**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for elopement. The facility failed to ensure Resident #1, who was an elopement risk, was not left outside in the secure unit courtyard by himself on 08/13/24. The noncompliance was identified as PNC IJ. The IJ began on 08/13/24 and ended on 08/18/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving their medications and meals, going missing, or sustaining injuries, dehydration, or death. Findings included: Review of Resident #1's face sheet, dated 09/25/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified dementia (a group of diseases that cause a loss of cognitive functioning that interferes with daily life), anxiety disorder, and unspecified mood disorder. Review of Resident #1's admission MDS assessment, dated 08/19/24, reflected he had a BIMS of 4, which indicated he had severe cognitive impairment. Review of Resident #1's care plan, dated 08/16/24, reflected he had a diagnosis of dementia and resided in the secure unit due to his known history of wandering and poor safety awareness allowing freedom of mobility. Staff noted on 08/13/24, Resident #1 eloped from secure unit courtyard stating he climbed over the fence. Interventions included refer Resident #1 to behavioral facility for evaluation and treatment, initiate 1:1 monitoring until psychological services discontinues 1:1 monitoring, psychological/psychiatric services evaluation and treatment, initiated medication review with psychologist/MD/Pharmacist as needed, Resident #1 required supervision when he wanted to go outside and encourage extra hydration, encourage to attend group activities daily, have an elopement assessment done on admission, quarterly, and with significant change in condition, provide Resident #1 with activities based on his prior lifestyle/interests if Resident #1 wanders, conduct medical evaluation per MD orders, speech will evaluate and treat for cognition, staff will monitor Resident #1 and report changes in exit seeking behaviors to the ADM, DON, physician and RP, and provide comfort measures for Resident #1's basic needs when he began to wander. Review of Resident #1's elopement risk assessment, dated 08/08/24, reflected he was at risk for elopement with an intervention of being placed in the secure unit. Review of Resident #1's progress notes reflected the following: - LVN A documented on 08/12/24 at 5:48 p.m., Resident day 3/7 admission and resident alert and oriented to self with forgetfulness. Resident noted up pacing all night and as he was pacing proceeded to knock on adjacent doors and required staff redirection. Resident would apologize to staff then continued to pace up and down hall and stated he cannot sleep. Resident will continue to be monitored. - LVN B documented on 08/13/24 at 12:20 a.m., Resident day 6/7 new admit, resident very pleasant, able to make needs known, stated to the nurse he has no pain or discomfort. Nurse noted him wandering from room to room throughout the night, open other residents room doors, he was confused as to what he need and what he was looking for. Staff had to keep directing him back to his room. -LVN B documented on 08/13/24 at 5:22 a.m., Resident did not sleep throughout the night he kept coming out of his room going into other rooms. Staff had to be redirected back into his room. -LVN A documented on 08/13/24 at 6:58 p.m., This staff was alerted by CNA staff that resident was let out to courtyard. This staff walked perimeter of the fence line and alerted other staff as well as DON of missing resident. [PD] was contacted and given description of resident wearing longhorns baseball hat along with grey shirt and khaki shorts. Head count was completed by this staff of 17 accounted for with 1 resident eloping noted 18 before elopement. [PD] then called this staff and alerted resident was found and will be returned per [PD]. Resident returned with no visible sign of injury. Resident ambulated independently back to secured unit without any behaviors and was noted happy and noted with sweaty shirt. Head to toe assessment was noted with no injuries b/p taken and noted 127/68 p74 temp 98.3 spo 97% on rrom air. Resident denies pain or distress, officer stated resident stated he had to walk because his car broke down. Resident sitting in common area water offered and taken well. This staff was then told by don 1 to 1 in place. -DON documented on 08/13/24 at 8:13 p.m., This nurse went to check on resident after returning to facility. Resident was noted to be happy and sitting in recliner in common area drinking water. Resident noted to have sweat on T-shirt. resident ask where he went and he stated for a long walk. Resident denied pain and had no noted visible sign of injury. I ask resident if he could he show me what he did and he said yes, physical therapist and myself walked him outside in courtyard and resident went to fence pointing up to a post and showing us that he just grabbed up and pulled over the fence. resident was easily redirected to inside the building. I ask resident if he would like more water and a snack and he stated yes. Water and pizza was provided to staff and he ate all and drank as he was eating. Resident remains happy and joking. states that he is a little tired now. -DON documented on 08/13/24 at 9:13 p.m., I went to check on resident and he was in bed at this time, I ask if he would like to shower and he declined at this time, I did a head to toe assessment and noted no bruises or scratches to body on anterior or posterior side. Left knee noted to be red in color and resident stated hit it on fence. Resident given glass of water and tolerated well. MD notified of elopement with med review done and stated no lab to be done at this time. Medical director notified as well. Resident remains one on one monitoring at this time. -DON documented on 08/13/24 at 9:31 p.m., I notified resident [family] about elopement and updated on resident overall condition. Resident [family] stated he did this at home all the time. [Family] states they went hiking all the time with me as I am a wildlife photography and he can out do me for sure. [Family] stated he is appreciative for the update and has no concerns at this time. During a group interview on 09/25/24 at 10:31 a.m., the DON and the HRC stated Resident #1 was a new resident. The DON and the HRC stated Resident #1 was in the facility's secure unit courtyard and hopped over the fence. The DON and the HRC stated staff searched for Resident #1, notified the police, and found him. The DON stated her and a physical therapist took Resident #1 out to the secure unit courtyard again and Resident #1 demonstrated how he climbed over the fence. The DON and the HRC stated Resident #1 was in the secure unit courtyard getting fresh air. The DON and the HRC stated they did not know if anyone was outside in the secure unit courtyard with Resident #1. The DON stated CNA C let Resident #1 out into the secure unit courtyard, went to check on another resident, came back to secure unit courtyard, noticed Resident #1 was missing, and notified a night shift nurse. The DON stated she was in the facility when staff notified her that Resident #1 was missing. The DON stated Resident #1 told staff that he wanted to leave, when asked why he climbed over secure unit courtyard fence. The DON stated Resident #1 also told staff he climbed over the secure unit courtyard fence because his car broke down and he was trying to find a phone. The DON stated Resident #1's family told staff that Resident #1 would leave home in the past. The DON stated Resident #1 never eloped at the facility in the past and had been at the facility for one week since admission. The DON stated CNA C told her that Resident #1 did not leave the secure unit courtyard in the past, wanted to go outside, let him out, and did not think he would climb over the fence. The DON stated Resident #1 had no prior exit-seeking behaviors, but Resident #1's family told her that Resident #1 would leave the house in the past prior to his admission, which was why he was considered exit-seeking. The DON stated she believed the secure unit courtyard fence was approximately 8-10 feet and CNA C did not think Resident #1 would climb the fence and leave. The DON stated staff implemented visual observations of Resident #1 and had psychological services visit Resident #1 following the incident. The DON stated Resident #1 was no longer on 1:1 monitoring at the time of the interview because psychological services told staff that they could stop 1:1 monitoring of Resident #1. The DON stated staff documented all 1:1 monitoring performed on Resident #1. The DON stated Resident #1 had short-term memory issues. The DON stated Resident #1's family wanted to place Resident #1 in a facility because he wanted to wander out of the house and would get up and leave the house. The DON stated staff were educated on elopement and other trainings. The DON stated staff did not have orientation training specifically on the topic of elopement prior to beginning employment. The DON stated staff were in-serviced monthly and with elopement being one of the topics reviewed. The DON stated staff were taught to be out in the secure unit courtyard accompanying and supervising residents following Resident #1's incident. The DON stated before Resident #1's incident, residents could walk in the secure unit courtyard, staff could frequently check on residents and were not required to supervise residents in the area. During an interview on 09/25/24 at 10:46 a.m., the DON stated Resident #1 was sent to a behavior hospital on [DATE] because of his exhibited aggressive behaviors towards another resident and returned 09/13/24 because he had no behaviors in the hospital. The DON stated Resident #1 did not exhibit any aggressive or exit-seeking behaviors since returning from the hospital. An observation of the secure unit courtyard on 09/25/24 at 11:46 a.m. reflected the courtyard was empty, there were no residents in the area at the time of the observation, there was a fence that stretched the entire landscape with no openings, and approximately 10 feet tall. An observation of the door leading to the secure unit courtyard on 09/25/24 at 11:51 a.m. reflected a sign posted on the door that indicated, Do not let residents out of the facility unassisted. During an interview on 09/25/24 at 11:56 a.m., CNA D stated she could not recall when staff posted the sign on the door leading to the secure unit courtyard, but she believed it was a month or two months ago. During an interview on 09/25/24 at 11:59 a.m., LVN E stated she was given orientation training on elopement and in-serviced by the DON 2-4 times in the last four months on the topic. LVN E stated if a resident asked to go to the secure unit courtyard, she was trained to go out to the courtyard with the resident. LVN E stated she would also bring the resident inside and not leave the resident alone in the secure unit courtyard if another resident needed her help. LVN E stated if a resident was not in the secure unit courtyard, she was trained to initiate the facility's missing resident protocol, start searching the resident, and immediately notify the DON. LVN E stated she never observed a resident climb over the secure unit courtyard fence and did not know how Resident #1 climbed over the secure unit courtyard fence. LVN