**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #6) reviewed for abuse. The facility failed to ensure Resident #6 had the right to be free from abuse when Resident #7 pushed her on 01/21/25, causing Resident #6 to fall which resulted in a pelvic fracture. An IJ was identified on 03/12/25. The IJ template was provided to the facility on [DATE] at 4:51 PM. While the IJ was removed on 03/13/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed residents at risk for abuse. Findings included: Record review of Resident #6's face sheet, dated 02/27/25, reflected the resident was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #6's significant change in status MDS Assessment, dated 01/29/25, reflected she had a BIMS score of 06, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included unspecified fracture of sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis) and depression. Record review of Resident #6's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #6] had a fall. Was accidentally pushed by another resident. Sent to ER. Record review of Resident #6's Progress Notes reflected the following: 01/21/25 5:36 PM - Resident was pushed to floor by another resident, resident was crying stating her hip hurt, resident was assessed, assisted from floor to dining chair, pain medication administered. DON, MD and RP notified. Stat hip x-ray ordered. Resident is now sittingin [sic] dinning [sic] area, away from other resident eating dinner. Resident stated she has no pain at this time and will let staff know if her hip starts to hurt again. This entry was written by LVN Z. 01/21/25 11:11 PM - X-ray performed at this time awaiting for results. This entry was written by LVN Y. 01/22/25 2:15 AM - Result viewed, No acute fracture, dislocation, destructive bony process noted, result will be relayed to MD by incoming nurse. This entry was written by LVN Y. 01/22/25 9:15 AM - Resident has been sent out to [Hospital X] r/t uncontrolled pain (L) hip. Resident is status post fall 1/22/25. STAT Xray result (L) hip shows No Acute Fracture, Dislocation or destructive bony process. Resident c/o pain (L) hip, Tramadol 50mg prn and Tylenol 650mg was administered for pain. Medication was not effective, resident unable to ambulate as she normally does. Notified [the DON] and resident sent out to ER for [NAME] evaluation. [Resident #6's RP] was also notified. This entry was written by LVN W. 01/25/25 12:15 PM - Resident arrived facility [sic] from [Hospital X] by ambulance via stretcher accompanied by [Resident #6's RP] DX open displaced fracture of anterior wall of left acetabulum [an anterior wall acetabular fracture is a break in the front column of bone or area around the bony rim (wall) of your hip socket].Resident [sic] assisted in bed by two nurses, complained of some little pain, tylenol [sic] 650 mg prn given with positive outcome . This entry was written by LVN V. Record review of Resident #6's hospital records, dated 01/30/25, reflected the following: As Per admission history and physical dated 1/22/2025 Patient is a 84 y.o. female has a past medical history of Dementia (HCC). admitted after fall at care facility resulting in pelvic fracture and difficulty ambulating. [Resident #6's RP] reports [Resident #6] was previously independent, 'very active' and 'walks on her own'. Recently completed PT at facility and 'checked all the boxes', discharged from therapy last Friday [01/17/25]. Fall mechanism- patient reports being pushed by 'lady' and feeling pain 'from the back'. [Resident #6's RP] unaware of circumstances, states facility noticed fall and difficulty walking. Hospital Course/Summary: Ptient [sic] presented after fall unable to bear weight. Found to acute minimally displaced fractures of the anterior left acetabulum, left inferior pubic ramus [describes a type of crack or break in a person's pelvis] and left sacrum . Record review of Resident #6's Radiology Results Report, dated 01/21/25, reflected: Procedure: HIP UNI W OR W/O PELVIS 2-3 V .INTERPRETATION: Findings: No acute fracture, dislocation or destructive bony process. No soft tissue abnormally. Osteopenia. Mild degenerative changes. Conclusion: No acute osseous abnormality. Interview on the phone on 02/27/25 at 11:15 AM with Resident #6's RP revealed Resident #6 was pushed by a different resident and her pelvis was fractured as a result. Resident #6's RP said Resident #6 was admitted to the hospital and the fracture did not require screws or any surgery, so the doctor said it was going to heal on its own. Resident #6's RP said before the incident, Resident #6 was able to walk around freely without the use of a walker or wheelchair and now she was no longer mobile, requiring the use of a wheelchair. Resident #6's RP said Resident #6 was able to stand and take some steps, but it hurt the resident and she was not like she was before. Observation and interview on 02/27/25 at 11:57 AM with Resident #6 revealed she was sitting in a wheelchair at the nurse's station. Resident #6 said she was not in any pain, had never had a fall, and would never let anyone push her. Resident #6 did not appear to be in any pain. Record review of Resident #7's face sheet, dated 02/27/25, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #7's Quarterly MDS Assessment, dated 01/24/25, reflected she had a BIMS score of 03, indicating severe cognitive impairment. Her MDS indicated she had delusions but no other behaviors. Her diagnoses included heart failure, non-Alzheimer's dementia, and depression. Record review of Resident #7's care plan, revised 01/22/25, reflected the following: Focus: 1/21/25- [Resident #7] accidentally pushed another resident to the floor. Education completed, Redirected as needed. Goal: [Resident #7] will not harm self or others through the review date. Interventions/Tasks: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Record review of Resident #7's Progress Notes reflected the following entries: 01/21/25 5:25 PM - Resident pushed another resident to the floor, no injuries noted to this resident. Resident was separated from resident she pushed to floor. DON, MD, and RP notified. This entry was written by LVN Z. 01/23/25 4:06 PM - .Patient is seen per staff request due to reports of combativeness, and agitation. Patient is up in the dining area, calm at the moment, and in no distress at this time. She reportedly pushed another resident who sustained injuries, requiringhospitalization [sic]. Patient presents with spontaneous disruptive mood, and combativeness. She is alert to self, and unwilling or unable to participate in the assessment at this time .Chart reviewed, medication profile reviewed .Upon review, based on presenting will further increase Depakote and start patient on Atarax 10 mg twice daily as needed for anxiety. Primary nurse notified, will monitor closely. This entry was written by NP LL. Observation and interview on 02/27/25 at 2:00 PM with Resident #7 revealed she was sitting in a chair at a table with other residents around her. Resident #7 said she was doing good today and did not appear to have any behaviors. Interview on 02/27/25 at 11:57 AM with LVN Z revealed she was passing medications when Residents #6 and #7 were having an argument and Resident #7 stood up. LVN Z said before she could get to the area where the residents were at, Resident #7 ended up pushing Resident #6. LVN Z said she assessed Resident #6, gave her some pain medication, took her to her room to assess her, and then brought her back to the dining room to eat dinner and everything was fine. LVN Z said she did not see any obvious signs of injuries and Resident #6's pain seemed to be managed. LVN Z said a STAT x-ray was ordered for Resident #6, she notified Resident #6's RP, the DON, the ADON, and the doctor of the incident. LVN Z said during the assessment, there was not any discoloration or bruising to make her think something was injured but the resident did have a slight limp when she pivoted to sit in the chair. LVN Z said before the incident, Resident #6 was completely and independently ambulatory but the next day she was not able to walk so that nurse on shift sent her to the hospital. LVN Z said at the hospital, they found out she had a pelvic fracture. LVN Z said Resident #7 had not been physically aggressive towards other residents before, only combative during care with staff. LVN Z said Resident #7 did get upset though when people were talking around her, thinking that they were talking to her. LVN Z said she knew the Administrator was the abuse coordinator for the facility and that a resident-to-resident altercation that resulted in injuries would be considered abuse. Interview on 02/27/25 at 12:23 PM with CNA V revealed it was around dinner time while staff were serving trays, and Resident #7 was talking to the air and yelling, and some residents were replying back to her. CNA V said they were trying to calm the residents down and telling them to relax when all of a sudden, she saw Resident #7 get up and storm over to push Resident #6 down. CNA V said she went over to stay at Resident #6's side until LVN Z came over. CNA V said after LVN Z took over, she went to check on Resident #7 who was in her room upset but wanted to be left alone. CNA V said Resident #6 looked like she was injured after being pushed because she was shouting and screaming in pain. CNA V said before the incident occurred, Resident #6 was up and walking around and did not need a wheelchair or walker. CNA V said Resident #7 did not have any physically aggressive behaviors before this incident. CNA V said she knew to report abuse to the Administrator who was the abuse coordinator for the facility. Interview on 02/27/25 at 2:36 PM with the DON revealed he received a report that Resident #6 had a fall and then the resident complained of pain and was sent to the ER. The DON said that another resident (Resident #7) had pushed Resident #6 and she fell. The DON said Resident #6 had a pelvic fracture. The DON said he was notified immediately after it happened and when Resident #6 was sent to the ER. The DON said Resident #7 was a little feisty with staff during care but had never attacked another resident. The DON said he was not sure what happened to make Resident #7 push Resident #6 but that it was an accident and was not intentional. The DON said he talked to Resident #7, and she did not mean to hurt anyone, but a resident-to-resident altercation was considered abuse. The DON said he would have to ask the Administrator if she reported the situation or not. The DON said all residents had the right to be free from abuse and all staff were responsible for making sure residents were free from abuse. The DON said Resident #6 was harmed from the situation because she suffered a pelvic fracture and now required the use of a wheelchair. The DON said Resident #6 was independently ambulatory before the incident. Interview on 02/27/25 at 3:03 PM with the Administrator revealed what she understood was the situation happened in the hallway, LVN Z was standing there and talking with Resident #6 when Resident #7 walked past and bumped her, causing Resident #6 to fall and sustained a fracture. The Administrator