and the facility was not aware. Review of the in-service training provided to the facility staff by the RNC dated 05/29/2024 through 05/31/2024 reflected the topic was elopement, safety, supervision, and unauthorized departures. The in-service was signed by 31 of the 38 total employees. In an interview on 05/31/2024 at 11:30 AM the DON stated the employees not yet in serviced will be in serviced before they come to work. In an interview on 05/30/2024 at 3:18 PM CNA G stated, We had an in-service about the difference in elopement and leave without signing. Elopement is when they leave with no one knowing and the other is when they tell someone first. Stated they are to monitor for these behaviors and if some is trying to leave, they have to be put on every 15 min checks. In an interview on 05/30/2024 at 4:30 PM LVN Charge nurse LVN A she stated she was trained on elopement, and they are doing q15 min checks on Resident #25. She stated they told her that if they do have a resident that is missing to notify administration right away. She stated she was also told to make sure the front door is locked at 10 pm if she is working the evening shift. In an interview on 05/31/2024 at 11:38 AM LVN B she stated she was trained on elopement, and they are doing q15 min checks on Resident #25. She stated they told her that if they do have a resident that is missing to notify administration and to make sure the door alarms are on and working. In an interview on 05/31/2024 at 11:58 AM CNA Y stated she was in-serviced on elopement and monitoring residents that try to leave and to notify nurses if it occurs. She stated elopement was when a resident leaves and you did not know about it. Also, to keep an eye on Resident #25 every 15 min. In an interview on 05/31/2024 at 12:05 PM CNA J (night) stated she was in-serviced over the phone and was instructed the doors are to be lock at 10:00 PM till 6:00 AM and monitor wandering behaviors. They talked about elopement and to report to nurse if someone is missing. In an interview on 05/31/2024 at 12:20 PM CNA K stated she was in serviced on 05/29/2024 about residents leaving and if a resident is trying to leave tell the nurse and put them every 15 min checks and if they get out to tell charge nurse right away. Also, to keep doors locked at night now. In an interview with the Maintenance supervisor on 05/31/2024 at 11:38 AM checked all door alarms and replaced with louder alarms. Inspected the door locking mechanisms and all were working. Was in-serviced on elopement and monitoring residents for behavior. Observation on 05/31/2024 at 11:45 AM revealed alarms working on all exit doors and alarms are audible. Review of the list of Dementia residents provided by the facility reflected 14 residents. Review of the 14 Resident EMR's reflected elopement assessment done. No high risk for elopement was identified. On 05/31/2024 at 2:00 PM the facility was notified the IJ was lowered to no actual harm with the potential for more than minimal harm.