E stated Resident #1 had no exit seeking behaviors since his incident. LVN E stated Resident #1 was placed on 1:1 monitoring following his incident and taken off 1:1 monitoring after psychological services verified, he was okay. LVN E stated the CNAs and supervising nursing staff initiated Resident #1's 1:1 monitoring. During an interview on 09/25/24 at 12:11 p.m., CNA D stated she was given orientation training on elopement and in-serviced by the DON two weeks ago on the topic. CNA D stated if a resident asked her to go to the secure unit courtyard, she was trained to go out to the secure unit courtyard with them. CNA D stated she would bring the resident back inside the facility and not leave the resident alone in the secure unit courtyard if another resident needed her help. CNA D stated if a resident was not in the secure unit courtyard, she was trained to notify a nurse. CNA D stated there was also a doorbell for assistance in the secure unit courtyard. CNA D stated she helped conduct 1:1 monitoring for Resident #1 every 15 minutes after his incident. CNA D stated Resident #1 had no previous or subsequent elopement incidents. CNA D stated she documented Resident #1's 1:1 monitoring on physical log sheets. CNA D stated she never had a resident climb over the secure unit courtyard fence. CNA D stated she did not know how Resident #1 climbed over the secure unit courtyard fence because Resident #1 did not have any marks, scratches, or scars. CNA D stated Resident #1 had no exit seeking behaviors since the incident. CNA D stated Resident #1 was taken off 1:1 monitoring after psychological services verified, he was okay. During an interview on 09/25/24 at 12:23 p.m., the MR stated she helped supervise residents in the secure unit. An observation of the secure unit and interview on 09/25/24 at 12:24 p.m. reflected Resident #2 wandering to the secure unit entrance doors. CNA D monitored and redirected Resident #2 away from the doors. Resident #2 stated she was doing fine, felt safe, never wanted to leave the facility, and staff checked on her. An observation of the secure unit on 09/25/24 at 12:26 p.m. reflected Resident #3 wandering to the secure unit entrance doors. LVN E monitored and redirected Resident #3 away from the doors. An attempt to interview Resident #3 was made, but he was unable to answer any questions. An observation and interview of Resident #1 on 09/25/24 at 12:28 p.m. reflected he had no scratches, marks, or scars. Resident #1 stated he could not remember how and why he climbed over the secure unit courtyard fence, but he believed it was determination. Resident #1 did not explain why it was determination. Resident #1 stated he also could not remember how long he was away from the facility after he climbed the secure unit courtyard fence. Resident #1 stated he never attempted to climb over the secure unit courtyard fence after his incident. Resident #1 stated he felt safe, staff checked on him often, he had no injuries from his incident, and did not want to leave the facility. An attempt to contact Resident #1's RP was made on 09/25/24 at 12:46 p.m. A voicemail and call back number was left. Resident #1's RP did not return the call prior to exit. During an interview on 09/25/24 at 12:47 p.m. the NP stated staff notified her about Resident #1's elopement episodes. The NP stated Resident #1 tried to leave when he was admitted , which was why he was assigned to reside in the secure unit, because staff had an elopement unit. The NP stated she was notified whenever Resident #1 tried to leave the facility. The NP stated Resident #1 had behavior issues. The NP stated police were called when Resident #1 somehow climbed over the secure unit courtyard fence. The NP stated staff encouraged Resident #1 to come back to the facility. The NP stated to her knowledge, Resident #1 was never out of staff's sight. The NP stated to her understanding, Resident #1 broke through the secure unit courtyard fence and did not climb over the fence. The NP stated Resident #1 was always trying to leave, but he never got that close to leaving the facility. The NP stated Resident #1 medications changed and staff had no problems since he returned from the behavior hospital. The NP stated she heard about Resident #1's incident 1-2x weeks before his transfer to a behavior hospital. The NP stated she last visited Resident #1 at the facility 3 weeks ago. The NP stated she reviewed Resident #1's new medications implemented at the behavior hospital and continued the medications after he returned from the behavior hospital because they were effective. An attempt to contact LVN A was made on 09/26/24 at 9:42 a.m. A voicemail and call back number was left. LVN A did not return the call prior to exit. An attempt to contact CNA F was made on 09/26/24 at 9:43 a.m. An attempt to leave a voicemail and call back number was made, but there was an automatic message that indicated the person the user was trying to reach was not accepting calls at the time and automatically ended the call after the message. An attempt to contact LVN G was made on 09/26/24 at 9:44 p.m. A voicemail and call back number was left. LVN G did not return the call prior to exit. During an interview on 09/26/24 at 11:09 a.m., CNA C stated she was given orientation training on elopement and in-serviced by the DON on the topic. CNA C stated if a resident asked her to go to the secure unit courtyard, she was trained to go with the resident. CNA C stated before the training, she was trained to supervise residents within eyesight from the inside of the facility whenever a resident requested to go out into the secure unit courtyard. CNA C explained she would have another staff member monitor the resident in the secure unit courtyard if another resident asked her for help while another resident was in the secure unit courtyard. CNA C stated she was working in the secure unit when Resident #1 eloped from the facility two months ago. CNA C stated Resident #1 asked her if he could go out to the secure unit courtyard and she allowed Resident #1 to go in the secure unit courtyard. CNA C explained residents could go into the secure into courtyard and be supervised by staff within eyesight at the time of the incident. CNA C explained she went back inside the facility to help lie a resident down into bed, returned 5 minutes later, observed Resident #1 was gone from the secure unit courtyard, and immediately notified the nurse. CNA C stated there was another CNA who was supposed to work on her shift the day of the incident, but the CNA called out sick. CNA C stated the DON, LVN G, and LVN A were working at the time when she notified them that Resident #1 was missing. CNA C stated Resident #1 was placed on 1:1 monitoring after his incident. CNA C stated she participated in monitoring Resident #1 every 15 minutes and documented the monitoring she performed on physical log sheets. Review of Resident #1's elopement risk evaluation, dated 08/13/24, reflected he was at risk for elopement with additional interventions of being placed in secure unit, structural activities, and ensuring room was located close to nursing stations and away from exit doors. Review of Resident #1's orders reflected an order by the MD on 08/13/24 to place Resident #1 on one-on-one monitoring through the night and then monitor every 15 minutes for 72 hours. The order was discharged by the MD on 08/28/24 because Resident #1 was discharged to the behavior hospital on [DATE]. Review of Resident #1's psychological evaluation note, dated 08/20/24, reflected he was seen by psychological services 1-5 times a month. Session summary indicated, Patient reported that he missed his home and family very much and reported he thought frequently about returning home. When asked, patient reported he did remember trying to make one elopement attempt reporting that he thought he would go to [NAME]. Patient was a poor historian, he initially reported he had zero family in the area and had no children. Later in the interview, he reported that he did have sons and one son was living somewhere in [NAME]. He acknowledged one escape attempt, reporting that he could vaguely remember going over the fence, but could not remember any details about additional attempts. Plan was to see patient one week to assist with identifying coping strategies to assist with reducing anxiety and improving adjustment as well as referring him for psychiatric evaluation to assist with identifying medications that might assist with reducing agitation and improving his adjustment. Review of Resident #1's psychologist progress note, dated 08/27/24, reflected Resident #1 reported that he continued to miss home, but did not think about eloping because he would have nowhere to go. Plan was to consult with Resident #1's staff regarding his psychotropic medications and supervision and the plan was to see him in two days to reevaluate his status and assist with behavior management. Review of Resident #1's 1:1 monitoring sheets, 08/23/24-08/28/24, reflected staff checked on him every 15 minutes and he had no exhibited abnormal behaviors. Review of Resident #1's census report, dated 09/25/24, reflected he discharged on 08/28/24 and returned 09/13/24. Review of the facility's provider investigation report reflected Resident #1's incident happened on 08/13/24 at 7:41 p.m. in the secure unit and was reported to SA on 08/14/24 at 7:00 p.m. Resident #1 was placed on 1:1 monitoring for 3 days after the incident. There were notices placed on all doors that indicated, No resident should be outside without supervision. Staff were educated on abuse and neglect, wandering, and elopement. Staff also conducted elopement practice drills on 08/13/24. CNA C was interviewed and stated on 08/13/24, she let Resident #1 into the secure unit courtyard at 6:45 p.m. because he asked, she went to change another resident's brief, came back around 7:00 p.m., noticed Resident #1 was not in visible site, and notified the charge nurse on duty. Resident #1 was interviewed and stated he grabbed a bar and climbed over the fence when staff asked him how he got out of the secure unit courtyard. Staff reviewed the facility's missing resident and elopement and wandering policies on 08/13/24. Staff accounted for all residents during their head count except Resident #1 at the time of his incident. Staff also checked all maintenance records on for all doors and gates and ensured they were operable, locked, and secured from 08/12/24 through 08/22/24. Gates and doors passed inspection during the previously mentioned timeframe. All residents were reevaluated for elopement risk observation and had care plans reviewed and revised with new interventions implemented. Staff also verified that all residents' electronic health records included photos of the residents. Staff also updated residents' elopement risk records. Staff were educated on behavior and communication on 08/22/24. Resident #1's progress notes and care plan were updated. Staff were also educated on aggressive behavior on 08/14/24, off-duty call in on 08/13/24, missing resident on 08/13/24, wandering elopement and running away on 08/14/24, abuse and neglect on 08/13/24, and secure unit gates at unknown date. Staff initiated 1:1 monitoring on Resident #1 every 15 minutes from 08/13/24 through 08/18/24. There were no subsequent incidents of elopement. Staff initiated 15 resident safety surveys on 08/14/24, which found residents reported never been harmed by any staff or other residents, never witnessed any form of mistreatment by any staff or other residents, felt safe at facility, staff treated them with respect, and knew who to report mistreatment to. Review of the facility's incident and accident reports reflected Resident #1's elopement incident was documented on 08/13/24 at 8:06 p.m. in which he was placed on 1:1 monitoring every 15 minutes for 72 hours and had a medical work up completed. Review of the facility's admission/discharge report reflected Resident #1 was discharged to a behavior hospital on [DATE]. Review of the facility's wandering, elopement, and running away policy, undated, reflected the following: Wandering: Random or repetitive locomotion that may be foal directed, non-goal directed, or aimless. Elopement: Occurs when a resident leaves the premises or safe area unplanned. Running Away: Occurs when a resident is in distress about admission to a facility. Review of the facility's emergency policy and procedure for missing resident, revised December 2021, reflected the following: Policy statement: Resident elopement resulting in a missing resident is considered a center emergency. Policy Interpretation and Implementation: 1. Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. 2. Staff will implement the protocol for missing resident immediately upon discovering that a resident cannot be located. Review of the facility's wandering and elopements policy and procedure, undated, reflected the following: Policy Statement: The facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. Definitions: 'Wandering' is random or repetitive locomotion that may be goal-directed (e.g., the per on appears to be searching for something such as an exit or person), non-goal directed, or aimless. 'Elopement' occurs when a resident leaves the premises or safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The noncompliance was identified as PNC IJ. The IJ began on 08/13/24 and ended on 08/18/24. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to residents received food prepared in a form designed to meet individual needs for 2 of 2 (Resident #7 and Resident #56) residents reviewed for therapeutic diets. The facility failed to ensure CK K prepared pureed meat for Resident #7 and Resident #56. The facility failed to ensure the Dietary Manager checked the service line for correct consistencies for Resident #7 and Resident #56. The facility failed to ensure CK J did not serve ground meat in place of pureed meat to Resident #7 and Resident #56. The facility failed to ensure DA L checked diet texture against therapeutic orders for Resident #7 and Resident #56. The facility failed to ensure LVN D thoroughly checked Resident #7 and Resident #56's trays for texture-modified diet. The facility failed to ensure CNA F did not feed the wrong texture to Resident #7. An Immediate Jeopardy was identified on 1/17/2024 at 5:13 p.m. While the immediacy was removed on 1/19/2024 at 11:28 a.m., the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm due to the facility's need to continue training and monitoring of the preparation and serving of therapeutic diets as prescribed by the attending physician. These failures placed residents at risk of choking, aspiration (the taking of foreign matter into the lungs with the respiratory current), and death. Findings included: A record review of Resident #7's face sheet dated 1/19/2024 reflected an [AGE] year-old male admitted on [DATE] with diagnoses of unspecified dementia (cognitive impairment), muscle wasting and atrophy (muscle loss), muscle weakness, dysphagia (difficulty swallowing), nausea with vomiting, essential (primary) hypertension (high blood pressure), hyperlipidemia (high cholesterol), and vitamin B12 deficiency anemias. A record review of Resident #7's quarterly MDS assessment dated [DATE] reflected a BIMS score of 3, which indicated severely impaired cognition. This care plan did not reflect Resident #7's need for ADL help while eating. This care plan reflected Resident #7 had coughing or choking during meals or when swallowing medications. This care plan reflected Resident #7 was on a mechanically altered diet. A record review of Resident #7's care plan last revised on 1/18/2024 reflected he was to receive a pureed diet as ordered. A record review of Resident #7's diet order dated 9/13/2023 reflected he was on a pureed diet. A record review of Resident #7's MBSS (Modified Barium Swallow Study) report dated 2/15/2023 reflected the following: RECOMMENDATIONS o Meal Diet: Mechanical soft solids with pureed meats, all solids ground, small bites, slow rate, encourage thorough mastication , effortful swallow, Thin liquids, controlled sips, slow rate, no consecutive swallows, no straws. TREATMENT PLAN Recommendations determined by pathology of swallow function. Tolerance of treatment recommendations to be assessed by facility SLP for appropriateness. Patient will likely benefit from a skilled dysphagia feeding, exercise, and/or management plan directed by a Speech Language Pathologist. A record review of Texas Health and Human Services' document titled Evidence-Based Practices: Managing Aspriation Risk dated December 2023 reflected the following: Overview Aspiration occurs when oropharyngeal (near the esophagus) secretions, food particles, or gastric contents are inhaled into the respiratory tract, often resulting in aspiration pneumonitis or aspiration pneumonia. ·Aspiration Pneumonitis: Chemical injury to the tracheobronchial tree (lower respiratory tract) and lung caused by acute, often witnessed, inhalation of regurgitated sterile gastric contents (gastric acid). ·Aspiration Pneumonia: Infection caused by inhaling oral secretions, stomach contents, or both into the lung, leading to colonization by bacteria. Between 1999 and 2017, over 300,000 deaths were reported due to aspiration pneumonia, with people aged 75 or older making up over three-quarters of those deaths. A record review of Resident #56's face sheet dated 1/19/2024 reflected an [AGE] year-old male readmitted on [DATE] with diagnoses of nausea with vomiting, dysphagia (difficulty swallowing), pain, atypical facial pain, essential (primary) hypertension (high blood pressure), and fracture of base of skull. A record review of Resident #56'admission MDS assessment dated [DATE] reflected a BIMS score of 99, which indicated severely impaired cognition. This MDS assessment reflected Resident #56 was dependent on staff for eating. The MDS did not reflect Resident #56 had signs or symptoms of possible swallowing disorder. The MDS reflected Resident #56 was on a mechanically altered diet. A record review of Resident #56's care plan last revised on 1/18/2024 reflected he was to receive a pureed diet as ordered. A record review of Resident #56's diet order dated 12/26/2023 reflected he was on a pureed diet. During an interview on 1/17/2024 at 10:39 a.m., CK J stated lunch that day was cornbread, black-eyed peas, cauliflower and pork. During observations on 1/17/2024 from 10:40 a.m.-11:30 a.m., CK K was observed pureeing sandwich bread, black-eyed peas, and cauliflower. CK K did not puree pork. During an interview on 1/17/2024 at 11:30 a.m. CK K stated it was her second day working in the facility. An observation on 1/17/2024 at 12:00 p.m. revealed CK J asked CK K, where is the pureed food? CK J then served ground meat to Resident #7 and Resident #56. Observed DA L place plates on food cart. An observation of the tray cart on 1/17/2024 at 12:05 p.m. revealed Resident #7 and Resident #56 had ground meat instead of pureed meat on their trays. An observation on 1/17/2024 at 12:09 p.m. revealed LVN D checked the trays on the cart with Resident #7 and Resident #56's trays. LVN D did not send anything back to the kitchen to be fixed and she approved the trays without lifting the lids from the food items on Resident #7's and Resident #56's trays. An observation on 1/17/2024 at 12:25 p.m. revealed CNA F took Resident #56's tray back to the dining room because liquid had spilled all over the tray. When CNA F got a new tray from the kitchen, the ground meat for Resident #56 was left off the tray. An observation on 1/17/2024 at 12:37 p.m. revealed CNA F set Resident #7's tray on his bedside table as Resident #7 sat up in bed. Resident #7 was non-interviewable and did not speak. During an observation and interview on 1/17/2024 at 12:40 p.m., CNA F stated Resident #7 was on a pureed diet. CNA F took the lid off the ground meat, stirred it, and said to Resident #7 do you want to start with the meat? as she raised the utensil up to spoon feed Resident #7. When asked if the meat looked pureed, CNA F said no and it's ground as she stopped herself from spoon feeding Resident #7. CNA F stated it had happened once before where the pureed meat came ground. CNA F said Resident #7 could choke if he got ground meat and said, I'm not gonna feed him that. During an interview on 1/17/2024 at 1:46 p.m., LVN D stated she had checked the trays for lunch that day. LVN D stated she just started working in the facility the day prior (1/16/2024) and her training had not covered checking for diet textures. LVN D stated when checking trays, she checked for choices, diet and texture. LVN D stated she had not lifted the lids off trays and I should have looked more in depth. LVN D stated they could possibly choke if residents on a pureed diet were served ground meat. During an interview on 1/17/2024 at 2:29 p.m., when asked how staff were trained on diet textures, the Dietary Manager stated, we have a binder with different diet textures and when we have a question-if we're unsure about anything we ask our dietitians. The Dietary Manager stated, if there's something we're not doing right, [the dietitians] tell us how to fix it. The Dietary Manager stated CK J was the head cook and she was trained by the previous dietary manager. The Dietary Manager stated she started working in the facility a year and a half ago and she had not done any training with cooks on diet textures because they had been previously trained. The Dietary Manager stated CK K started working there that week and it was her second day working on 1/17/2024. The Dietary Manager stated she monitored staff by checking food consistency but no she had not had a chance to check the service line that day (1/17/2024). The Dietary Manager stated that day (1/17/2024), CK K had been trained by CK J and it was CK K's first hands-on day. The Dietary Manager stated yes the pureed meat could have been missed. The Dietary Manager stated CK J was usually on point, she did not see how it was missed, and maybe she was moving fast. The Dietary Manager stated staff only had so many days of actual training and that she had not yet trained CK K on preparing texture-modified diets. The Dietary Manager stated residents could choke and it's on us if they were served the wrong texture. During an interview on 1/17/2024 at 2:48 p.m., the RD stated he could not remember how long he had been coming to the facility, but he had been there once or twice. The RD stated if residents on a pureed diet received ground meat they could aspirate and get pneumonia, or they could choke and die. The RD stated that month (January) he had not covered