said when she spoke to the staff about it, she did not get the impression that it was intentional. The Administrator said Resident #6 was able to ambulate independently before the incident and since the fracture occurred she now used a wheelchair. The Administrator said she did not complete an investigation into what happened because of what she was told by the staff. The Administrator said she only talked to LVN Z about the incident but was not aware she did not see what had happened. The Administrator said she did not speak with CNA V who witnessed the incident between the two residents. The Administrator said she only knew that Resident #6 had a fall, and an x-ray was ordered which had negative results, but she was still complaining of pain. The Administrator said since she was still complaining of pain the facility sent her to the ER and that was when they found out about the fracture. The Administrator said if LVN Z documented that Resident #7 pushed Resident #6 then that was intentional and had a different connotation than an accidental bumping into each other. The Administrator said with the new information regarding the situation, it was considered abuse between two residents. The Administrator said she would have wanted staff to report the incident to her immediately. The Administrator said if she had known the details of the incident, she would have reported it to HHSC. The Administrator said all residents had the right to be free from abuse, even from other residents. The Administrator said everyone was responsible for making sure residents were free from abuse. The Administrator said the purpose of keeping residents safe from abuse was to ensure their continued health and safety. Interview on 03/12/25 at 1:08 PM with LVN W revealed while he did not directly work with Resident #7, he worked on the secured unit and was familiar with her. LVN W said he had never seen or heard about Resident #7 being physically aggressive towards a resident prior to the 01/21/25 incident. LVN W said if Resident #7 started to get agitated he would try to calm her down by redirecting her away from the area or removing the other residents from the area. LVN W said he had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse. Interview on 03/12/25 at 1:28 PM with CNA Q revealed while she did not directly work with Resident #7, she worked on the secured unit and was familiar with her. CNA Q said she had never seen or heard about Resident #7 being physically aggressive towards a resident. CNA Q said when Resident #7 started to get agitated she would try to calm her down by redirecting her away from the area or removing the other residents from the area. CNA Q said she had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse. Interview on the phone on 03/12/25 at 1:40 PM with RN R revealed she cared for Resident #7 before and knew that sometimes she would get aggressive towards others by yelling at them. RN R said when Resident #7 started to get agitated she would try to calm her down by redirecting her away from the area or removing the other residents from the area. RN R said she had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse. Interview on the phone on 03/12/25 at 1:54 PM with CNA S revealed she cared for Resident #7 and knew she had behaviors of yelling at others. CNA S said she had not seen Resident #7 be physically aggressive towards anyone at the facility. CNA S said when Resident #7 started to get agitated she would try to calm her down by redirecting her away from the area or removing the other residents from the area. CNA S said she had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse. Interview on 03/12/25 at 2:00 PM with RA T revealed she cared for Resident #7 and knew that she had behaviors of yelling at others. RA T said she had not seen Resident #7 be physically aggressive towards anyone at the facility. RA T said when Resident #7 started to get agitated she would try to calm her down by redirecting her away from the area or removing the other residents from the area. RA T said she had been in-serviced on the facility's abuse policy and knew that a resident-to-resident altercation was considered abuse. Record review of the facility's Course Completion History report from 09/12/24 to 03/12/25 regarding Abuse, Neglect, and Exploitation Training reflected the following: LVN Z had completed the trainings on 11/30/24 and 02/2/25; CNA V had completed the training on 02/11/25. Record review of the facility's incidents/accidents report from 11/27/24 to 02/27/25 reflected there were no other situations that involved Resident #6 or Resident #7. Record review of the facility's policy, revised September 2022, and titled Identifying Types of Abuse reflected: 1. Abuse of any kind against residents is strictly prohibited .4. 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .5. Abuse toward a resident can occur as: a. resident-to-resident abuse . An IJ was identified on 03/12/25. The IJ template was provided to the facility on [DATE] at 4:51 PM. While the IJ was removed on 03/13/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 03/13/25 at 9:45 AM and reflected the following: .F600 Plan of Removal 03/12/2025 Immediate Corrective Action for residents affected by the alleged deficient practice: On 01/21/25 resident #7 was noted to be walking towards her room, at this time she pushed past resident #6 who fell to the ground. Residents were separated by the nurse and redirected. At this time the staff assisted resident #6 up and assessed her, she was medicated for pain. Stat X-rays were called, initial series was negative for fracture. Upon further complaints of pain, the resident was sent to the hospital for additional imaging. The DON, MD, and daughter were notified. These revealed a pelvic fracture for which no surgery was necessary. Resident #6 returned to the facility with no additional injuries noted. Actions taken to prevent a serious adverse outcome from recurring: This alleged deficient practice had the potential to affect all residents who reside in the facility. The medical director was notified of the IJ by assistant director of nursing. On 01/21/2025 MDS nurse care planned a new behavior of aggressiveness towards other residents. With interventions of a psych consult and redirection when agitated, this has not been displayed since the initial incident. Staff will be able to identify this behavior and de-escalation techniques in the future based on the resident's care plan and [NAME]. Education on de-escalation techniques will be provided to all staff. A psychiatric consult was called by the medical director for resident #7 to review medications and behaviors, this was completed the next day on 01/22/2025. On 03/12/2025 the Administrator and Director of Nursing were educated on abuse and neglect, resident to resident altercations, and de-escalation of resident behaviors. This was done by the VP of Clinical Operations. Staff were previously trained on abuse and neglect as well as de-escalation of resident behaviors in December, by the administrator and DON and through [facility training software] in January and February. We will continue to educate new staff as they are hired. New educations on abuse and neglect, resident to resident altercations, and de-escalation of resident behaviors were started on 03/12/2025. These were implemented by the DON and the administrator; all staff will be educated prior to the start of their next shift. An Ad Hoc QAPI meeting was held on 03/12/2025 to inform all the management team. The DON and ADON will review resident behaviors daily in morning clinical meetings while viewing the 24-hour report/EMR and then weekly in IDT. This will be monitored monthly in QAPI. When Actions will be complete: The [Facility Name] will have completed staff education by 03/13/2025, if any staff member working in the facility is unable to be educated, they will be removed from the schedule until training has been provided. The [Facility Name] requests the removal of the immediate jeopardy on 03/12/2025. Monitoring of the facility's Plan of Removal included the following: Interviews with the following staff from 03/13/25 at 9:46 AM to 2:04 PM who worked all shifts and all days of the week revealed they had been in-serviced on de-escalation techniques for when a resident has aggressive behaviors towards another resident, abuse and neglect, and resident-to-resident altercations: LVN D, LVN G, LVN U, CNA BB, CNA CC, CNA DD, RA EE, CNA FF, CNA GG, CNA HH, CNA II, MA JJ, RN KK, LVN W, CNA V, CNA Q, CNA M, RA T, the ADON, the DON, and the Administrator. Record review of an in-service sign in sheet, dated 03/12/25, and titled Resident to Resident Abuse reflected 52 staff had been in-serviced. Record review of an Ad Hoc QAPI Agenda, dated 03/12/25, reflected all IDT members were in attendance. Record review of an in-service sign in sheets, dated 03/12/25, and titled Abuse, Neglect, and Misappropriation Policy and Redirection of a resident that is becoming combative with others, reflected both the DON and Administrator had signed. An IJ was identified on 03/12/25. The IJ template was provided to the facility on [DATE] at 4:51 PM. While the IJ was removed on 03/13/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure personnel provided basic life support, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 8 residents (Resident #11) reviewed for CPR. LVN A failed to initiate CPR when Resident #11 did not have a State recognized advance directive which meant the resident was a Full Code status, and he was found on the floor on the fall mat with his face noted to be reddish purple, weak pulse with no obvious respirations or breathing patterns noted. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:45 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could affect the residents by placing them at risk for a delay in intervention and life-saving treatments, which could result in death. Findings included: Record review of Resident #11's MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke, heart failure, high blood pressure, diabetes, aphasia (language disorder), alcohol abuse, other psychoactive substance abuse, and cerebral ischemia (condition where the brain does not receive enough blood flow, leading to a lack of oxygen and nutrients). Resident #11's cognition was moderately impaired with a BIMS score of 11. The MDS further reflected the resident required assistance with most all ADLs. Record review of Resident #11's care plan revised on [DATE] reflected he was a full code. Interventions included to initiate basic life support CPR if the resident was without a heartbeat or not breathing. Record review of Resident #11's progress notes dated [DATE] documented by LVN A reflected the following: 8:45 PM Upon walking halls in observation of residents, this nurse, upon peeping into res room, noticed resident in prone position while on landing mat appearing asleep. Called res name while attempting to clear visual of res and/or breathing pattern while entering room. After reaching resident, head noted on pillow slightly tilted, face abnormal in color appearing reddish purple. Neck palpated. Weak pulse ascertained. Sternal rub to no avail. No obvious respirations or breathing pattern noted. Nurses X2 assisted res to bed as other nursing staff initiated Emergency response while simultaneously checking resident's code status. During this time at res bedside, O2 initiated and continued efforts were made to arouse res. by this nurse. Res, per demographics in echart, reported to be a DNR as relayed by additional staff. 9:00 PM Emergency response noted in facility in resident's room. Writer informed first responders of said code status as documented in echart. Cpr initiated by fire dept pending receipt of physical copy of advance directives with md signature. This nurse continued to obtain signed verification of code status while calling resident's [family] several times at both listed numbers to no avail. Resuscitation efforts continued awaiting requested info. Spoke with Resident #11's [friend] first contact to notify of incident. Speaker was aware of res code status but did not know specifics, he stated. [sic]Contnued to try to reach [family] in which after approximately 15 min did answer. Was informed by resident's [family] who is listed as surrogate per [county] stated in hospital dnr received upon admission [DATE] that is was resident's wishes to decline life saving measures in the event res codes or is incapacitated, he explained. Per fire dept, they were attempting to reach [family] in which I did notably transfer call to fireman to confirm res code status as explained. [Family] spoke with said fireman in which he stated twice that I was his father's request to not be resuscitated. Emergency did inform res [family] that they would be ceasing resuscitation in 15 min 9:15 PM .Cellphone was brought to this nurse by fire dept in which their medical director stated the requirements of dnr also informing me that the issue 'would be moved up' in chain due to our inability to produce said document During conversation with their medical director I, in fact had located hospital dnr signed by NP with surrogate [family] present and in aggreeance with resident's wishes to not perform 'life saving measures' decision was made by the fire dept to transfer res to ER also stating 'we would probably get a visit tomorrow morning' This nurse stated to fire dept [family] was awaiting on line in which he then informed to tell [family] they were transferring him to hospital after obtaining signs of life after resuscitation because we could not produce documentation Record review of Resident #1's monthly physician orders for February 2025 reflected LVN B input an DNR order on [DATE]. Further review of Resident #1's electronic health record reflected there was not a State recognized Advance Directive nor an Out-of-Hospital DNR for Resident #1. Record review of Resident #11's hospital form titled Medical Orders for Scope of Treatment dated [DATE] signed by a nurse practitioner reflected A Do Not Attempt Resuscitation/Allow Natural Death .D. Direct conversation with surrogate decision-maker/proxy for incapacitated patient Surrogate/Proxy Name: [Resident #1's family] Relationship: Adult Child Primary Contact Number: Designated in: Texas Statutory Surrogate Signature of Physician [NP] Date and Time: [DATE] 4:08 PM Record review of Resident #11's Fire Department Run Form dated [DATE] reflected the following: A Physician Resuscitation Order: Has no pulse or is not breathing. Do Not Attempt Resuscitation/Allow Natural Death Narrative: Subjective Medic was called for a reported breathing problem at 1500 [Facility] in the [City]. Call notes stated 'faintly breathing//currently getting oxygen', 'patient is confused' 'patient has dementia'. On arrival, a [AGE] year old male made was found in cardiac arrest. Staff stated the patient has a DNR. Staff later stated they could not find the DNR. Multiple attempts to contact patient's family were unsuccessful. Objective: At 20:57, the patient was lying supine on the bed. A NRB was on the patient's face, placed by staff, with oxygen connected but no staff was nearby. Initial assessment revealed the patient was pulseless and apneic (a condition where breathing temporarily ceases). The patient's skin was mottled by warm. The patient had no visible trauma or external bleeding. Assessment: The field impression of the patient was Cardiac Arrest Plan: Upon finding the patient pulseless and apneic a 4-lead was established (a diagnostic tool that uses four electrodes to record the heart's electrical activity) and the patient was confirmed to be in asystole (a cardiac arrest that occurs when the heart stops beating and there is no electrical activity. After the staff stated that they could not find the DNR, the patient was transferred to the ground and CPR was initiated. Using the face sheet, family was contact was attempted but failed After 15 minutes of ACLS (Advanced Cardiac Life Support- a set of medical procedures and skills used to treat cardiac emergencies) the patient had a rhythm change for asystole to PEA (Pulse Electrical Activity - type of cardiac arrest where the heart's electrical activity is present, but there is no pulse) Due to the change in rhythm and rate of PEA, medical direction instructed us to transport the patient to the ER No further change in rhythm was noted throughout transport. Upon arrival at the ER the resident was transferred from the stretcher to the hospital bed The medical director checked heart motion and continued CPR for two more minutes before ending resuscitation attempts. Multiple attempts to contact LVN A on [DATE] and on [DATE] were unsuccessful. Attempts to contact Resident #11's family on [DATE] were unsuccessful. Interview on [DATE] at 1:21 PM with the Social Worker revealed Resident #11 was a full code and did not have DNR paperwork. The Social Worker said someone in the family said they had been discussing Resident #11 become a DNR but that was a far as that went, and nothing else was said . Interview on [DATE] at 4:24 PM with LVN C revealed LVN A said she was making rounds, [DATE], when she found Resident #11 unresponsive, and he had gone to assist and noticed he had a weak pulse. The resident's lips were blue, and he was not responding. LVN C said they checked the computer, and it showed the resident was a DNR and 911 was called. When EMS arrived, they asked for Resident #11's DNR paperwork and they were not able to produce it, so EMS started CPR as LVN A and LVN C continued to look for the DNR. LVN C said that because they thought Resident #11 was a DNR, the AED machine was not applied. LVN C further stated he heard one of the EMS staff members say Resident #11 had flatlined when they put the machines on the resident . Interview on [DATE] at 1:29 PM with the ADON revealed she was not aware CPR had not been initiated on Resident #11 on [DATE] and if the resident was a full code, then CPR should have been initiated . Interview on [DATE] at 2:07 PM with the DON revealed he was told Resident #11 had coded, [DATE], and had been found unresponsive. The DON said the resident just returned from the hospital, [DATE], and with a DNR but it was not an Out of Hospital DNR. Based on the progress notes, had read Resident #11 had a weak pulse, put oxygen on, and staff dialed 911. The DON said it appeared the AED was not used because the resident still had a pulse. The DON also said it appeared LVN A was unsure if Resident #11 was a full code. The DON further stated the staff could have used the AED machine to confirm the resident had a pulse . The DON further stated CPR should have been initiated if a resident was a full code or the code status was unknown. Interview on [DATE] at 5:47 PM with the Administrator revealed the EMS had met with her, because they had a concern, because the staff had gone back and forth whether Resident #11 was a DNR on [DATE]. The Administrator said it appeared they had a hospital DNR on file and the nurse, LVN A, did not know it was not valid in a nursing home. The EMS told her they required an Out of Hospital DNR and the facility staff should have started CPR when Resident #11 was found unresponsive . Interview on [DATE] at 1:18 PM with the Physician revealed Resident #11 was known to the facility and the nurses assumed the resident was a DNR because the resident had a hospital DNR. He said he was glad the resident was not revived because everyone knew that is what Resident #11 wanted. The Physician said nursing homes required Out of Hospital DNR's and that paperwork should be done when the residents were admitted . He further stated if the residents were a full code, CPR should be initiated if they code. Interview on [DATE] at 9:08 AM with the EMS Captain revealed they were called to the facility for a resident having difficulty breathing. When EMS arrived, they found Resident #11 with oxygen on a high flow, and he was not breathing. When the EMS crew put the monitors on the resident, he was flatlined. The EMS staff asked the facility staff if Resident #11 was a full code or a DNR. They were told the resident was a DNR but 20 or 30 minutes later the facility staff were still trying look for the DNR paperwork. When the facility staff finally said they found the DNR it was make shift from a nurse practitioner that was not valid in the state of Texas for a nursing home. He said Texas required an Out of Hospital DNR in a nursing home, otherwise the residents were a full code. The EMS Captain stated they were not able to get a heart beat on the resident and he had to be transported because they were able to get a PEA . They were not able to get in touch with the family so there was no one that could tell them to stop CPR. The EMS Captain further stated, after the incident, he met with the Administrator because he had been concerned there was so much confusion on whether a resident was a DNR or a full code. Record review of the facility's policy titled Emergency Procedure-Cardiopulmonary Resuscitation revised on 09/2024 reflected the following: .6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR .7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR An Immediate Jeopardy/Immediate Threat was identified on [DATE]. The Administrator and DON were notified of the Immediate Jeopardy on [DATE] at 4:36 PM. The IJ template was provided to the facility on [DATE] at 4:45 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The facility's Plan of Removal for the Immediate Jeopardy was accepted on [DATE] at 9:00 AM and reflected the following: Immediate Corrective Action for residents affected by the alleged deficient practice: On [DATE] the resident was noted to be in a prone position appearing asleep during staff rounds. The staff member entered the room and checked the resident who was noted with weak pulse but was unresponsive to sternal rub. At this time the facility called 911, while checking residents code status. The resident was placed on oxygen and efforts were made to arouse the resident who had a pulse. EMS arrived at the facility and began resuscitation efforts for the resident, who was taken to [Hospital] by the EMS team. Actions taken to prevent a serious adverse outcome from recurring: This deficient practice had the potential to affect