the building and he was not sure whether another dietitian had been there that month (January 2024). During an interview on 1/17/2024 at 1:50 p.m., the DOR stated the facility's last speech therapist quit, they were trying to get a new one, and no one was currently providing speech therapy services to residents. The DOR stated new graduates worked there as speech therapists from time to time to get credentialed, but they left after one year and no one wanted to work there due to the geographical location. The DOR stated the facility did not have speech therapy via telehealth services. The DOR stated nurses oversaw food to ensure the right texture was provided by checking trays. The DOR stated she was not aware of any choking incidents in the past year. The DOR stated PTs and OTs were not trained in this practice of food texture and said it was not a scheduled thing for them to oversee dietary. The DOR stated speech, if we had one would oversee dietary for texture modified diets. The DOR stated, residents come in and they need speech and said she thought it affected resident a lot to not receive speech therapy services. The DOR stated if residents received the wrong texture, they could choke. An observation on 1/18/2024 at 8:31 a.m. revealed Resident #56 was lying in bed asleep with his food tray at his bedside table. The consistency of the pureed food was observed to be correct. During an interview on 1/19/2024 at 2:21 p.m., the DON stated nurses were supposed to check trays in the dining room and yes she expected them to lift up the lids to look at the food. The DON stated she monitored during mealtime by walking through the dining room to make sure staff were where they needed to be. The DON stated nursing staff had been trained on checking trays through in-services in the past but I can't tell you the dates. The DON stated residents on a pureed diet were one step away from being tube fed and being served the wrong texture could easily cause them to aspirate a particle or they could choke. During an interview on 1/19/2024 at 4:20 p.m., the Administrator stated therapeutic diets should be prepared and said the Dietary Manager trained dietary staff on texture-modified diets according to their policy. The Administrator stated yeah the Dietary Manager monitored dietary staff because she was there every day. The Administrator stated nurses were responsible for checking trays to ensure food textures matched diet orders and even aides who were passing out trays should monitor. The Administrator stated nursing staff were trained by the ADON and DON. The Administrator stated if residents on a pureed diet received the wrong texture, they could choke and it could cause respiratory problems. A record review of the facility's diet spreadsheet titled Wednesday SLP FW 2023 5wk - Week - 5 reflected residents on a pureed diet were to receive pureed pork with gravy for lunch on 1/17/2024. A record review of the kitchen's recipe for pureed pork with a printed date of January 18, 2024 reflected the following: Place prepared recipe portion(s) into a blender or food processor. Add adequate amount of liquid and/or thickener needed to achieve the consistency as appropriate for resident(s) and puree until smooth. Pureed foods normally are pudding-like consistency. A record review of the facility's incidents and accidents log dated January 2023 to January 2024 reflected no previous choking incidents with residents on a pureed diet. A record review of the facility's in-service trainings from January 2023 to January 15th, 2024 reflected no in-service trainings for nursing staff on texture-modified diets. A record review of the kitchen's in-service titled Diets Offered dated 8/28/2023 reflected the Dietary Manager trained dietary staff on the facility's policy titled Diets Offered by the Facility. A record review of the kitchen's in-service titled Tray Service dated 10/04/[23] reflected the Dietary Manager trained dietary staff on the facility's policy titled Tray Service. A record review of the facility's document titled Mechanically Altered Textures dated 2016 reflected the following: Mechanically altered textures are available for persons having difficulty with chewing or swallowing as prescribed by their physician, speech therapist or registered dietitian. Dysphagia diets Used for residents with swallowing difficulties due to medical conditions such as stroke, degenerative diseases like Huntington's or Parkinson's, cancer and/or radiation therapy DYS L1 - Pureed o This level is for people with moderate to severe swallowing difficulty and have a poor ability to protect their air way o This diet allows pureed food (pudding like consistency) that is smooth and easily stays together o Food should be avoided if they require chewing. Coarse and dry textures, raw fruits and vegetables, breads and nuts should also be avoided. A record review of the facility's policy titled Diets Offered by the Facility dated 2018 reflected the following: Policy: The facility is committed to providing the best nutritional care possible to its residents. All residents will receive diets as ordered by the attending physicians. There are many different names for similar diets. Diet order terminology should be standardized to ensure that the correct diets are served. The following diets are available: Regular No Added Salt LCS Liberal Renal Puree Mechanical Soft Procedure: 1. All diets must be ordered by the attending physician and recorded in the resident's medical record. A record review of the facility's policy titled Tray Service dated 2018 reflected the following: Policy: The facility believes that accurate tray service and adequate portion sizes are essential to the residents' well-being and safety. The facility will ensure that diets are served accurately and in the correct portions and that resident preferences are met. Procedure: 3. For tray line service, Nutrition & Foodservice staff will check each resident's tray card prior to service to ensure that preferences and dislikes are honored, the correct diet is served, portion sizes are accurate and appropriate substitutions provided. 4. For non-tray line service methods, staff will obtain food preferences for the meal from each resident. Serving staff will check each tray against the extensions to ensure that the diet is served accurately and the portion size of each item is correct. A record review of the facility's policy titled Tray Line Service dated 12/01/2011 reflected the following: Policy: The consultant dietitian will monitor the tray line to ensure that diets are served accurately and in the correct portions and that patient/resident preferences are met. See Section 6 for Quality Assurance Monitor forms and schedule. The following guidelines should be followed. Guidelines: 4. Each tray is checked by the tray line personnel to ensure that the diet is served as ordered, the portion size of each item is correct and preferences are met. A record review of the facility's policy titled Food and Nutrition Services dated September 2021 reflected the following: Policy Statement Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Policy Interpretation and Implementation 1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. 6. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. a. If an incorrect meal is provided to a resident, or a meal does not appear palatable, nursing staff will report it to the dietary staff so that a new food tray can be issued. On 1/17/2024 at 5:13 p.m., the Administrator was notified of an Immediate Jeopardy due to above listed failures and an Immediate Jeopardy template was provided. The facility's Plan of Removal was accepted on 1/19/2024 at 11:28 a.m. and included: Plan of Removal: 808: Therapeutic Diet Prescribed by Physician On 1/17/2024 recertification survey was initiated at [the facility]. An Immediate Jeopardy was identified for 808: Therapeutic Diet Prescribed by Physician by the survey team on 1/17/2024. Residents requiring altered diets could be affected by this deficient practice. Action (Immediate Action): Residents #7 and #56 were assessed by the Director of Nursing and/or Designee. No adverse effects were identified through assessment for identified residents. Neither resident Start Date & Completion Date: 1/17/2024 Person(s) Responsible: Director of Nursing and/or Designee Action (Identification): The RD and DON audited all residents' diet textures were audited to identify other residents that could possibly be affected by this alleged deficient practice. The RD reviewed all Diet Orders in Matrix to ensure the Tray Cards matched the current Physician Orders Start Date & Completion Date: 1/17/2024 Person(s) Responsible: Director of Nursing and/or Designee, Registered Dietician Action (Prevention): Residents' diet textures have been printed and are available for staff to review to ensure residents receive the appropriate diet texture. Location of the diet textures are in each dining room and the nurses station. Employees will know the location through education provided by the administrator, Director of Nurses, and/or designee. The DON will review all new physician orders for changes in Diets or New admission Diet Orders during the Daily Morning meeting and will communicate these changes to the Dietary Manager during this meeting to update the Tray Card system. The DON will update the Diet Roster in the Dining Rooms and the Nursing Stations Start Date: 1/17/2024 & Completion Date: 1/18/2024 Person(s) Responsible: Administrator and/or Designee Action (Prevention): Education: 1. All kitchen staff, including the Dietary Manager, have been educated by a Registered Dietitian to include how to prepare/process the pureed texture meal. The Registered Dietician conducted a Competency Evaluation (return demonstration) for Mechanically Altered Diet Food Preparation on all kitchen staff. All new or temporary (agency) kitchen staff will be educated prior to working their next scheduled shift and a competency Evaluation will be completed by the Dietary Manager. Start Date: 1/17/2024 & Completion Date: 1/18/2024 Person(s) Responsible: Registered Dietitian 2. The Director of Nurses was educated by the Registered Dietitian and the Clinical Company Leader regarding the below information (trained the trainer). Charge Nurses and Nurses Aides have been educated by the Director of Nurses and Clinical Company Leader. A Competency Evaluation (return demonstration) was completed with all staff by the Director of Nurses. All staff not present at the training will be inserviced by the Director of Nurses/designee prior to working the next scheduled shift and a Competency Evaluation will be completed. New staff and temporary staff (agency) will be inserviced by the Director of Nurses/designee prior to working the next scheduled shift and a Competency Evaluation will be completed. a. Description and appearance of Pureed and Mechanical Soft Diet texture. b. Meal Service Guidelines including Diet Rosters in the Dining Rooms: checking the food on the tray prior to delivering the tray to the resident to ensure the food on the tray matches the texture on the resident's tray card and visualizing the food on the tray to ensure it is the right texture. Start Date: 1/17/2024 & Completion Date: 1/18/2024 Person(s) Responsible: Clinical Company Leader alongside the Registered Dietitian, Director of Nursing, and/or Designee Start Date: 1/17/2024 & Completion Date: 1/18/2024 Person(s) Responsible: Director of Nurses and Clinical Company Leader Action (Monitoring): Charge Nurses are responsible for monitoring meals/meal textures at meal times, everyday. They have been educated regarding the diet textures as noted in the action item above by the Director of Nurses. Start Date: 1/17/2024 & Completion Date: 1/18/2024 Person(s) Responsible: Director of Nursing, Administrator, and/or Designee Action (Monitoring): 5x a week, for a minimum of 4 weeks, a meal will be monitored by the Dietary Manager, Director of Nursing, Administrator, and/or Designee to ensure dietary is plating the appropriate diet texture and nursing is checking the diet texture vs the meal cards and serving/assisting with the appropriate diet ordered for the residents. Start Date: 1/18/2024 & Completion Date: 4 weeks or, longer if needed, determined by results of observations and IDT determination. Person(s) Responsible: Dietary Manager, Director of Nursing, Administrator, and/or Designee Action (QAPI ): Medical Director was informed of the Immediate Jeopardy, the contents of the IJ template, and the center's plan to remove the immediacy. Start Date & Completion Date: 1/17/2024 Person(s) Responsible: Administrator Action items listed above will be monitored by [the facility's] Clinical Resource Nurse, Dietitian, Clinical Company Leader (Regional VP of Clinical Services) and Company Leader (Regional Director of Operations) for completion. The Plan of Removal was monitored in the following ways: A record review on 1/18/2024 reflected an ad hoc QAPI meeting was held on 1/17/2024 to review monitoring of meals and food preparation. Attendees included the Medical Director, the DON, the Administrator, the Dietary Manager and the Dietitian. A record review on 1/18/2024 of an in-service dated 1/17/2024 reflected the DON and Dietitian had in-serviced 56% of facility staff on meal service guidelines, altered texture diets, description of pureed texture, and checking diet type against food texture. A record review on 1/18/2024 reflected 29% of nursing staff had been quizzed on mechanically altered diets. A record review on 1/18/2024 reflected the Dietitian in-serviced 100% of the facility's cooks on 1/18/2024 on how to prepare a pureed diet. During an interview on 1/18/2024 at 8:28 p.m., DA L reported she had been in-serviced on what a pureed diet looks like. During an interview on 1/1/8/2024 at 8:31 a.m., CK J reported she had been trained by the Dietitian via in-service and video presentations on how to prepare a pureed diet. An observation of a test tray on 1/18/2024 at 1:00 p.m. revealed the pureed foods were of proper texture and consistency. A record review on 1/19/2024 of the Dietitian's in-service dated 1/18/2024 reflected 85% of dietary staff were in-serviced on pureed foods, dysphagia, and how to prepare pureed foods. A record review on 1/19/2024 reflected 85% of dietary staff received competency trainings on 1/18/2024 on preparing pureed food. During an interview on 1/19/2024 at 3:36 p.m., the DON stated she was in-serviced one-on-one by the Dietitian regarding nursing staff checking all trays prior to trays going out of the kitchen to ensure all trays have the appropriate diets and diet consistency. During an interview on 1/19/24 at 03:30 p.m., LVN D stated she was in-serviced by the Regional Nurse Consultant and the DON regarding checking trays as they come out of the kitchen to ensure they are the right diet orders and the right consistency. LVN D stated for pureed diets the consistency should be pudding like without any lumps. During an interview on 1/19/24 at 03:40 p.m., CNA H stated she was in-serviced regarding checking the residents' trays to make sure the residents received the right diet and the right consistency. CNA H reported an understanding of pureed diet consistency. During an interview on 1/19/24 at 3:45 p.m., CNA G stated she was in-serviced on checking residents' trays before giving to the resident to make sure they have the right diet. CNA G reported an understanding of pureed consistency. During an interview on 1/19/24 at 3:50 p.m., CNA I stated she was in-serviced on checking residents' diets prior to giving residents their trays. CNA I stated pureed diets should be creamy with no lumps and she stated the trays should go through a 3 point inspection-the kitchen, the nurses and the nursing assistants. A record review on 1/19/2024 of Resident #7 and #56 assessments reflected the DON assessed both residents for any signs of injury related to the deficient practice and it was documented in the residents' medical record. A record review on 1/19/2024 reflected 62% of nursing staff had been quizzed on mechanically altered diets. A record review on 1/19/2024 of all residents' diet orders reflected all diet orders were audited to ensure all diet orders were correct. An observation on 1/09/2024 at 3:55 p.m. revealed posting of diet orders and textures were in the kitchen, at the service window and at the nurse's station. A record review on 1/19/2024 of the facility's Competency Evaluation with return demonstration for mechanically altered diets reflected staff were checked for understanding on pureed diet consistency and what to do if they thought the texture or type of diet might be incorrect. Further review reflected 80% of nursing staff had competencies completed. A record review on 1/19/2024 of the facility's diet monitoring checks reflected checks were completed for each meal on 1/17/2024, 1/18/2024, and 1/19/2024. These monitoring checks were signed off by the Dietary Manager and the DON. A record review on 1/19/2024 of all staff in-service training reflected staff were trained on preparing altered texture diets, description of pureed food texture, meal service guidelines and checking diet type and texture to ensure it matched the tray prior to serving residents. The staff in-serviced included 100 % of full-time staff and 84% of PRN staff. The Immediate Jeopardy was removed on 1/19/2024 at 11:28 a.m. and the Administrator was notified. However, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm due to the facility's need to continue training and monitoring of the preparation and serving of therapeutic diets as prescribed by the attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free of accidents/hazards for one of twenty residents (Resident #1) reviewed for Quality of Care. The facility failed to ensure LVN A checked the temperature of a cup of hot coffee she had heated in a microwave oven prior to serving it to Resident #1. Resident #1 spilled the coffee on his abdomen and thighs resulting in 2nd and 3rd degree burns. On 05/05/2023 at 4:17 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 05/08/2023, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed all residents at risk for injuries, pain, and mental anguish. Findings include: Review of Resident #1's undated Face Sheet reflected he was an [AGE] year-old male admitted on [DATE] with diagnoses of Transient Ischemic Attack (brief stroke- like attack that still requires immediate medical attention to distinguish from an actual stroke), muscle weakness, pain in right hand, pain in left hand, age related cognitive decline (overall slowness in thinking and difficulties sustaining attention, multitasking, retaining information and finding words), unspecified lack of coordination and Calcifications and Ossification (calcium deposits as a result of muscles being damaged by burns causing hard areas in the affected muscles, can cause pain in that area) of muscles associated with burns left thigh. Review of Resident #1's Care Plan dated 04/15/2023 reflected Category: Skin (Resident #1) has 1st and 2nd degree burns to R side of abdomen blister measures 1.6 cm X 4.5 cm, L inner posterior thigh with no opening measures 9.5 cm X 10 cm, R upper inner thigh with total area of burn measuring 6.5 cm X 13 cm with 2 open blisters measuring 1.2 cm X 4.5 cm and 6.5 cm X 4.3 cm. R/T spilling coffee on himself causing blister. 4/19/23 Umbilicus [navel] L side 2.8 X 4.2 X 0.1 cm, L upper inner thigh - 8 X 10 X 0.1 cm, R thigh anterior - 2.5 X 3.8 X 0.1 cm, R thigh posterior 6 X 5 - intact skin. Goal: [Resident #1's] burns will heal without complications. Approach: Apply topical antimicrobial medication, Silvadene cream daily. Created by: [DON] Assess the psychosocial impact of burns on [Resident #1's] body. [family member] to bring resident coffee cups with lids in order to prevent future spills. Review of Resident #1's Quarterly MDS dated [DATE] reflected he had a BIMS score of 9 indicating moderate cognitive impairment. Functional status reflected Resident required assistance X 1 staff for adls. Observation and interview on 05/05/2023 at 9:25 AM Resident #1 stated he spilled a whole cup of coffee on his abdomen and right thigh. He stated someone brought hot coffee to his room and there was not a lid on the cup. Resident #1 pulled his short up on his right thigh and pointed to a dressing. Review of a resident progress note dated 04/15/2023 at 4:29 PM by LVN A for Resident #1 reflected Resident spilled a cup of hot coffee on himself causing redness to the area below his navel and on both of his inner thighs. His [family member] and his MD were notified. Review of a Progress Note dated 04/15/2023 at 7:00 PM for Resident #1 and recorded as a late entry on 04/16/2023 at 4:48 AM by the DON reflected I went in to evaluate this resident s/p spilling coffee on himself and noted a blister to the R side of umbilicus that measures 1.6 cm X 4.5 cm. No noted redness or discoloration to peri area. Noted discolored skin to right inner thigh that measures a total of 6.5 cm X 10 cm with two areas with blisters have ruptured within the area, 1st one that is anterior [front] measures 1.2 cm X 4.5 cm and the second to the posterior [back] side measures 6.5 cm X4.3 cm. Both areas with no noted skin coverage. The left inner thigh is discolored with a total area of 9.5 cm X 10 cm with no noted open areas but there are areas that appeared to be very fragile. Resident does complain of pain when areas are touched. Other progress notes regarding the wounds associated with the hot coffee burns were documented on 04/16/2023 and 04/18/2022. A progress note for an assessment for unspecified pain was dated 04/22/2023. Review of a Wound Evaluation and Management Summary dated 05/01/2023 by the wound care MD reflected they performed a wound care evaluation and treatment at the request of the primary care MD for Resident #1. They stated Patient presents with a wound on his abdomen. He has a non-pressure wound on abdomen for at least 15 days duration. There is light serous [clear] exudate [drainage]. Patient spilled coffee on himself. Surgical excision debridement procedure: Remove necrotic [dead] tissue and establish the margins of viable [living] tissue. The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to surgically excise [cut out] 1.06 cm of devitalized [dead tissue from damage] tissue including slough [yellow, stringy, thick tissue adhering to wound bed ], biofilm [formed when certain microorganisms, mostly pathogenic (can cause disease) bacteria adhere to the wound surface] and non-viable (non-living) subcutaneous [layer of tissue that underlies the skin] level tissues