all residents who reside in the facility, the EMS Captain visited the facility on [DATE] to discuss the incident with the administrator. At this time the administrator completed a code status audit of all residents residing in the facility. All were found to have the appropriate documentation in the miscellaneous section of the chart listed as advanced directives or out of hospital DNRs. The administrator also had the social worker complete a chart audit to double-check that no code statuses were missed. On [DATE] the administrator reached out to the EMS captain to inform him of the results of the audit and thank him for the collaboration with the facility. The director of nursing started an education on Code Status and CPR on [DATE], education continues at present. The director of nursing and administrator were educated by vice president of clinical services on the topics of: Code Status, Out of Hospital DNRs, when to initiate CPR, and when to apply the AED. This education took place on [DATE]. New training initiated on [DATE] will include all nurses. They will be educated on identifying the appropriate code status including out of hospital DNR vs. Hospital DNR, when to initiate CPR, and how to use the AED correctly. The nursing staff checks all residents for orders and appropriate paperwork on code status upon admission/readmission to the facility. This is checked again by the nurse management team in the morning meeting, and the social worker in weekly audits. The administrator and social services director will continue to audit code statuses weekly. All results will be discussed monthly in QAPI. The Medical Director was notified of the deficiency (F678) on [DATE]. When Actions will be complete: The [Facility] will have completed education by [DATE], if any staff member working in the facility is unable to be educated, they will be removed from the schedule until training has been provided. The [facility] requests the removal of the immediate jeopardy on [DATE]. Monitoring of the facility's Plan of Removal included the following: Record review of the facility DNR audit dated [DATE] revealed all residents had the appropriate paperwork if they were a DNR. Record review of 12 current facility residents on [DATE] revealed they had the correct code status, physician order, and Out of Hospital DNR in their clinical file. Record review of in-services dated [DATE] reflected staff were educated on code status, Out of Hospital DNRs, when to initiate CPR, and when to apply the AED. They were also educated to check all residents' orders and appropriate paperwork on code status before they input the order. Interview on [DATE] from 9:53 am to 4:00 PM with staff from various shifts were the Administrator, DON, ADON, LVN A, LVN B, LVN C, LVN D, LVN E, RN F, LVN G, and LVN H. All staff stated they were educated on the following: - On code status - Full code/DNR - Identify the difference between a hospital and Out of Hospital DNR - When to initiate CPR - If code status is unclear, resident is a full code until further notice and CPR will be initiated. - How to apply and use the AED - Verify through orders and paperwork a resident's code status before it is put in the computer system. Interview on [DATE] at 2:28 PM with the Social Worker she was responsible for conducting weekly DNR audits to ensure each resident had the correct code status. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:45 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a change in the resident's condition or a need to alter treatment for one (Resident #1) of three residents reviewed for physician consultation. LVN A failed to consult with the physician for Resident #1 when the resident had a change of condition on 06/15/24. Resident #1 displayed signs and symptoms of pain when her left leg was touched on 06/15/24 at 7:45 PM. The physician was not notified the resident had a change of condition until the next morning 06/16/24 at approximately 6:00 AM and ordered x-rays, which reflected the resident had a left hip fracture, and she was sent to the hospital for evaluation and treatment. An Immediate Jeopardy (IJ) situation was identified on 0719/24. While the IJ was removed on 07/19/24, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. The failure placed residents at risk for delayed physician intervention. Findings included: Record review of Resident #1's MDS assessment, dated 06/24/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, arthritis, hip fracture, Alzheimer's disease, non-Alzheimer's dementia, vitamin D deficiency, hypocalcemia (calcium deficiency), and cognitive communication deficit. Resident #1 had long and short- term memory impairment and decision making was severely impaired. Resident #1 had unclear speech and rarely understood/understands. The MDS further reflected the resident was in a manual wheelchair and dependent for all ADLs. Record review of Resident #1's care plan, revised 07/29/21, reflected she had a communication problem related to dementia. Interventions included to monitor and document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. Record review of Resident #1's progress notes, dated 06/15/24, documented by LVN A reflected: Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed. At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to oncoming nurse to monitor resident discomfort if worsens to report to NP/MD. Record review of Resident #1's x-ray report, dated 06/16/24, reflected: .EXAM: Pelvis and left hip HISTORY: Pain .FINDINGS: There is a fracture involving the proximal left femur centered within the intertrochanteric space. There does appear to be approximately a centimeter of shortening as well as a few degrees of varus angulation. There is no dislocations. A significant joint effusion is not seen. Mild symmetric osteoarthritis is seen . IMPRESSION: 1. Proximal left femur fracture . Record review of Resident #1's hospital records, dated 06/16/24, reflected Resident #1 had been diagnosed with an acute fracture of the left proximal femur (hip fracture). Record review of the facility's Provider Investigation Report, dated 06/17/24, reflected the following: .This resident is a 60 yo (year old) female who resides on the secured unit. The resident ambulates independently on the unit. This resident also ambulates in a wheelchair. This resident has dementia, osteoarthritis, and vitamin D deficiency. The weekend RN supervisor informed this admin that x-rays were ordered due to a resident possible leg fracture .On-coming aide notified charge nurse that during peri care resident was favoring her left leg. Charge nurse stated that resident is non-verbal and that she would monitor resident throughout her shift. Charge nurse indicated that resident slept through the night. Facility received x-rays, indicating possible fracture . Observation on 07/02/24 at 10:00 AM of Resident #1 revealed she was in a low bed with her eyes closed. After knocking, the resident's name was called out, but Resident #1 barely opened her eye, closed them right away and did not speak. Interview on 07/02/24 at 10:54 AM CNA B stated she was making her rounds on, 06/15/24, around 7:45 PM. She went in to change Resident #1 and when she started peri care, Resident #1 yelled out like she was in pain, so she went to get LVN A. At that time both the CNA B and LVN A tried to assist the resident to a standing position and Resident #1 yelled again. and They noted something was wrong, and it appeared like her left foot was hurting so she was put back in bed. Resident #1 was not able to speak therefore could not tell them what was wrong. CNA B said it was not normal for Resident #1 to yell out when she was being changed. CNA B further stated she worked from 7:00 PM to 7:00 AM and during the night she continued to monitor Resident #1. and during her brief change, the resident did not groan or appear to be in pain the remainder of her shift. Record review of LVN A's undated handwritten and signed statement reflected the following: To whom it may concern, Cc: [Resident #1] Upon my shift on June 15th, this writer [LVN A] noted patient sitting on w/c but seems sleepy (eyes closed). Notified nurse aide to lay patient in bed. During rounds for incontinent care with nurse aide, noted facial grimacing when touching pt on left leg but since patient is non-verbal, assessed pt left extremities no bruises noted, or any other skin issues. Layed [laid] pt comfortably in bed, while continuous monitoring, pt slept all night long. This writer reported oncoming nurse to monitor if patient persist with pain to touch to notify MD. Review of LVN A's undated typed and signed statement on 07/02/24 reflected the following: To whom it may concern, Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed., At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3: 00 AM ] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to on coming nurse to monitor resident discomfort if worsens to report to NP/MD. Record review of LVN A's personnel file on 07/02/24 reflected the signature on LVN A's handwritten statement matched the signatures on her new hire paperwork. Interview on 07/02/24 at 2:25 PM LVN A stated she arrived to work around 6:00 PM on, 06/15/24, and Resident #1 was in her wheelchair and appeared to look tired, so she asked an aide to lay her down in bed. Later that evening, CNA B told her the resident was having some discomfort while she was trying to change her brief, so she went into Resident #1's room to assess the resident. LVN A denied trying to make the resident stand up and said Resident #1 indeed looked to have some discomfort, but it was not pain. LVN A described the discomfort as someone that was tired and did not want to be touched and again denied the discomfort as pain . LVN A said she continued to monitor the resident throughout the night and there were no concerns as Resident #1 has slept comfortably the whole night. LVN A was asked about her handwritten statement where she had documented facial grimacing when the resident's left leg was touched and LVN A denied writing a statement. LVN A further stated the only thing she wrote was her narrative in the progress notes of Resident #1's clinical record and again denied she wrote a statement of the incident. LVN A also said she did not contact the doctor because Resident #1 was not in pain and the resident had slept comfortably all night. Interview on 07/02/24 at 1:40 PM RN C stated when she arrived at the facility on, 06/16/24 at 6:00 AM, Resident #1 was in bed sleeping. She got report from the night nurse, LVN A, that Resident #1 was having pain to her left leg. RN C went in to assess the resident in her room and Resident #1 did not appear well, was not her normal self, and when she tried to move her left leg, the resident expressed pain through facial grimacing. RN C called the doctor and ordered an x-ray of the resident's leg, and the results came back positive for a hip fracture, so she was sent out to the hospital. Interview on 07/02/24 at 1:54 PM ADON stated she was not informed of all the details with Resident #1. The ADON said she only assisted in gathering a few statements from the staff and the Administrator had conducted the investigation with Resident #1's incident. Interview on 07/02/24 at 2:43 PM Administrator stated she had been made aware of Resident #1's hip fracture and she began an investigation of the incident. The Administrator was made aware LVN A denied writing a statement., and she was shown the handwritten statement that was part of the provider investigation report and shown the matching signatures. The Administrator said she had provided the wrong statement. The Administrator said had found LVN A's handwritten statement under her door and because corporate preferred their statements to be typed out, the [NAME] President of Clinical Operations had gotten LVN A's other statement. The Administrator further stated she would provide the LVN A's typed statement and that was the correct one. The Administrator could not explain why there were two statements where one addressed Resident #1 was having pain and the other statement did not. Interview on 07/02/24 at 3:19 PM with the [NAME] President of Clinical Operations revealed she was not aware LVN A had written a statement. and the facility did not have a DON at the time, so she called LVN A into the facility and had her type up a statement. The [NAME] President of Clinical Operations said LVN A further stated LVN A had been suspended and educated on pain management and resident assessment after the incident with Resident #1 because they felt like LVN A could have assessed the resident better and wanted to make sure she knew how to fully assess a resident and contact the doctor if needed. Record review of the facility's Change in Resident's Status or Condition policy, revised February 2021, reflected the following: Policy Statement: Our promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .b. discovery of injuries of an unknown source; .i. specific instruction to notify the physician of changes in the resident's condition. This was determined to be an Immediate Jeopardy (IJ) on 07/19/24 at 8:44 AM. The Administrator, the DON and ADON were notified. The Administrator was provided with the IJ template on 07/19/24 at 8:50 AM. The following Plan of Removal submitted by the facility was accepted on 07/19/24 at 2:37 PM: Problem: Facility failed to immediately consult with the resident's physician when there was a change in the resident's condition, when Resident #1 had a change of condition on 06/15/24 and did not receive timely treatment. - The following in-services were initiated by - started on 7/2/2024 and completed on 7/5/2024 COMPLIANCE NURSE DON: Any nursing staff member not present or in-service will not be allowed to assume their duties until in-serviced and expectations acknowledged. Licensed Nurses: - Promptly and accurately assessing a resident when change of condition has been identified / reported. Education started on 7/2/2024 and completed on 7/5/2024. - Assessing a resident's change in condition using SBAR, so that all necessary information is communicated to the physician or Nurse Practitioner. Education started on 7/2/2024 and completed on 7/5/2024. -Reporting changes of condition to the physician or nurse practitioner based on Change of Condition Form. Education started 7/2/2024 and completed on 7/5/2024. Non-licensed nursing staff: - Reporting changes in a resident's condition to a nurse immediately. Education started 6/16/2024 and completed on 7/5/2024. - If the nurse does not assess timely, the DON/Designee must be notified. Education started 6/16/2024 and completed 7/5/2024. The Administrator, DON and ADON were in-serviced .regarding .ensuring all staff applicable to the in-service receive the training, to use online resources and / or in person training, to ensure all trained staff have attested that they have received the training by a signed acknowledgement. An ADHOC QAPI meeting was conducted on 7/8/2024 regarding this plan and monitoring. The Medical Director .was notified of this plan and monitoring on 7/2/2024. Monitoring -The DON/Designee will monitor all kiosk (dashboard) alerts a minimum of 4 times per week to ensure any potential change of condition has been addressed timely. -The DON/Designee will randomly ask nurses per week what they would do if a resident had a change of condition, or it was report to them that a resident had a change of condition. -The QAPI committee will review the findings and make any needed changes. Monitoring of the facility's Plan of Removal included the following: Record review of the facility's Incident by Incident type reflected Resident #2, Resident #3, Resident #4, Resident #5 had unwitnessed falls and nursing staff documented, assessed the residents, and reported to the Interim DON, family, and physician. Record review of Admit/Discharge Report, from 06/16/24 through 07/19/24, reflected Resident #6, Resident #7, Resident #8, Resident #9 were discharged to the hospital due to change in condition. Residents were assessed and nursing staff documented change in condition using SBAR and notified the Interim DON, family, and physician. Record review of the facility's Change in Condition Evaluation - SBAR (Situation, Background, Assessment, and Recommendation), undated, reflected the form addressed signs and symptoms identified, start date, review findings and provider notifications, mental status evaluation, functional status evaluation, vital signs evaluation, provider notification and feedback, behavioral status evaluation, respiratory status evaluation, cardiovascular status evaluation, abdominal/GI status evaluation, genitourinary status evaluation, skin status evaluation, pain status evaluation, neurological status evaluation, general background evaluation and available laboratory test/diagnostic procedures and resident representative notification. Record review of the facility's Record of In-service Education, dated 06/16/24, reflected training for abuse, neglect policy - who was coordinator; resident rights; pain policy; and timely notification. In-services reflected all staff completed the trainings. The in-services were conducted and signed by nursing on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 06/25/24, reflected the training participant would be able to verbalize and demonstrate proper transfer techniques in order to safely provide patient care handling, transfers included sit to stand, stand - pivot, squat- pivot, slide board, and mechanical lift. The in-services were conducted and signed by CNAs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 06/26/24, reflected the Administrator, the Interim DON and ADON were in-serviced on all staff applicable to receive training to use online resources or in person training to ensure all trained staff have attested to receiving education. Record review of the facility's Record of In-service Education, dated 07/02/24, reflected training for what was change of condition, what to do when a change of condition happens, who to notify, orders to receive, full head to toe assessment, assess for pain, medicate as ordered and continue to assess and to follow through any new orders. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 07/03/24, reflected training regarding how to identify pain and what to do. The training record reflected: .pain may be late on set and resident may not be able to verbalize, job is to assess pain and treat timely, once treated - [you] have to assess for effectiveness, continue to monito if not effective new orders may be needed. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Monthly QA Meeting reflected the meeting was completed on 07/08/24. Interviews conducted on 07/19/24 from 2:40 PM through 5:45 PM with the Administrator, the Interim DON, ADON, LVN A, RN D, RN E, RN F, LVN G, LVN M, RN O, LVN Q, who worked the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM verbally revealed nurses were able to verify education was provided to them. Nursing staff were able to accurately summarize what was change of condition, what to do when a change of condition occurred, who to notify, orders to receive, completing a full head-to-toe assessment, assessing for pain, medicating as ordered and continuing to assess, following through any new orders, documenting, and completing the SBAR. The Interim DON and ADON stated they would be responsible for monitor all kiosk (dashboard) alert a minimum of 4 times per week to ensure any potential change of condition had been addressed timely and continue education on change of condition. Interviews conducted on 07/19/24 from 3:48 PM through 5:45 PM with CNA B, CNA H, CNA I, CNA J, CNA K, CNA L, CNA N, CNA P, CNA R, CNA S, and CNA T who work the shifts of 6:00 AM- 6:00 PM- 6:00 PM - 6:00 AM verbally revealed staff were able to verify education was provided to them, staff were able to accurately summarize what was change of condition, how to identify pain and who to notify. The Administrator and Interim DON was informed the Immediate Jeopardy was removed on 07/19/2024 at 5:50 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care. LVN A failed to ensure Resident #1 was provided with timely treatment when the resident had a changed of condition on 06/15/24. Resident #1 displayed signs and symptoms of pain when her left leg was touched on 06/15/24 at 7:45 PM. The physician was not notified the resident had a change of condition until the next morning 06/16/24 at approximately 6:00 AM and ordered x-rays, which revealed the resident had a left hip fracture, and she was sent to the hospital for evaluation and treatment. An Immediate Jeopardy (IJ) situation was identified on 0719/24. While the IJ was removed on 07/19/24, the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for delay in needed treatment and care. Findings included: Record review of Resident #1's MDS assessment, dated 06/24/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included end stage renal disease, arthritis, hip fracture, Alzheimer's disease, non-Alzheimer's dementia, vitamin D deficiency, hypocalcemia (calcium deficiency), and cognitive communication deficit. Resident #1 had long and short- term memory impairment and decision making was severely impaired. Resident #1 had unclear speech rarely understood/understands. The MDS further reflected the resident was in a manual wheelchair and dependent for all ADLs. Record review of Resident #1's care plan, revised 07/29/21, reflected she had a communication problem related to dementia. Interventions included to monitor and document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. Record review of Resident #1's progress notes, dated 06/15/24, documented by LVN A reflected: Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed. At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to oncoming nurse to monitor resident discomfort if worsens to report to NP/MD . Record review of Resident #1's x-ray report, dated 06/16/24, reflected: .EXAM: Pelvis and left hip HISTORY: Pain .FINDINGS: There is a fracture involving the proximal left femur centered within the intertrochanteric space. There does appear to be approximately a centimeter of shortening as well as a few degrees of varus angulation. There is no dislocations. A significant joint effusion is not seen. Mild