were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Hemostasis [stopping of flow of blood] was achieved and a clean dressing was applied. Continue Silver Sulfadiazine [topical cream used to prevent and treat wound infections in patients with 2nd and 3rd degree wounds] once daily for 18 days and use a gauze island dressing with bdr. Observation and Interview on 05/05/2023 at 10:01 AM, [NAME] C stated the kitchen staff check coffee temperatures after placing it in decanters and prior to placing the decanters in the dining room. [NAME] C then demonstrated the technique she used for checking the coffee temperature. She stated they keep a temperature log for coffee in the kitchen which she showed the surveyor. She stated some staff say to nuke the coffee (in the microwave oven) to heat it up but she knew that was not correct as it could get too hot. Observation on 05/05/2023 at 10:08 AM of the Resident Nourishment Room which was open to a hallway outside the dining room revealed a microwave oven at countertop height. A sign on a cabinet above the oven stated Please remember that as hot liquids heat up, they release steam or may be spitting. Never cover any container fully. Always leave a gap for steam to release. No instructions were noted to check the temperatures of hot liquids or foods prior to serving them to a resident. There was no thermometer in the room. No coffee cups or lids were observed in the room. Interview on 05/05/2023 at 10:10 AM, MA D stated she normally worked at the corporate office in another city and was assisting at the facility for the day. She stated coffee in the decanters should already be heated and cups should have a lid on them prior to being served to a resident. Interview on 05/05/2023 at 10:14 AM, CNA E stated if a resident wants coffee he goes to the dining room, gets it from the decanter and places a lid on the cup prior to serving it. He stated, I don't microwave it. I've seen the dressings on Resident #1, but I was not here the day he got burned. He stated he could not recall receiving any in-services on serving hot beverages. Interview on 05/05/2023 at 10:17 AM, CNA F stated she had worked at the facility for three months and would never heat coffee in the microwave adding most of the time they [residents] are going to spill it. Interview on 05/05/2023 at 10:21 AM, LVN B stated LVN A told her she had served Resident #1 coffee that she had heated in the microwave. LVN B stated when she observed the burns on Resident #1, they looked like he had been in a fire. Interview on 05/05/2023 at 10:56 AM, a family member of Resident #1 stated he had burns on both legs and his abdomen that blistered. The family member stated he was not sent to the hospital and some kind of ointment was ordered for the burns. Observation on 05/05/2023 at 11:11 AM of Resident #1's abdomen revealed an approximately 3-inch X 1.5-inch oval shaped, scabbed area on his abdomen with slight yellow drainage on the dressing which was pulled back by the DON. He had a scarred, indented area approximately 4 inches X 3 inches on his left inner thigh. A dressing was noted to his right thigh. Interview on 05/05/20223 at 12:06 PM, LVN G stated Resident #1 had spilled hot coffee on himself in his room on 04/15/2023 and she had to go get someone to help her change his brief. She stated she knew not to heat coffee in the microwave and there was no thermometer available to check beverage or food temperatures. Record review of a facility in-service dated 04/15/2023, titled Safety of Hot Liquids given by the DON reflected LVN A and LVN G had not signed the in-service. Record review of a facility in-service dated 04/17/2023, given by the ADON and titled Microwave Heating Safety was signed by twelve out of fifty-five staff members. The Inservice did not include any information regarding how hot liquids could get after microwaving or how to check for a safe serving temperature. LVN A and LVN G who were on duty 04/15/2023 when Resident #1 received hot coffee burns did not sign the in-service. Interview on 05/05/2023 at 1:50 PM, the DON stated she had given LVN A a disciplinary action and a verbal in-service on handling of hot liquids and foods after Resident #1 sustained burns. She stated LVN A had been in the facility working since the incident on 04/15/2023 but had not signed any in-services on microwave heating safety. She stated she thought LVN A had received all the in-services after the incident but had not signed them. The DON stated LVN A gave Resident #1 coffee from the dining room, after she heated it up in the microwave, took it to his room and told him to be careful. She further stated the resident was not responsible for what happened, and he received 2nd degree burns from the hot coffee. She stated she thought they needed to do temperature checks on foods and liquids to validate the temperature was safe prior to serving and they needed to keep a temperature log. The DON stated the ADON was not available for any interviews regarding the in-services she presented to the staff as she was attending RN school that day. Record review of a facility policy and procedure titled Safety of Hot liquids dated 2001 and revised in October 2021 reflected Appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury. The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. 1. Residents with these or other conditions may suffer from accidental burns and related complications stemming from thinner, more fragile skin that may burn quickly and severely and take longer to heal. 2. Residents who prefer hot beverages with meals (i.e., coffee, teas, soups, etc.) will not be restricted form these options. 3. When indicated, appropriate interventions will be implemented and included in the resident's care plan to minimize the risk from burns. This was determined to be an Immediate Jeopardy (IJ) on 05/05/2023 at 4:17 PM. The Acting ADM and DON were notified. The Acting ADM was provided with the IJ template 05/05/2023 at 4:17 PM. The Plan of Removal was accepted on 05/06/2023 at 11:00 AM and included the following: Action: Nurse involved in the incident was provided one on one education with discipline. Start Date: 5/5/2023 Completion Date: 5/5/2023 Responsible: Director of Nursing Who and how will this action be monitored: The Regional Resource team will ensure this action has been completed as of 5/6/2023 via an onsite review of the documentation. Action: Microwave was removed from the nutrition room until all staff are educated on safe temperatures to serve hot liquids and a thermometer and a temperature log has been placed in the room in which employees will know how to utilize through education completed. Start Date: 5/5/2023 Completion Date: 5/6/2023 Responsible: Director of Nursing Who and how will this action be monitored: The regional resource team will ensure this action is completed and will monitor for compliance during onsite visits x 4 weeks and/or until substantial compliance. Action: All staff to be reeducated on accidents, hazards, and supervision, safe temperatures to serve hot liquids, microwave heating safety, taking temperatures (and what appropriate temperatures to serve liquids and food at, and how to document the liquid/food being provided to the resident at a safe temperature with accordance with regulation). Start Date: 5/5/2023. Completion Date: 5/6/2023 Responsible: Administrator/Director of Nursing/Designee Who and how will this action be monitored: The regional resource team will ensure this action has been completed as of 5/6/2023 via an onsite review of the documentation. Action: Regional Resource team reviewed Resident #1's care plan to ensure person centered interventions are in place to avoid resident spilling hot liquids on himself, again. Start Date: 5/6/2023. Completion Date: 5/6/2023 Responsible: Regional Resource Nurse Who and how will this action be monitored: The Clinical Company Leader will review the completion of the care plan review and will additionally review for any necessary changes to ensure resident's safety. Action: Ad Hoc QAPI with IDT to review incident, IJ and POR. Start Date: 5/5/2023. Completion Date: 5/5/2023 Responsible: Director of Nursing Who and how will this action be monitored: Regional Resource and Clinical Company Leader witnessed Ad Hoc QAPI being performed with Medical Director Monitoring for Plan of Removal was completed from 05/06/2023 - 05/07/2023 as follows: Interview on 05/06/2023 at 2:45 PM the DON stated approximately 80% of the staff had been in-serviced regarding use of the microwave to heat liquids and foods. She stated education was provided to all staff regarding monitoring temperatures of food and liquids after microwave use. The DON stated only staff were allowed to use the microwave. Observation and interview on 05/06/2023 at 3:15 PM, Resident #1 was observed with his own coffee cup that was covered. Resident #1 stated he was not in pain and was currently being treated with a cream for his wounds. Interview on 05/07/2023 at 11:30 AM, the DON stated all facility in-services on handling hot liquids, warming up food and checking temperatures were completed in the late afternoon on 05/06/2023. Record review on 05/07/2023 of an in-service regarding food and liquid temperature safety reflected all staff were trained in the safety of hot liquids/food temperatures, supervision of residents and a post-test was completed by all staff. Interview on 05/07/ 2023 at 11:54 AM, LVN A stated she had received verbal training from the DON the day after the hot coffee burns incident with Resident #1. She stated she was educated on coffee temperature, to not heat coffee in the microwave because coffee is served in the dining room and to monitor residents for safe serving of hot liquids. LVN A stated on 05/06/2023 she was re-educated on handling foods and liquids that were hot and checking the temperatures to serve them safely to the residents. The acting ADM and the corporate survey resource person were informed the Immediate Jeopardy was removed on 05/08/2023 at 11:30 AM. The facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm that is not Immediate Jeopardy 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 were free from abuse for 1 (Resident #1) of 10 residents reviewed for abuse. The facility failed to ensure Resident # 1 of 10 residents was free from abuse. Resident # 1 was forced to take her medication by staff who forced the medication in Resident # 1 mouth with a spoon that cut her lip and caused her to bleed. This failure could place residents at risk for abuse. An IJ was identified on 1/5/2023. The IJ template was provided to the facility on 1/5/2023 at 12:30pm. While the IJ was removed on 1/7/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy because (e.g.) all staff had not been trained on resident rights, Medication Administration, Notification of Responsible Party and Physician, Documentation of the event of a refusal of medication, Abuse and Neglect Prevention policy and completed the skills competency test regarding abuse and neglect prevention. Findings included: Record review of facility Abuse/Neglect policy dated June 2021stated the following: The Administrator will suspend immediately anyone who is suspected of abuse. The residents have a right to be free from abuse Protect residents during abuse allegations Review of Resident #1 face sheet undated, reflected Resident # 1 was an 85- year- old woman, admitted to the facility on [DATE]. Resident # 1 was diagnosed with an altered mental status, cognitive communication deficit (difficulty with thinking and how someone uses language), unspecified dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), psychotic disturbance (when a person lose contact with reality and experience a range of extreme symptoms such as hallucinations, hearing or seeing things that are not real), mood disturbance ( feeling of distress, sadness, or symptoms of depression), and anxiety ( intense, excessive, and persistent worry and fear about everyday situations). Observation on 1/3/2023 at 10:30am, revealed Resident # 1 lying in bed unable to speak. Facility staff assisted and observed Resident # 1's mouth. Resident # 1 observed to have a slight redness to the inside of the bottom lip, no blood observed. Resident # 1's teeth were observed in poor condition. Resident # 1's teeth were decayed with a lot of plaque buildup. Resident # 1's care plan reflected it was last reviewed and revised on 12/15/2022. The care plan reflected the following goal: Resident # 1 would have fewer episodes of yelling/screaming before/during care over the next 90 days. The plan reflected the following interventions: 1. Intervention: Encourage diversional activities 2. Remove from public area when behavior is unacceptable 3. Keep environment calm and relaxed 4. Always ask for help if it becomes abusive/ resistive 5. Convey acceptance during periods of inappropriate behavior 6. Talk to resident during entire procedure of care Quarterly MDS reviewed dated 12/3/2022, reflected Resident # 1 had a BIMS score of 00 (unable to complete assessment). Resident # 1 had a diagnosis of mild depression. The MDS reflected Resident # 1 had significant change in condition on 1/2/2023 and was referred for hospice service. Order for medication reviewed of Resident # 1 medication dated 5/31/2022, reflected an order for Remeron (mirtazapine) tablet; 15mg 1x at bedtime oral and an order for medication to be crushed, open capsules and mix with food or jelly. Record review of Facility event report, dated 12/26/2022 completed by ADM, reflected the incident was witnessed by a staff member of Resident # 1's injury to her lip. The report reflected Resident# 1 had a vertical slit inside the center bottom lip measuring 0.5cm (centimeters) x 0.1cm (centimeters) and a horizontal broken skin to the left side to the left side inside bottom lip measuring 0.4cm (centimeters) x 0.1cm (centimeters) scant (barley sufficient) amount of blood was noted inside the bottom lip and on resident # 1 bottom 2 teeth. The report also reflected Resident # 1 was assessed by LVN C, notified on-call physician with no new orders recommended. Record review of facility progress notes dated, 12/26/2022 reflected Resident # 1 was assessed by LVN C at approximately 8:45pm and noted Resident # 1 had a vertical slit to the inside of her bottom lip measuring 0.5cm(centimeters) and 0.1cm(centimeters) and horizontal broken skin to the left side of the bottom lip measuring 0.4cm(centimeters) and 0.1cm(centimeters). The progress note reflected Resident # 1 had a scant (barley sufficient) amount of dried blood inside the bottom lip and on Resident # 1 two bottom teeth. Record review of the MAR (medication administration record) dated 12/26/2022, reflected Resident #1 was administered Remeron (mirtazapine) (for depression/mood) 15mg (milligram) oral at bedtime. Record review of facility investigation report dated 12/26/2022 reflected, RN administered Resident # 1 medication at 8:00pm. Record review of facility timecards dated 12/26/2022, reflected RN clocked in at 5:52pm and clocked out at 9:58pm. LVN C, clocked in at 9:00pm and clocked out at 3:00am. During a phone interview on 1/3/2023 at 1:46PM, LVN B, stated he arrived to work on 12/26/2022 around 10:00PM to relieve the RN. LVN B stated when he arrived the RN had completed administering medication to all the residents on the 300 Hall, he stated he took over from there and completed the 600 Hall medication pass. LVN B, stated he checked on Resident # 1 when he arrived and noted that Resident # 1 had a little bright red blood in her mouth, and stated Resident #1 still had some of the pudding on her face and in her mouth. LVN B stated he was advised of the abuse to Resident #1 and that he needed to come in to take over RN's shift. During a phone interview on 1/3/2023 at 3:21PM, CNA A, revealed she worked on the evening of 12/26/2022, she stated she visited with Resident # 1 in her room that evening when she witnessed the RN forcing the spoon in Resident # 1 mouth trying to administer her medication after she refused. CNA A stated the RN continued to push the spoon in Resident# 1 mouth and stated Resident # 1 was very upset. CNA A stated even after she asked the RN to stop and she would try to give Resident # 1 her medication, she stated she ignored her and continued to force the spoon in Resident # 1 mouth. CNA A stated after the RN finished, she noticed Resident # 1 had pudding all over her mouth and she offered to clean Resident # 1 mouth and that's when CNA A noticed that Resident # 1 had blood in her mouth and her bottom tooth appeared to be pushed back. CNA A stated she told LVN A about the abuse. During a phone interview on 1/3/2023 at 3:31PM, with RN revealed she attempted to administer Resident #1 her evening medication in some pudding. RN stated Resident #1 did push her hand back however, Resident #1 would always be aggressive and try to resist staff from providing care. RN stated she did not hold Resident # 1 down, she stated she was not mean to Resident # 1. RN stated she understood that Resident # 1 had the right to refuse her medication, but stated she needed to try because it would help Resident # 1 sleep. RN stated she was not aware that anything had happened until LVN C showed up and relieved her of duty. RN stated Resident # 1 was the first resident that she administered medication to the night of 12/26/2022. She stated she administered medication to all the residents on the 300 Hall the night of 12/26/2022. During a phone interview on 1/4/2023 at 11:05am, LVN A, revealed he worked on the secure unit the night of 12/26/2022. LVN A stated he had another situation with another resident at the time CNA A told him of the abuse to Resident # 1. LVN A stated he immediately called the ADM. and advised her of the situation he had and of the abuse to Resident # 1. LVN A stated he never saw Resident # 1 because he was on the secure unit, LVN A stated the ADM. contacted LVN C to come to work. During an interview on 1/5/2023 at 9:10am LVN C, revealed she arrived at the facility at approximately 8:50pm and stated she contacted the ADM after she arrived. LVN C stated the RN was at the nurse's station with the medication cart when she arrived. LVN C stated she was not aware of which residents the RN had administered medication to prior to her arrival. LVN C stated the RN did not administer anymore medication to any residents after she arrived at the facility. LVN C stated the ADM sent her the suspension paperwork via email around 9:13pm and she completed the paperwork with RN. LVN C stated RN did not administer anymore medications after she arrived and remained at the nurse's station until they went into the office to complete the suspension paperwork. During an interview on 1/3/2023 at 4:45PM the ADM, revealed she was on vacation at the time of the incident. The ADM stated once she received the call from LVN A at approximately 8:07PM, she immediately contacted LVN C to come to the facility and relieve RN. The ADM stated LVN C arrived at the facility at 8:30pm. She stated the suspension paperwork was completed with RN at approximately 9:13PM by the ADM via phone, LVN C and RN. The ADM stated RN was suspended pending the investigation. Record review of in-services revealed last education on refusal of medication was held 10/7/2022. Record review of the in-services revealed education on Abuse/ Neglect not dated, the ADM stated it was last given 1/5/2023. The ADM was notified on 1/5/2023 at 12:30pm that an Immediate Jeopardy had been identified due to the above failure. The IJ template was provided to the ADM on 1/5/2023 at 12:30pm. A Plan of Removal was first submitted by the ADM on 1/5/2023 at 4:29PM. The Plan of removal was accepted on 1/8/2023 at 3:30pm. Plan of Removal F600- The facility failed to ensure that the resident was free from abuse. Impact Statement On 01/03/2023 an abbreviated survey was initiated at facility. On 01/05/22 the facility was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate threat to resident health due to the failure to protect 58 residents assigned to the charge nurse that day. The resident was forced to take medication that resulted in an injury to her mouth. Action Item: Safe Surveys to be performed on interviewable residents residing in the same Hall as an abused resident and randomly throughout the facility. Weekly skin checks were reviewed all on residents that were under RN's care during the time of the abuse. Start Date: 1/5/23 End Date: 1/6/23 (Completed) Who is Responsible: Social Worker, RNC (Regional Nurse Consultant) DON (Director of Nursing) and LVN C Who will Monitor: Administrator Action Item: Education will be provided on the topic of the Abuse and Neglect Prevention policy now and quarterly. A skills competency test regarding abuse and neglect prevention will be administered to all employees. To ensure 100 percent completion of education of employees has been completed the Administrator will verify with the employee roster that everyone has completed training. All agency employees will be educated before they are allowed to work with facility residents. All new employees will receive this education before they are allowed to start working with residents. Note: No employee will be allowed to work until in-services are completed Start Date: 1/5/23 for education and review End Date: 1/09/23 - New Staff and Agency Staff education will be ongoing as new staff are hired Who will be Responsible: DON/LVN C Who Will Monitor: Administrator ongoing and monthly to ensure the training of new employees and agency staff Action Item: Resident Rights Education including the list below, will be given to all nurses and MA's who administer medications in the facility and will be provided now and quarterly. The DON/LVN C will provide this training every quarter. To verify that 100 percent of the employees complete their education, the Administrator will verify with the employee roster that everyone has completed training. All agency employees will be educated before they are allowed to give medications. All new employees and agency employees will receive this education before they are allowed to give medications. - Resident rights - Medication Administration - Notification of the Responsible Party and Physician - Documentation of the event of a refusal of medications Note: No employee will be allowed to work until in-services are completed Start Date: 1/5/23 for education and review End Date: 1/9/23 for current staff - New Staff ongoing for education and review Who will be Responsible: DON/LVN C -36 Who Will Monitor: Administrator ongoing and monthly to ensure the training of new employees and agency staff Action Item: Medical Director was notified on 1/5/23 of the Abuse IJ related to this event. Start Date: 1/5/23 End Date: 1/5/23 Who was Responsible: DON/Administrator Who Will Monitor: Monitoring is not needed. The action was completed. Information shared. Not an ongoing notification. Action Item: Involvement of Ad hoc QA (Quality assurance) - On 1/5/2023 an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting was held with the facility administrator, Director of Nursing, and Medical Director. The IJ's for abuse and Dietary were discussed and a PIP (Performance Improvement Plan) will be developed for monitoring of action items and future education. The Medical Director will make a final review of the PIP (Performance Improvement Plan) on 1/10/23. Start Date: 1/5/23 End Date: 1/10/23 Who was Responsible: DON/Medical Director Who Will Monitor: Administrator Action Item - Leadership in the facility when the Administrator and the DON are not in the building. When no one at the management level is on-site the charge nurses are considered the managers on duty for the facility. Steps to take regarding abuse and neglect are placed at the nurse's station as a constant reminder of those steps. All charge nurses will be educated on the steps they are to follow in the event of abuse or neglect allegations. All newly hired charge nurses will be trained in this area prior to taking on this role. Note: No employee will be allowed to work until in-services are completed Start Date: 1/6/23 End Date: 1/10/23 and ongoing for new charge nurse employees Who was Responsible: Administrator Who Will Monitor: Regional Director of Operations Action Item - The staff member that failed to stop the abuse was brought to the administrator's office where the staff member was educated on abuse and neglect prevention. She was educated on the fact that even though the abuser left the resident's room that it was her responsibility to make sure that the abuser had no further access to that resident or any other resident while waiting for a management team member or another supervisor to arrive to take control of the situation. Start Date: 1/5/23 End Date: 1/5/23 Who was Responsible: Administrator Who Will Monitor: DON/ LVN C The Surveyor monitored the Plan of Removal on 1/7/2023 as follows: 12:25pm Entered facility 12:55 PM Reviewed in-service for Abuse and Neglect: Charge Nurse Responsibilities for abuse and neglect accusation. Reviewed Abuse and Neglect: Abuse & Neglect Prevention, Resident Rights Reviewed Abuse and Neglect Prevention Reviewed Resident Rights Skills Test Reviewed Inservice for Medication Administration Reviewed Inservice for Events and Grievances Report Reviewed Inservice for Charting and Documentation During an interview on 1/7/2023 at 1:20PM LVN D, revealed she had worked at the facility for 3 months. LVN D stated her job duties were to pass medication, oversee CNAs, and assist residents. LVN D stated she had been in-serviced on the Charge Nurse responsibilities for Abuse and Neglect allegations. LVN D stated the responsibilities were to immediately remove staff from access of to residents, direct another staff member to stay with the affected resident. LVN D stated she would also have the alleged abuser to clock out and leave, contact the administrator, director of nursing, or designee, and notify the director of nursing of any injuries either mental or physical. During an interview on 1/7/2023 at 1:35PM LVN E, revealed she had worked at the facility for 1 year and 6 months. LVN E job duties were to pass medication, ensure residents needs are met, ensure documentation is completed and oversight of CNAs and medication aides. LVN E stated she was in-serviced on the charge nurse responsibilities for abuse and neglect allegations. Record Review on 1/7/2023 reflected, 38 staff members had completed the Skills Test for Abuse and Neglect. Record review also reflected 12/14 staff members that were on duty on 1/7/2023 had completed the skills test for abuse and neglect. ADM and CNA B had not completed the skill test for abuse and neglect. During an interview on 1/7/2023 at 2:10 PM CNA B, revealed she had worked at the facility for 17 years and 6 months. CNA B stated her job duties were to provide residents with assistance eating, make beds and assist with ADL's (activities of daily living). CNA B stated she had not witnessed any abuse or neglect and stated she would notify the ADM and DON if she did. CNA B stated she was in-serviced abuse/neglect about a month ago but not in the last few days. CNA B stated she had not taken a skill test for abuse or neglect yet. Record Review reflected; 15 satisfactory resident safe surveys had been completed. During an interview on 1/7/2023 at 2:50PM with Resident # 2 stated the social worker had spoken with him about being safe at the facility and being free of abuse. Resident # 2 stated he felt safe. During an interview on 1/7/2023 at 3:00 PM Resident # 3 stated the social worker conducted a resident safety survey with him. Resident # 3 stated he felt safe in the facility. During an interview on 1/7/2023 at 3:10 PM Resident # 4 stated the social worker conducted a resident safety survey with him. Resident # 4 stated he felt safe in the facility. During an interview on 1/7/2023 at 3:20pm Resident # 5 stated the social worker had not conducted a resident safety survey with her. Resident # 5 stated she had recently moved into the facility last week. Resident # 5 stated she felt safe in the facility. During an interview on 1/7/2023 at 3:20pm with Resident# 6, stated the social worker has not conducted a resident safety survey with her. Resident # 6 stated she had just moved into the facility last week and that she felt safe in the facility. During an interview on 1/7/2023 at 3:45pm the ADM, stated the DON and LVN C were responsible for staff being in-serviced and completing the skills test for abuse and neglect prior to the beginning of the staff members shift. The ADM stated she was the responsible person for today. The ADM stated she will in-service herself and CNA B after this interview. 4:15 PM Investigator exited the facility. The Surveyor monitored the Plan of Removal on 1/8/2023 as follows: In an interview on 1/8/23 at 5:46 CNA B stated she had attended multiple in-services on abuse, abuse reporting and infection control. She stated she understood abuse was to be reported immediately and knew the building abuse coordinator was her ADM. In an interview on 1/8/23 at 5:51 LVN F stated she was an agency nurse but had been in-serviced on abuse prior to starting her shift. She stated she was told the ADM was the abuse coordinator and if she wasn't there any reports of abuse would be given to the DON, LVN C or charge nurse. The Surveyor monitored the Plan of Removal on 1/9/2023 as follows: 1:45PM conducted entrance conference with ADM advised of monitoring visit for POR's (Plan of Removal) in place. ADM was advised of the information needed for review. She reported the census was 57. ADM stated Resident # 1 passed away over the weekend. ADM stated Resident # 1 passing was expected, stated Resident # 1 has been referred to hospice. Reviewed 19 satisfactory resident safe surveys completed. Action Item 2: Education Abuse/Neglect Prevention Policy and Skills Competency test regarding abuse/ neglect prevention. Reviewed Abuse and Neglect Prevention in-service dated 1/5/2023 completed by staff Reviewed Abuse/Neglect Prevention Policy and Skills Competency test regarding abuse/ neglect prevention dated 1/5/2023. All staff except 5 have completed the skills test Action item 3: Education of Resident rights, Medication Administration, Notification Responsible Party /Physician, documentation of the event refusal of medication dated 1/5/2023 Reviewed in-service for Abuse and Neglect: Charge Nurse Responsibilities for abuse and neglect accusation. Reviewed Resident Rights in-service dated 1/5/2023 completed by staff Reviewed Inservice for Medication Administration dated 1/5/2023 completed by staff Reviewed Inservice for Events and Grievances Report dated 1/5/2023 completed by staff Reviewed Inservice for Charting and Documentation dated 1/5/2023 completed by staff All nursing staff have been trained except 5 staff who are out sick or have not returned to work Action item 4: Medical Director notification Reviewed notification for IJ called letter dated 1/5/2023 Action Item 5: ad HOC QAPI notification Reviewed notification letter dated 1/5/2023 Education of Supervisor Staff Reviewed in-service education completed with supervisor staff ADM and DON dated 1/6/2023 Action item 6: Leadership in the facility when the Administrator and DON are not in the building. Reviewed - All nursing staff have been trained except 5 staff who are out sick or have not returned to work. Interview on 1/9/2023 at 1:48PM LVN D, revealed if someone refused their medication she would document refused and let the doctor know. She stated she had been trained on abuse /neglect to contact the ADM immediately if not available then DON, if not available then LVN C, and then the charge nurse. She stated she had never seen or suspected abuse or neglect in the facility. Observed on 1/9/2023 at 1:48pm LVN D, medication administration stated she used the MAR in the matrix system (electronic records system) to verify the dosage, the medication, and the correct resident before administering to resident. During an interview on 1/9/2023 at 2:10pm with CNA B, revealed her job duties were to feed residents, make beds and assist with ADLs (Activities of Daily Living). CNA B stated she had not witnessed any abuse or neglect but stated she would notify the ADM and DON if she did. CNA B stated she had been in-serviced on abuse and neglect and completed the skills test. During interviews on 1/9/2023 at 3:25pm with Resident # 2, Resident # 3, Resident # 5, Resident # 7, Resident # 8, Resident # 9, and Resident # 10, stated they felt safe at the facility. All resident interviewed appeared to be clean and dressed appropriate with no marks or bruises noted. Observed Resident # 11 in the common area with others, resident is not able to speak clearly. Resident appeared to be clean and dressed appropriate. Resident did not appear to be in any pain or distress during this observation Resident # 12 was observed at 3:45 sitting his room fixing his clothes, resident looked when surveyor spoke to him and continued to fix his clothing. Resident appeared to be clean and dressed appropriate, resident did not appear to be in any distress or pain During an interview on 1/9/2023 at 4:00pm the ADM stated the DON and LVN C were responsible for staff in-serviced, and skills test completed for abuse and neglect prior to the beginning of the staff members shift. The ADM stated staff that have not yet been trained were either out with COVID or vacation, she stated when they returned to work, they would be trained. She stated RN was referred to the nursing board, she stated she terminated The ADM and corporate support were notified on 1/9/2023 at 5:30pm that the IJ had been lowered. While the IJ was lowered on 1/7/2023 at 4:15 pm, the facility remained out of compliance at a level of actual harm with potential for more than minimal harm that is not Immediate Jeopardy identified due to the facility's need to evaluate the effectiveness of the corrective systems.