symmetric osteoarthritis is seen . IMPRESSION: 1. Proximal left femur fracture . Record review of Resident #1's hospital records, dated 06/16/24, reflected Resident #1 had been diagnosed with an acute fracture of the left proximal femur (hip fracture). Record review of the facility's Provider Investigation Report, dated 06/17/24, reflected the following: .This resident is a 60 yo (year old) female who resides on the secured unit. The resident ambulates independently on the unit. This resident also ambulates in a wheelchair. This resident has dementia, osteoarthritis, and vitamin D deficiency. The weekend RN supervisor informed this admin that x-rays were ordered due to a resident possible leg fracture .On-coming aide notified charge nurse that during peri care resident was favoring her left leg. Charge nurse stated that resident is non-verbal and that she would monitor resident throughout her shift. Charge nurse indicated that resident slept through the night. Facility received x-rays, indicating possible fracture . Observation on 07/02/24 at 10:00 AM of Resident #1 revealed she was in a low bed with her eyes closed. After knocking, the resident's name was called out, but Resident #1 barely opened her eye, closed them right away and did not speak. Interview on 07/02/24 at 10:54 AM CNA B stated she was making her rounds on, 06/15/24, around 7:45 PM. She went in to change Resident #1 and when she started peri care, Resident #1 yelled out like she was in pain, so she went to get LVN A. At that time both the CNA B and LVN A tried to assist the resident to a standing position and Resident #1 yelled again. and They noted something was wrong, and it appeared like her left foot was hurting so she was put back in bed. Resident #1 was not able to speak therefore could not tell them what was wrong. CNA B said it was not normal for Resident #1 to yell out when she was being changed. CNA B further stated she worked from 7:00 PM to 7:00 AM and during the night she continued to monitor Resident #1. and during her brief change, the resident did not groan or appear to be in pain the remainder of her shift. Record review of LVN A's undated handwritten and signed statement reflected the following: To whom it may concern, Cc: [Resident #1] Upon my shift on June 15th, this writer [LVN A] noted patient sitting on w/c but seems sleepy (eyes closed). Notified nurse aide to lay patient in bed. During rounds for incontinent care with nurse aide, noted facial grimacing when touching pt on left leg but since patient is non-verbal, assessed pt left extremities no bruises noted, or any other skin issues. Layed [laid] pt comfortably in bed, while continuous monitoring, pt slept all night long. This writer reported oncoming nurse to monitor if patient persist with pain to touch to notify MD. Review of LVN A's undated typed and signed statement on 07/02/24 reflected the following: To whom it may concern Upon my shift on June 15, this writer noted patient sitting on w/c but seems sleepy eyes closed. Notified to lay patient in bed. During rounds this writer was notified to patient room upon incontinent care, this writer could not see abnormal in left extremities, assessed patient, no bruises, swelling, nor skin tear noted to lower extremities. Assisted aide to reposition patient to comfortably lay back in bed., At 0100 [1:00 AM] checked patient was comfortably sleeping eyes closed, rise, and fall of chest noted. At 0300 [3:00 AM] checked patient no discomfort noted. During morning meds pass check patient was in bed no movement noted. This writer gave report to on coming nurse to monitor resident discomfort if worsens to report to NP/MD. Record review of LVN A's personnel file on 07/02/24 reflected the signature on LVN A's handwritten statement matched the signatures on her new hire paperwork. Interview on 07/02/24 at 2:25 PM LVN A stated she arrived to work around 6:00 PM on, 06/15/24, and Resident #1 was in her wheelchair and appeared to look tired, so she asked an aide to lay her down in bed. Later that evening, CNA B told her the resident was having some discomfort while she was trying to change her brief, so she went into Resident #1's room to assess the resident. LVN A denied trying to make the resident stand up and said Resident #1 indeed looked to have some discomfort, but it was not pain. LVN A described the discomfort as someone that was tired and did not want to be touched and again denied the discomfort as pain. LVN A said she continued to monitor the resident throughout the night and there were no concerns as Resident #1 has slept comfortably the whole night. LVN A was asked about her handwritten statement where she had documented facial grimacing when the resident's left leg was touched and LVN A denied writing a statement. LVN A further stated the only thing she wrote was her narrative in the progress notes of Resident #1's clinical record and again denied she wrote a statement of the incident. LVN A also said she did not contact the doctor because Resident #1 was not in pain and the resident had slept comfortably all night. Interview on 07/02/24 at 1:40 PM with RN C revealed when she arrived to the facility on, 06/16/24 at 6:00 AM, Resident #1 was in bed sleeping. She got report from the night nurse, LVN A, that Resident #1 was having pain to her left leg. RN C went in to assess the resident in her room and Resident #1 did not appear well, was not her normal self, and when she tried to move her left leg, the resident expressed pain through facial grimacing. RN C called the doctor and ordered an x-ray of the resident's leg, and the results came back positive for a hip fracture, so she was sent out to the hospital. Interview on 07/02/24 at 1:54 PM with the ADON revealed she was not informed of all the details with Resident #1. The ADON said she only assisted in gathering a few statements from the staff and the Administrator had conducted the investigation with Resident #1's incident. Interview on 07/02/24 at 2:43 PM with the Administrator revealed she had been made aware of Resident #1's hip fracture and she began an investigation of the incident. The Administrator was made aware LVN A denied writing a statement., and she was shown the handwritten statement that was part of the provider investigation report and shown the matching signatures. and The Administrator said she had provided the wrong statement. The Administrator said had found LVN A's handwritten statement under her door and because corporate preferred their statements to be typed out, the [NAME] President of Clinical Operations had gotten LVN A's other statement. The Administrator further stated she would provide LVN A's typed statement and that was the correct one. The Administrator could not explain why there were two statements where one addressed Resident #1 was having pain and the other statement did not. Interview on 07/02/24 at 3:19 PM with the [NAME] President of Clinical Operations revealed she was not aware LVN A had written a statement. and the facility did not have a DON at the time, so she called LVN A into the facility and had her type up a statement. The [NAME] President of Clinical Operations said LVN A further stated LVN A had been suspended and educated on pain management and resident assessment after the incident with Resident #1 because they felt like LVN A could have assessed the resident better and wanted to make sure she knew how to fully assess a resident and contact the doctor if needed. Record review of the facility's Change in Resident's Status or Condition policy, revised February 2021, reflected the following: Policy Statement: Our promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .b. discovery of injuries of an unknown source; .i. specific instruction to notify the physician of changes in the resident's condition. This was determined to be an Immediate Jeopardy (IJ) on 07/19/24 at 8:44 AM. The Administrator, the DON and ADON were notified. The Administrator was provided with the IJ template on 07/19/24 at 8:50 AM. The following Plan of Removal submitted by the facility was accepted on 07/19/24 at 2:37 PM: Problem: Facility failed to immediately consult with the resident's physician when there was a change in the resident's condition, when Resident #1 had a change of condition on 06/15/24 and did not receive timely treatment. - The following in-services were initiated by - started on 7/2/2024 and completed on 7/5/2024 COMPLIANCE NURSE DON: Any nursing staff member not present or in-service will not be allowed to assume their duties until in-serviced and expectations acknowledged. Licensed Nurses: - Promptly and accurately assessing a resident when change of condition has been identified / reported. Education started on 7/2/2024 and completed on 7/5/2024. - Assessing a resident's change in condition using SBAR, so that all necessary information is communicated to the physician or Nurse Practitioner. Education started on 7/2/2024 and completed on 7/5/2024. -Reporting changes of condition to the physician or nurse practitioner based on Change of Condition Form. Education started 7/2/2024 and completed on 7/5/2024. Non-licensed nursing staff: - Reporting changes in a resident's condition to a nurse immediately. Education started 6/16/2024 and completed on 7/5/2024. - If the nurse does not assess timely, the DON/Designee must be notified. Education started 6/16/2024 and completed 7/5/2024. The Administrator, DON and ADON were in-serviced .regarding .ensuring all staff applicable to the in-service receive the training, to use online resources and / or in person training, to ensure all trained staff have attested that they have received the training by a signed acknowledgement. An ADHOC QAPI meeting was conducted on 7/8/2024 regarding this plan and monitoring. The Medical Director .was notified of this plan and monitoring on 7/2/2024. Monitoring -The DON/Designee will monitor all kiosk (dashboard) alerts a minimum of 4 times per week to ensure any potential change of condition has been addressed timely. -The DON/Designee will randomly ask nurses per week what they would do if a resident had a change of condition, or it was report to them that a resident had a change of condition. -The QAPI committee will review the findings and make any needed changes. Monitoring of the facility's Plan of Removal included the following: Record review of the facility's Incident by Incident type reflected Resident #2, Resident #3, Resident #4, Resident #5 had unwitnessed falls and nursing staff documented, assessed the residents, and reported to the Interim DON, family, and physician. Record review of Admit/Discharge Report, from 06/16/24 through 07/19/24, reflected Resident #6, Resident #7, Resident #8, Resident #9 were discharged to the hospital due to change in condition. Residents were assessed and nursing staff documented change in condition using SBAR and notified the Interim DON, family, and physician. Record review of the facility's Change in Condition Evaluation - SBAR (Situation, Background, Assessment, and Recommendation), undated, reflected the form addressed signs and symptoms identified, start date, review findings and provider notifications, mental status evaluation, functional status evaluation, vital signs evaluation, provider notification and feedback, behavioral status evaluation, respiratory status evaluation, cardiovascular status evaluation, abdominal/GI status evaluation, genitourinary status evaluation, skin status evaluation, pain status evaluation, neurological status evaluation, general background evaluation and available laboratory test/diagnostic procedures and resident representative notification. Record review of the facility's Record of In-service Education, dated 06/16/24, reflected training for abuse, neglect policy - who is coordinator; resident rights; pain policy; and timely notification. In-services reflected all staff completed the trainings. The in-services were conducted and signed by nursing on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 06/25/24, reflected the training participant would be able to verbalize and demonstrate proper transfer techniques in order to safely provide patient care handling, transfers included sit to stand, stand - pivot, squat- pivot, slide board, and mechanical lift. The in-services were conducted and signed by CNAs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 06/26/24, reflected the Administrator, the Interim DON and ADON were in-serviced on all staff applicable to receive training to use online resources or in person training to ensure all trained staff have attested to receiving education. Record review of the facility's Record of In-service Education, dated 07/02/24, reflected training for what was change of condition, what to do when a change of condition happens, who to notify, orders to receive, full head to toe assessment, assess for pain, medicate as ordered and continue to assess and to follow through any new orders. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Record of In-service Education, dated 07/03/24, reflected training regarding: how to identify pain and what to do. The training record reflected: .pain may be late on set and resident may not be able to verbalize, job is to assess pain and treat timely, once treated - [you] have to assess for effectiveness, continue to monito if not effective new orders may be needed. The in-services were conducted and signed by RNs and LVNs on both shifts, 6:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. Record review of the facility's Monthly QA Meeting reflected the meeting was completed on 07/08/24. Interviews conducted on 07/19/24 from 2:40 PM through 5:45 PM with the Administrator, the Interim DON, ADON, LVN A, RN D, RN E, RN F, LVN G, LVN M, RN O, LVN Q, who worked the shifts of 6:00 AM-6:00 PM and 6:00 PM-6:00 AM revealed nurses were able to verify education was provided to them. Nursing staff were able to accurately summarize what was change of condition, what to do when a change of condition occurred, who to notify, orders to receive, completing a full head-to-toe assessment, assessing for pain, medicating as ordered and continuing to assess, following through any new orders, documenting, and completing the SBAR. The Interim DON and ADON stated they would be responsible for monitor all kiosk (dashboard) alert a minimum of 4 times per week to ensure any potential change of condition had been addressed timely and continue education on change of condition. Interviews conducted on 07/19/24 from 3:48 PM through 5:45 PM with CNA B, CNA H, CNA I, CNA J, CNA K, CNA L, CNA N, CNA P, CNA R, CNA S, and CNA T who work the shifts of 6:00 AM- 6:00 PM- 6:00 PM - 6:00 AM revealed staff were able to verify education was provided to them, staff were able to accurately summarize what was change of condition, how to identify pain and who to notify. The Administrator and Interim DON was informed the Immediate Jeopardy was removed on 07/19/2024 at 5:50 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and that each resident received adequate supervision to prevent accidents for 5 of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1, who resided in the memory care unit, was provided a hazard free environment with adequate supervision when Resident #1 ingested body wash on 02/07/23, which was found while wandering in the room of Resident #2 and Resident #3. 2. The facility failed to provide a hazardous free environment in the memory care unit, even after Resident #1 ingested body wash on 02/07/23, when bottles of body wash and body lotion were left out in the room of Residents #4 and #5 on 02/15/23. These failures put memory care residents at risk of serious injury, hospitalization, or even death. An Immediate Jeopardy situation was identified on 02/15/23 at 3:54 PM. The Immediate Jeopardy was removed on 02/16/23 at 2:50 PM. The facility remained out of compliance at a scope of pattern and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. Findings Included: Resident #1 Record review of Resident #1's electronic Facesheet, dated 02/15/23, revealed Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's diagnoses included senile degeneration of brain (the mental deterioration and loss of intellectual ability), neurocognitive disorder with Lewy bodies (affect chemicals in the brain whose changes, can lead to problems with thinking, movement, behavior, and mood), and schizoaffective disorder bipolar type. Record review of Resident #1's Quarterly MDS assessment, dated 01/21/23, revealed Resident #1's BIMS score was 00 which indicated severe cognitive impairment. Record review of Resident #1's care plan, initiated on 11/07/22, reflected Resident #1 had a communication problem due to dementia and the interventions included Ensure/provide a safe environment . avoid isolation. Further review revealed Resident #1 had behavior potentially causing harm, due to dementia, as evidenced by ingested non-food substance and the interventions included if wandering or pacing, initiate visual supervision during acute episode . staff will keep all potential non-food items out of view or accessibility. A record review of Resident #1's Progress Notes, dated 02/07/23, revealed LVN A documented Upon passing medication this am, resident was noted to be walking down hallway with red container in hand, this writer seen resident put container to mouth, resident was able to take one drink from container before I approached her. I noted that the container was a bottle of liquid hand soap from another resident's room. Assessed resident's oral cavity and rinsed mouth out. NP made aware, new order to monitor and obtain CBC, BMP. Poison control notified. Spoke with RN, stated push water as possible, monitor tolerance of water. Call back if further assistance needed. Case #75473317. RP, DON, Administrator Aware. Resident #2 Record review of Resident #2's electronic Facesheet, dated 02/15/23, revealed Resident #2 was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2's diagnoses included unspecified dementia with behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities., agitation, anxiety, and psychosis), bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs), wandering in disease classified elsewhere, and cognitive communication deficit. Record review of Resident #2's Quarterly MDS assessment, dated 01/12/23, revealed Resident #2's BIMS score was 5 which indicated severe cognitive impairment. Record review of Resident #2's care plan, initiated on 01/24/23, reflected Resident #2 had communication problem due to dementia with interventions that included Ensure/provide a safe environment. Further review revealed Resident #2 had complication due to impaired cognitive function/dementia and the interventions included cue, reorient, and supervise as needed. Record review of Resident #2's Progress Notes, dated 02/07/22, revealed Communication with Family this nurse spoke with RP and asked him not to bring anything such as soaps, colognes, spray bottles, any sort of chemicals. If there are any question regarding this to contact me. Cell phone number provided. Verbalized an understanding. Resident #3 Record review of Resident #3's electronic Facesheet, dated 02/15/23, revealed Resident #3 was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #3's diagnosis included unspecified dementia, unspecified severity, without behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Record review of Resident #3's Quarterly MDS assessment, dated 12/14/23, revealed Resident #3's BIMS score was 3 which indicated severe cognitive impairment. Record review of Resident #3's care plan, initiated on 01/24/23, reflected Resident #3 had risk for complications due to impaired cognitive dementia or impaired though process with the interventions included monitor to MD any changes in cognitive function, specifically changes in decision making ability. Resident #4 Record review of Resident #4's electronic Facesheet, dated 02/15/23, revealed Resident #4 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #4's diagnoses included unspecified dementia with behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities., agitation, anxiety, and psychosis), schizoaffective & bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs), and restlessness and agitation. Record review of Resident #4's Comprehensive MDS assessment, dated 12/23/22, revealed Resident #4's BIMS score was 99 which indicated the resident was unable to complete the interview. Record review of Resident #4's care plan, initiated on 01/04/23, reflected Resident #4 was at risk for wandering with interventions that included identify pattern of wandering and was a resident looking for something. Resident #5 Record review of Resident #5's electronic Facesheet, dated 02/15/23, revealed Resident #5 was an [AGE] year-old female who admitted to the facility on [DATE]. Resident #5's diagnoses included unspecified dementia without behavioral disturbance (impaired ability to remember, think, or make decisions that interferes with doing everyday activities., agitation, anxiety, and psychosis) and Alzheimer's disease. Record review of Resident #5's Comprehensive MDS assessment, dated 02/03/23, revealed Resident #5's BIMS score was 0 which indicated severe cognitive impairment. Record review of Resident #5's care plan, initiated on 01/28/23, reflected Resident #5 had risk for complications due to impaired cognitive dementia or impaired though process with the interventions included monitor to MD any changes in cognitive function, specifically changes in decision making ability. In an interview on 02/15/23 at 9:45 AM, the ADMN stated LVN A noticed Resident #1 putting a red container to her mouth and immediately went to the resident and took the bottle. The ADMN stated it was a liquid soap bottle from Bath & Body works. She stated LVN A contacted poison control and was told to provide lots of water and monitor for change in condition. The ADMN stated LVN A was taking vitals and monitoring resident during mealtimes. She stated Resident #1 did not have a change in condition. The ADMN stated the liquid soap should not have been in a resident's room in memory care. She stated they did a sweep in memory care and removed any items that would have been harmful. The ADMN stated the nurses' completed weekly sweeps. She stated she in-serviced staff on abuse/neglect, chemicals, and prohibited items in memory care. An initial observation of the Memory Care Unit on 02/15/23 at 9:59 AM, revealed majority of the residents in the center dining area of the unit. There were two residents walking up and down the hall. Some of the resident's doors were open in the unit and there were not residents in the rooms. An observation on 02/15/23 at 10:01 AM revealed the door to Resident #4 and Resident #5's room, was open and bottles of body wash and body lotion were left out on the sink. The bottles had liquid in them. The bottle of body wash was observed to have the cap flipped up and ready to pour. Resident #4 was observed in her bed asleep, and Resident #5 was not in the room. An interview was attempted with Resident #1 on 02/15/23 at 10:03 AM. Resident #1 was not verbally responding to the questions being asked, nor was she responding non-verbally by gesturing with her head or hands to yes and no questions. An observation on 02/15/23 revealed Resident #1's room was on the hall near the entrance of the Memory Care Unit. Residents #4 and #5's room (#310) was located on a different hall from Resident #1 towards the beginning of the hall entrance. Residents #2 and #3's room (#327) was located on a different hall than Resident #1's and was at the very end of the hall next to the emergency exit door. In an interview on 02/15/23 at 10:25 AM, the DON stated she removed the bottles of body wash and body lotion from the room of Residents #4 and #5. She stated the CNAs must have left it out when they got Residents #4 and #5 up for the day. The DON stated the body wash and body lotion should not have been left out because one of the residents could have got them, which could be harmful. She stated those items were supposed to be in the shower room, which was secured. In an interview on 02/15/23 at 10:35 AM, LVN A stated on 02/07/23 she was in the hallway passing meds and saw Resident #1 with a red bottle. LVN A stated she immediately started walking towards Resident #1 and saw her put the bottle up to her mouth and drink from the bottle. LVN A stated it was a bottle of body wash from Bath & Body Works and had Resident #2's name on it. She stated Resident #1 must have wandered into Residents #2 and #3's room and picked it up. She stated she took the bottle away from Resident #1 and had her open her mouth. LVN A stated there was soap residue on her tongue, so she knew she ingested the body wash. She stated the bottle was not empty and she did not know how much Resident #1 ingested. LVN A stated she knew the soap had chemicals that should not be ingested, so she contacted poison control and the facility's physician. She stated both poison control and the physician told her to give Resident #1 lots of water, monitor her for change in conditions, or if she was to become lethargic, then to send Resident #1 out to the hospital. LVN A stated she took Resident #1's vitals every 1-2 hours and vitals were good. She stated she had Resident #1 drink about 4-5 large cups of water and monitored her during lunch. LVN A stated Resident #1 ate her lunch well and seemed like her normal self. LVN A stated Resident #1 was known to walk around and go into other resident's rooms and take things. She stated Resident #1 was known to pick things up and ingest them. LVN A stated there was a time she picked up a bottle of orange juice from the nurses' cart and drunk the bottle. She stated luckily it was edible, but after that incident they had to keep the orange juice locked on the carts. LVN A stated the body wash should not have been out in Residents #2's room because it was memory care, and the residents did not know they were not supposed to ingest the body wash. She stated body wash was supposed to be kept in shower rooms, which were locked. LVN A stated families come to visit and sometimes they leave the residents' things to use, and the staff were unaware. She stated the nurses were supposed to do weekly sweeps. She stated she had not worked in memory care this week, so she did not know if they had completed a sweep. She stated after the incident with Resident #1, staff was in-serviced, and they did a swept to remove any dangerous items. In an interview on 02/15/23 at 10:46 AM, CNA B stated she was responsible for Residents #4 and #5. She stated Resident #4 was not ready to get out of bed, but she did get Resident #5 up. CNA B stated she changed Resident #5's brief, got her out of bed, and on the way out of the room, Resident #5 stopped and washed her hands in the sink. She stated she did not notice the body wash or body lotion on the sink. CNA B stated she did not put the products there nor did she use the products on Residents #4 or #5. CNA B stated she did not know how long the bottles were sitting out. She stated those items are not supposed to be left out and are normally locked in the shower rooms because they could be dangerous for residents. She stated she did get an in-service on 02/07/23 regarding those items should not be left out. CNA B stated she should have been looking would have removed the products, but she just did not notice them on the sink. A record review of the MSDS for the bottle of body lotion that was found on 02/15/23 in Residents #4 and #5's room revealed Hazards Identification: Classification Acute Toxicity-Oral, Eye Damage/Irritation . Hazard Statements: Causes eye irritation, May be harmful if swallowed. A record review of the MSDS for the bottle of body wash that was found on 02/15/23 in Residents #4 and #5's room revealed Hazards Identification: Classification Eye Damage/Irritation . Hazard Statements: Causes eye irritation. In an interview on 02/15/23 at 3:45 PM, the ADMN stated the facility did not have a policy regarding prohibited items in memory care. She stated for in-services they used pages 33 and 34 of the facility's admissions packet, which listed items residents could not have in their rooms. A record review of pages 33 and 34 of facility's admission packets , not dated, did not reveal resident's in memory care could not have soaps, body wash, or lotion; however, there was a Note, which stated the following: A good rule of thumb has been established by the Food and Drug Administration whereby any products labeled keep out of reach of children or carries any type of caution label is merchandise that contains ingredients which are harmful if taken without supervision or used in a way not designated. Many of our residents, due to mental impairments or poor eyesight might inadvertently drink or eat some of the above items causing irreparable harm. The Administrator was notified on 02/15/23 at 4:10 PM, that an Immediate Jeopardy had been identified due to the above failure. The IJ Template was provided to the Administrator on 02/15/23 at 4:13 PM. The Plan of Removal (POR) was accepted on 02/16/23 at 12:28 PM. The Plan of Removal reflected the following: 1. The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome, with completion date of 02/15/23. The DON educated the nurse aide leaving bath wash and lotion in memory care resident's room unattended to ensure hazardous products are not left in reach of memory care residents. The employee was suspended pending investigation. All resident on the Memory Care unit have potential to be affected and were assessed for complications by charge nurse, none were noted. All resident rooms and areas on the Memory Care unit were inspected for presence of bath wash and lotion or hazardous products by Administrator, DON, ADONs, department heads, none were noted. Going forward inspections will be carried out by the Interdisciplinary Team. 2. The facility took the following actions to prevent an adverse outcome from reoccurring, with completion date 02/15/23. The DON/Nursing Administration staff provided education to all staff on ensuring hazardous products are not left in reach of memory care residents. Bathing and lotion products are to be securely stored when not in use. All PRN Staff, Agency staff and staff not currently working will be in-serviced prior to their next shift on ensuring hazardous products are not left in reach of memory care residents. Orientation and training for new hires will include education to staff related to ensuring hazardous products are not left in reach of memory care residents. Review of the products showed they did not include keep out of reach of children, staff were instructed to read precautions of product use and check with the charge nurse when there is a question about products that are safe to leave in a resident's room. The facility Interdisciplinary Team Leaders will audit resident rooms daily to ensure compliance with the facility policy. Findings will be reported in daily QA Meeting. The Administrator/Maintenance Director will audit resident rooms weekly to validate compliance with facility policy. A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring of the facility's Plan of Removal included the following: A record review of the medical records for the 47 residents in the memory care unit revealed they were assessed for complications by the charge nurse and there were no issues. Further review of the 47 residents' medical records revealed there were progress notes indicated their families had been contacted and advised not to leave prohibited items in the resident's rooms. Observations on 02/16/23 from 2:00 PM to 2:05 PM revealed all rooms and areas in the memory care unit were free from hazardous products. Interviews were conducted on 02/16/23 from 1:25 PM to 2:40 PM with the Administrator, DON, Activity Director, Activity Assistant, Staff Coordinator, 1 RN, 7 LVNs, 10 CNAs, 2 housekeeping, and 3 therapy staff from multiple shifts. The staff all indicated they had been in-serviced on safety awareness, which included a list of prohibited items in memory care, how hazardous items should be stored, the procedures on storing prohibited items that family members might bring for resident use, and procedures in case they were not sure if an item is hazardous. A record review of the in-services dated 02/15/23 on Safety Awareness, No soaps, chemicals, colognes, shaving creams, cleaning supplies of any kind left in resident's rooms on Memory Care, and All staff to read the precautions of a product use and check with charge nurse when there is a question about products are safe to leave in a resident's room revealed 56 signatures from multiple shifts and multiple departments (RNs, LVNs, Therapy, Housekeeping, Laundry, Maintenance, and Administration) had received in-services which covered all aspects of the POR . A record review of document titled Facility: Room Sweep, dated 02/15/23 to 02/16/23, revealed the facility's Interdisciplinary Team Leaders had conducted room sweeps for all rooms in the memory care unit. Each room number (120-332) was listed on the form and the Interdisciplinary Team Leaders who inspected the room had provided their signatures on the document. The Administrator was informed the Immediate Jeopardy was removed on 02/16/22 at 2:50 PM; however, the facility remained out of compliance at a scope of pattern and a severity of potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems.