**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the residents had the right to be free from verbal abuse and neglect for 2 (Resident #1 and #2) of 7 residents reviewed for abuse. The facility staff failed to protect Resident #1 from verbal abuse from Resident #2 on 7/11/25 between 7:00 PM and 7:30 PM.The noncompliance was identified as PNC. The IJ began on 07/11/25 and ended on 7/25/25. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk of abuse, neglect, trauma, injury and psychosocial harm. Findings included: Resident #1 Record review of Resident #1's face sheet, 8/14/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), schizoaffective disorder (mental disorder), anxiety (increased worry), insomnia (difficulty sleeping), major depressive disorder (increase sadness) and UTI (infection in the urinary system). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Record review of Resident #1's care plan, dated 7/14/25, revealed the following:Resident #1 had a focus for elopement and wandering specifically that she wandered aimlessly (date initiated 8/14/25). The goal was for Resident #1 to remain safe within the facility unless accompanied by a staff or authorized person. Interventions included distracting resident from wandering by offering pleasant diversions and supervising closely and make regular compliance rounds. Resident #1 had a focus for coping, specifically Resident #1 had a tough time coping with a roommate as roommate might have been verbally aggressive towards Resident #1 (date initiated 7/14/25). The goal was for Resident #1 to feel comfortable in a safe living environment. Interventions included staff would listen to Resident #1's concerns. Staff would monitor if Resident #1 were unable to cope with roommate and the social worker would find a new roommate if applicable. Record review of Resident #1's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #1 and any other residents on 7/11/25.07/13/25 at 9:11 PM LVN B documented: family report a CNA reported to them Resident #1's roommate was cursing at her and telling her to clean up after herself in the bathroom. Initial treatment included skin assessment; roommate placed on 1:1 monitoring supervision. Medical doctor and nurse practitioner notified. Responsible party was notified. 07/13/25 at 10:37 PM LVN B documented skin assessment conducted with no negative findings. 07/14/25 at 2:58 AM LVN B documented trauma assessment conducted. There were no negative findings or experiences documented or found. Resident #1 did not express fear or anger. 7/14/25 at 9:36 PM the DON documented a late entry indicating Resident #1's family reported to administration that the CNA (unidentified in the progress note) told them Resident #1's roommate was cursing at Resident #1 and telling her to clean up after herself in the bathroom. Resident #1's roommate was placed on one-to-one monitoring. Skin Assessment performed on Resident #1. A room swap was made. Family was aware and notified. FNP was notified. 7/15/25 at 8:36 AM LVN EE documented that Resident #1 appeared to be in no pain and monitoring was conducted. 7/15/25 at 8:37 AM LVN EE documented that Resident #1 had no signs or symptoms of distress noted, resident in good spirits.7/15/25 at 10:13 PM LVN BB documented that Resident #1 had no signs or symptoms of distress and did not complain of any pain.During an interview on 8/14/25 at 12:31 PM, Resident #1 could not recall the incident that occurred between she and Resident #2. She could not identify her last roommate by name. She stated she could not remember if she was afraid on 7/11/25. She could not remember how long she had been in the room that she was and why she had moved. She reported that she felt safe at the facility. Resident #2 Record review of Resident #2's face sheet, dated 8/14/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include intermittent explosive disorder (mental disorder characterized by outburst of anger or violence), anxiety (increased worry) and dementia (memory loss). Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section E did not reveal any coded behaviors.Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: Section E Behavior Resident #2 had other behavioral symptoms not directed towards others.Resident #2's care plan, dated 7/14/25 revealed the following:Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had potential to demonstrate physical behaviors. (initiated 7/4/25) The goal was for Resident #2 to demonstrate effective coping skills. Interventions included staff analyzing key times, places, circumstances, triggers, and what de-escalates behavior and document. Staff should assess and address sensory deficits and notify the charge nurse of any physically abusive behaviors. When Resident #2 becomes agitated staff should intervene before agitation escalates. Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had a behavior problem related to being verbally aggressive to staff and other residents. (initiated 7/14/25) The goal was for Resident #2 to not have episodes of being verbally aggressive. Interventions included anticipate the needs of Resident #2. Staff should provide opportunity for positive interaction. Consultation with psychiatry will be made if needed. Staff should also intervene as necessary to protect the rights and safety of others. Staff will also monitor behavior episode of Resident #2. Record review of Resident #2's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #2 and any other residents on 7/11/25.7/13/25 at 9:11 PM the DON documented Resident #2 had a behavior (verbal, resident to resident alleged behavior). Resident #2 scolded her roommate (Resident #1) with curse words to clean up her mess in the bathroom. 1:1 mentoring supervision implemented. Consulted FNP for new orders of hydroxyzine 50 mg PO Q4 hours prn. Recommended to conduct room swap. Resident #2 stated we get along good. Resident #2 stated she worried about her roommate because she sleeps all day and does not sleep much. Attempted to contact Resident #2's family. 7/14/25 at 8:20 AM the DON documented late entry: Informed by administrator the resident's (unspecified in this progress note) roommate's family informed her the CNA (unspecified in this progress note) told them Resident #2 was cursing at her roommate and telling her to clean up after herself in the bathroom. Resident #2 was immediately place on one-on-one observation. Consulted psych provider for any new orders/recommendations. New order to start hydroxyzine 50 mg prn Q4 hours for anxiety/agitation. Performed a roommate swap and may d/c one-on-one monitoring but ensure frequent monitoring as the resident was not physically aggressive. Attempted to notify Family Member FF multiple times. D/c one-on-one supervision. Resident #2 currently does not have a roommate currently.07/15/25 at 10:18 AM the SW documented that she received notification from the administration that a referral to the behavioral center was needed. The SW notified Family Member FF, and he agreed to the referral and the referral was completed. 07/15/25 at 10:24 AM LVN EE documented no verbal behaviors noted, and Resident #2 was in good spirits. 07/15/25 at 10:29 PM LVN BB documented Resident #2 was quiet without negative behaviors, toward resident or staff. 07/16/25 at 8:57 AM LVN EE documented Resident #2 had no behaviors. 07/16/25 at 8:57 PM LVN B documented no behaviors reported during her shift. 07/17/25 at 2:57 PM The SW documented that the referral for Resident #2 was denied due to Resident #2's insurance being out of network. During an interview on 8/14/25 at 12:33 PM, Resident #2 stated she does not remember why her last roommate moved. She stated she got along well with her last roommate. She could not identify her last roommate by name. She could not report if she had an incident with Resident #1 on 7/11/25. During an interview on 8/14/25 at 9:31 AM, CNA A stated she did not have a calendar in front of her but believed the incident occurred on 7/11/25. She stated she worked the night shift (6:00 PM- 6:00 AM). She stated on that day (7/11/25) her partner that she worked with that day called in late. She stated she and LVN B were the only ones on the locked female unit. She stated around 7:00 PM or 7:30 PM while LVN B was attending to another resident next door to Resident #1 and Resident #2 they (CNA A and LVN B) heard Resident #2 yell a loud and clear Get your mother fucking ass in that God Damn bathroom and clean that shit up! CNA A stated she and LVN B looked at each other. CNA A stated LVN B asked her Who is she (Resident #2) hollering at? CNA A stated LVN B instructed her (CNA A) to go and look. CNA A stated when she stepped into Resident #1 and Resident #2's room she observed Resident #1 standing in front of Resident #2 and the look on Resident #1's face gave her (CNA A) the impression that she was scared. CNA A stated she motioned for Resident #1 to come with her. CNA A stated she took Resident #1 to where LVN B was and during this time LVN B then goes to Resident #2. CNA A stated she and Resident #1 stood outside the room where Resident #2 and LVN B were. CNA A stated LVN B asked Resident #2 what was going on and Resident #2 voiced her complaint about Resident #1 pissing on the bathroom floor. She stated LVN B instructed Resident #2 that if it happened again, she needed to call staff for help. CNA A stated she went to get a towel to clean up the urine in the bathroom and while she was doing this Resident #1 followed LVN B. CNA A stated Resident #2 yelled at her Don't clean up that shit! This is why she (Resident #1) don't learn because y'all baby her (Resident #1)! CNA A stated Resident #1 was afraid and did not go back to the room with Resident #2 for majority of the night. CNA A stated Resident #1 did not go to bed until Resident #2 was asleep. CNA A stated she was under the impression that since LVN B witnessed the incident along with her that she would report it to the abuse coordinator, document and notify the family. CNA A stated a couple of days later (unsure of the exact date), Resident #1's family came to the facility and in passing the family asked why is it that when they have come in Resident #1 is not in her bed and sometimes is found in other resident's bed. CNA A stated she told them that it was most likely because she (Resident #1) was afraid of her roommate (Resident #2). She stated that immediately once she mentioned the incident to Family Member CC, he became upset and exclaimed no one told him about the incident. She stated that LVN B was upset with her and told her at that time to complete a report. She stated unsure of the date the following Monday she was suspended because she failed to report the incident. CNA A stated she did not feel it was right that she was suspended for failure to report when LVN B also heard the incident and was present. CNA A stated that the ADM told her that LVN B may have misheard what happened. CNA A stated this was not the case because Resident #2 said what she said very loud, and they were next door to their room. CNA A stated Resident #1 slept in the same room with Resident #2 the night of the incident. CNA A stated she was told that Resident #1 was moved out of the room only after Resident #1's family complained. CNA A stated Resident #2 had a history of aggression and that she had expressed concern in the past. CNA A stated Resident #2 had broken the facility door before and was an exceptionally large lady in comparison to Resident #1. She stated although she did not believe Resident #2 physically hit Resident #1, she believed that Resident #1 was afraid because she would not go back in her room the night of the incident. She stated she and other staff reported to LVN B that even they (staff) were afraid of Resident #2. CNA A stated no other incidents had occurred between Resident #1 and Resident #2 since 7/11/25 but she could not attest for any time after she was suspended. She stated she was trained that if she suspects or witness abuse, she was to report abuse to her chain of command, and this would have been LVN B. She stated that being a CNA for over 25 years this was the way it has always been. She stated that the ADM stated at the time of her suspension that she was supposed to report the incident to her (the ADM). CNA A stated the nurses were responsible for reporting incidents to the family. CNA A stated the night of the incident Resident #1 did not have any injuries that she could visibly see. During an interview on 8/14/25 at 10:32 AM, CNA C stated she had never worked the female locked unit. She stated she had guarded the door once when the doors were not working. She stated she had not worked directly with Resident #1 and Resident #2. During an interview on 8/14/25 at 10:43 AM, CNA D stated she did not have any information regarding the verbal incident between Resident #1 and Resident #2 that occurred on 07/11/25. She stated she is unaware if any incidents had occurred since 7/11/25. During an interview on 8/14/25 at 11:09 AM, CNA E stated she did not have any firsthand information about the verbal incident that occurred on 7/11/25 between Resident #1 and Resident #2. She stated Resident #1 and Resident #2 had never had issues before 7/11/25 or since 7/11/25. She stated Resident #2 rarely has behaviors. She stated Resident #1 has no behaviors but will ask questions over and over. During an interview on 8/14/25 at 11:24 AM, CNA F stated she did not have any firsthand information about Resident #1's and Resident #2's verbal altercation that occurred on 7/11/25. She stated there had been no additional altercations between Resident #1 and Resident #2. She stated Resident #1 had an issue where she wanted to leave the unit but never had any altercations with residents in the unit. During an interview on 8/14/25 at 11:35 AM, CNA G stated she does not work the female unit and did not have any information regarding the incident that occurred on 7/11/25 between Resident #1 and Resident #2. During an interview on 8/14/25 at 11:45 AM, CNA H stated although she works the female locked unit at times, she did not have any information regarding the verbal altercation that occurred between Resident #1 and Resident #2. She stated she did not have any information about Resident #1 and Resident #2's behaviors as she had not worked the female locked unit in a while. During an interview on 8/14/25 at 11:55 AM, LVN I stated he did not have any firsthand information about the verbal altercation that occurred on 7/11/25 between Resident #1 and Resident #2. He stated Resident #1 and Resident #2 did not have a history of verbal altercations and there had been no incidents since 7/11/25. He stated Resident #1 was pleasantly confused. He stated she would wander but no other behaviors. He stated in the past Resident #2 had behaviors that included hoarding briefs. He stated in the past on an unknown date she (Resident #2) broke the female locked unit door but was sent to a behavior unit because of that behavior. He stated the facility manages Resident #2's behavior well through close monitoring. During an interview on 8/14/25 at 12:11 PM, LVN J stated she did not have any firsthand information about Resident #1 and Resident #2's verbal altercation that occurred on 7/11/25 as she did not work the female locked unit on that date. She stated she did not have any additional information regarding Resident #2 or Resident #1 behaviors. During an interview on 8/14/25 at 1:04 PM, CNA K stated she did not have firsthand information regarding Resident #1 and Resident #2 verbal altercation that occurred on 7/11/25. She stated she had worked with both residents before and after 7/11/25. She stated the two had never had any issues before or after. She stated Resident #2 never comes out of her room. She stated Resident #1 can be active at times. She stated neither resident has ever had significant behaviors in her presence. Interviews conducted on 8/14/25 between 10:32 AM-1:04 PM, revealed that daytime staff (CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, LVN I, LVN J and CNA K) had been trained on the facility's abuse policy. The staff were able to identify the abuse coordinator, and stated if they suspected or witnessed abuse, they would report directly to the abuse coordinator. During their interviews, staff was able to report that apart of the suspicion or witnessing abuse they would protect the resident. During an interview on 8/14/25 at 2:33 PM, the ADM stated that she was unsure of the date and time but while at home one-night LVN B called her and explained that Resident #1's family was upset. She stated LVN B told her about the initial complaint from the family involved cleaning supplies and them (Family Member CC) having to clean the restroom. The ADM stated that she received a call from Family Member DD 30 minutes later who stated that the real reason that they (family) were upset was because Resident #1 had been abused and her roommate (Resident #2) was screaming at her (Resident #1). The ADM stated at the time Family Member DD notified her of Resident #2 screaming at Resident #1 she was unaware of the incident. She stated once Family Member DD notified her, she notified the DON, and the DON instructed for 1:1 to be started for Resident #2 to LVN B. The ADM stated that LVN B stated she was unaware of any incidents of abuse that involved Resident #1 and Resident #2. She (the ADM) stated that she started her abuse process. The ADM stated LVN B reported to her that she (LVN B) heard yelling one night (date was not specified) and LVN B instructed CNA A to see what happened. The ADM stated LVN B reported to her that CNA A never reported to her that Resident #2 was yelling at Resident #1. The ADM stated Resident #2 had a history of yelling at staff. The ADM stated she immediately suspended CNA A for not reporting directly to her. She stated she interviewed CNA A and CNA stated she did tell Family Member CC about the incident between Resident #1 and Resident #2. The ADM stated she asked CNA A why she did not report the incident directly to her as the abuse coordinator as she had been trained and CNA A response was my bad. During an interview on 8/15/25 at 12:15 PM, the ADM stated that she was unsure of the exact date of the incident between Resident #1 and Resident #2, but voiced that she was notified of the incident on 7/13/25 by Family Member DD. The ADM stated she reported the incident to HHSC on 7/13/25 at 11:05 PM. She stated Resident #2 was placed on 1:1 supervision as soon as she was notified of the incident on 7/13/25. She stated Resident #1 was not moved out of the room with Resident #2 because of bed availability. She stated room moves had to be made before she could move Resident #1 out of the room with Resident #2. The ADM stated Resident #1 shared the same bedroom with Resident #2 after the incident up until she was notified on 7/13/25. The ADM said no additional incidents had occurred between Resident #1 and Resident #2. She stated she suspended CNA A on 7/14/25 and the last date CNA A had been in the facility was on the morning of her shift ended on 7/14/25. She started safe surveys were conducted on the female locked unit and there were no findings. She stated after consulting with the corporate office and gaining approval she terminated CNA A for failure to report ANE. She stated they started re-education on the facility's abuse policy and by 7/14/25 100 percent of her staff had been trained on the facility's abuse policy. The ADM stated she was sure all staff had been trained because the day they started re-education it was the facility's pay day and each staff that came in had to pick up their check. They re-educated and quizzed the staff verbally on the expectations. She stated staff had always been trained to report to her as the abuse coordinator. She stated Resident #2 was referred to psychiatric services for the incident.During an interview on 8/15/25 at 12:20 PM, the DON stated that on 07/09/25 Resident #2 had a recent change in medication where she had started Depakote. She stated because of the incident between Resident #1 and Resident #2 it was decided to continue to monitor the newly change medication and they added a PRN medication (Hydroxyzine). The ADM, DON, regional Nurse Consultant and Director of Operations were notified on 8/15/25 at 4:08 PM that a PNC IJ situation was identified due to the above failures and the IJ template and 3-strike letter was provided.Interviews conducted on 8/15/25 between 4:31 PM-6:16 PM, revealed that administration, daytime and nighttime staff (the DM, MDS Coordinator, ADON, HR, the Maintenance Supervisor, DS L, [NAME] M, LVN N, LVN O, CNA P, MA Q, CNA R, CNA S, RN T, CNA U, MA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, and LVN BB) had been trained on the facility's abuse policy recently (within the past 30-60 days). The staff voiced they had been trained by the ADM, DON and or the ADON. They stated that they were given the opportunity to ask questions if they needed to. They were all able to identify the abuse coordinator as the ADM and that they needed to report all suspected or witnessed abuse to the ADM. They all were able to voice that they would not assume that an incident had been reported but would report the incident as it was their responsibility. They all were able to report that protection of the resident(s) involved was a part of following the abuse protocol for the facility. They all were able to report that if they did not see any protection interventions put in place that they would follow up with management and or the abuse coordinator. All nurses interviewed were able to report that it was their responsibility to notify family and or responsible party of any significant events involving the residents that resided at the facility. All staff interviewed voiced that they were comfortable, confident in their role carrying out the facility's expectation regarding the facility's abuse policy and requirements. During an interview on 8/15/25 at 6:18 PM, Family Member CC stated they were not notified of the incident that occurred with Resident #1 and Resident #2 at the time of the incident. Family Member CC stated CNA A notified them that Resident #1 was afraid of her roommate (Resident #2). Family Member CC stated he had not observed any incidents between Resident #1 and Resident #2. He stated that they (he and his family) were incredibly pleased with how the facility responded to them reporting their concerns about Resident #1. Family Member CC stated as soon as they reported the incident the facility staff moved Resident #1. Family Member CC stated there had been no incidents since the incident. Family member CC stated that he was unsure if Resident #1 was afraid, but they (he and the family) had concerns that Resident #1 was sleeping in other resident's beds because she had a UTI. He stated when he asked CNA A about what she thought regarding Resident #1 sleeping in other's beds CNA disclosed the incident. He stated he honestly believed CNA was trying to console them because they had other concerns within the same night. He stated since the incident between Resident #1 and Resident #2 the facility staff have done so well notifying them (he and family). During an interview on 8/15/25 at 5:15 PM, the ADM stated regarding the failure to prevent abuse she had been trained on the facility's policy. She stated they review the abuse policy routinely. She stated the purpose of the policy was to protect the residents and ensure they investigate all allegations of abuse. The ADM stated when the allegation was reported to her on 7/13/25 she did investigate and found that CNA A failed to report timely. The ADM stated when she interviewed CNA A, she stated CNA A stated she thought LVN B had reported it. The ADM stated she reminded CNA A at that time it was her responsibility and CNA A's response was my bad. The ADM stated the potential negative outcome for not preventing abuse was residents could endure harm. The ADM stated she could not confirm if Resident #1 was abused. The ADM stated she had no indication that Resident #1 was harmed or was withdrawn. She stated after the incident no staff reported any changes. The ADM stated she was unaware that Resident #2 had yelled at Resident #1. She stated she became aware of the incident on 7/13/25 when the family called her. The ADM stated the system to monitor residents and ensuring they are not abused was re-educating staff, making rounds, and talking to residents and family about abuse. She stated staff are trained upon hire, annually and when there is an incident. The ADM stated she had never observed Resident #2 be aggressive to Resident #1 or any other residents. The ADM stated she expected facility staff to prevent abuse for all residents. The ADM stated all staff are responsible for preventing abuse. The ADM stated the reason abuse was not prevented in the incident involving Resident #1 and Resident #2 was because she was unaware of the incident as it was not reported to her by CNA A. The ADM stated she was unaware that Resident #2 was treating Resident #1 in any way that was negative. During an interview on 8/15/25 at 5:42 PM, the DON stated regarding the failure to prevent abuse that she was familiar with the facility's ANE policy. The DON stated the purpose of preventing abuse was to prevent harm to the residents. The DON stated they did not want to harm the residents. The DON stated Resident #1 has always had the behavior of wandering as she (Resident #1) was pleasantly confused. The DON stated Resident #1 may have been in other resident's room during the time the family noticed not because she was afraid of Resident #2 but because of her dementia diagnoses. The DON stated residents with dementia do not remember. The DON stated she did not feel that Resident #2 abused Resident #1. The DON stated she interviewed Resident #2 and Resident #2 expressed that she and Resident #1 were good. She stated Resident #2 expressed that she (Resident #2) had concern regarding Resident #1's eating and sleeping habits. The DON stated she was unaware of the incident and was made aware of the incident on 7/13/25 when the ADM notified her. The DON stated their system to monitor and ensure residents do not experience abuse was through education to staff. The DON stated the staff were repeatedly trained on the policy and should have known what to do. She stated they also investigate all allegations, speak to staff and residents. The DON stated CNA A failed to report to the abuse coordinator, the ADM, and if CNA A had reported the incident, then the facility could protect the residents. The DON stated she had been trained on the abuse policy and all staff had all been trained. The DON stated she had never observed Resident #2 be verbally abusive to Resident #1. The DON stated she expected staff to prevent abuse from happening. The DON stated all staff are responsible for preventing abuse. The DON stated she does not feel abuse occurred but that regarding the incident between Resident #1 and Resident #2 CNA A did fail to report the incident to the abuse coordinator. During an interview on 8/15/25 at 8:45 PM, LVN B stated she was unsure of the exact date of the incident that occurred between Resident #1 and Resident #2. LVN B stated that she was in the last room at the end of the hallway assisting another resident. She stated CNA A heard one of the residents raise their voice. She stated she asked CNA A which resident raised their voice and was told by CNA A that it was Resident #2 and Resident #1. LVN B stated CNA A told her that Resident #2 was raising her voice at Resident #1. LVN B stated she voiced to Resident #2 that she does not need to raise her voice. LVN B stated that was it and she left Resident #2 in her room. LVN B stated 5 minutes later both residents could not remember the incident. LVN B stated she does not know what specifically Resident #2 said to Resident #1. She stated CNA A did not specify what was said but only stated Resident #2 was yelling at Resident #1 because there was piss on the floor. LVN B stated she did not suspect abuse because normally Resident #2 was loud resident and that was the way she talked. She stated working on the locked unit residents have behaviors and she considered Resident #2 yelling as one of her behaviors and she needed redirection. LVN B stated Resident #1 did not appear afraid to her. LVN B stated Resident #1 went back to her room within an hour of the incident. LVN B stated that CNA A did not report to her or indicate that Resident #1 was afraid. LVN B stated after the incident between Resident #1 and Resident #2 she never had a discussion with Resident #1's family nor did she discuss the incident any further with CNA A. LVN B stated that had not been any other incidents since the verbal incident between Resident #1 and Resident #2 nor had there been any incidents before. LVN B stated CNA A reported to the Resident #1's family that Resident #1 felt threatened by Resident #2 and that is what caused them to call the ADM. She stated when they called the ADM, she was instructed to place Resident #2 on 1:1 supervision. LVN B stated she did not report the incident to the abuse coordinator because she felt it was a nursing judgement call to redirect Resident #2. LVN B stated she had been trained on the facility's abuse policy recently (within the past 30-60 days) by the ADM, DON and ADON. She stated that protection of the resident(s) involved was a part of following the abuse protocol for the facility. She stated if she did not see any protection interventions put in place that she would follow up with management and or the abuse coordinator. LVN B stated Resident #1 and Resident #2 shared the same room after the incident up until she was instructed to place Resident #2 on 1:1 supervision. LVN B stated no other incidents occurred with Resident #1 and Resident #2 after the verbal incident on the unknown date that she was aware of. She stated before the incident that occurred with Resident #1 and Resident #2, she had received training on the facility's ANE policy.During the investigation held on 8/14/25-8/15/25 there were no observation of any interactions between Resident #1 and Resident #2. Resident #1 and Resident #2 were observed in their separate rooms during the visit. Record review of the facility's Form 3614 (Provider Investigation Report), dated 7/17/25, revealed:Incident Date: 7/11/25Person(s) or Resident(s) involved:Resident #1 Alleged Perpetrator: None listed.Witnesses:CNA ADescription of the Allegation: Resident #1's roommate cusses at her and tries to make her clean up the bathroom. Assessment:7/13/25: Resident has no injuries. Provider Response: Resident #2 was placed on one-to-one monitoring immediately upon receiving report from Resident #1's family. Resident #1 was assessed for any injuries-none noted. Physician notified. Family, physician and psychiatry notified for Resident #2.Investigation Summary: Resident #1's family reported to LVN B, that they had been finding Resident #1 bathroom with bowel and urine on the floor and they had been bringing toilet paper because she had not had toilet paper and sometimes paper towels. LVN B notified the ADM via phone of the concern. The ADM later received a call from Family Member B stating what family had reported and added that Resident #2 had been yelling and cussing at Resident #1. LVN B was aware that one evening she heard raised voices and sent CNA A to see what was going on but nothing was ever reported to LVN B about cussing or demanding residents to het on her knees and clean up the bathroom. CNA A was suspended pending investigation and will be terminated for failure to report. Both residents lack capacity to m[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 2 of 7 residents (Resident #1, and #2) reviewed for abuse. CNA A failed to follow the facility's abuse policy by not reporting the incident (verbal abuse) to the facility's Abuse Coordinator involving Resident #1and Resident #2 that occurred on 7/11/25 between 7:00 PM and 7:30 PM.LVN B failed to follow the facility's abuse policy by not reporting the incident (verbal abuse) to the facility's Abuse Coordinator involving Resident #1and Resident #2 that occurred on 7/11/25 between 7:00 PM and 7:30 PM.The ADM failed to follow the facility's abuse policy by not reporting the incident (verbal abuse) to HHSC involving Resident #1 and Resident #2 that occurred on 7/11/25 between 7:00 PM and 7:30 PM.The facility failed to notify Resident #1's family of the verbal abuse incident that occurred on 7/11/25 between 7:00 PM and 7:30 PM.The facility failed to put protective measures to protect Resident #1 from Resident #2 after a verbal abuse incident occurred on 7/11/25.The noncompliance was identified as PNC. The IJ began on 07/11/25 and ended on 7/14/25. The facility had corrected the noncompliance before the survey began.These failures could place residents as risk for abuse and injury. Findings included: Record review of the facility's abuse policy, dated 3/29/18, revealed the following: The resident has the right to be free from abuse,.Residents should not be subjected to abuse by anyone, including, but notlimited to, facility staff, other residents,.PreventionThe facility will provide the residents, families, and staff an environment free from abuse and neglect.The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect.The facility has in place a method to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse.ReportingAny person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse,neglect or exploitation must report this to the DON, administrator, state and/or adult protective services.State law mandates that citizens report all suspected cases of abuse, neglect or financial exploitation ofthe elderly and incapacitated persons.When a suspected abused, neglected, exploited, mistreated or potential victim of misappropriation ofproperty comes to the attention of any employee, that employee will make an immediate verbal report tothe Abuse Preventionist or designee. If the discovery occurs outside of normal business hours, theAbuse Preventionist and/or designee will be called.Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report to HHSC.If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegationIf the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.Protection (Resident to Resident)The above policy will apply to potential resident-to-resident abuse. Provider letter 19-17 will be reviewed to determine if resident-to-resident abuse occurred.Resident #1 Record review of Resident #1's face sheet, 8/14/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), schizoaffective disorder (mental disorder), anxiety (increased worry), insomnia (difficulty sleeping), major depressive disorder (increase sadness) and UTI (infection in the urinary system). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Record review of Resident #1's care plan, dated 7/14/25, revealed the following:Resident #1 had a focus for elopement and wandering specifically that she wandered aimlessly (date initiated 8/14/25). The goal was for Resident #1 to remain safe within the facility unless accompanied by a staff or authorized person. Interventions included distracting resident from wandering by offering pleasant diversions and supervising closely and make regular compliance rounds. Resident #1 had a focus for coping, specifically Resident #1 had a tough time coping with a roommate as roommate might have been verbally aggressive towards Resident #1 (date initiated 7/14/25). The goal was for Resident #1 to feel comfortable in a safe living environment. Interventions included staff would listen to Resident #1's concerns. Staff would monitor if Resident #1 were unable to cope with roommate and the social worker would find a new roommate if applicable. Record review of Resident #1's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #1 and any other residents on 7/11/25.07/13/25 at 9:11 PM LVN B documented: family report a CNA reported to them Resident #1's roommate was cursing at her and telling her to clean up after herself in the bathroom. Initial treatment included skin assessment; roommate placed on 1:1 monitoring supervision. Medical doctor and nurse practitioner notified. Responsible party was notified. 07/13/25 at 10:37 PM LVN B documented skin assessment conducted with no negative findings. 07/14/25 at 2:58 AM LVN B documented trauma assessment conducted. There were no negative findings or experiences documented or found. Resident #1 did not express fear or anger. 7/14/25 at 9:36 PM the DON documented a late entry indicating Resident #1's family reported to administration that the CNA (unidentified in the progress note) told them Resident #1's roommate was cursing at Resident #1 and telling her to clean up after herself in the bathroom. Resident #1's roommate was placed on one-to-one monitoring. Skin Assessment performed on Resident #1. A room swap was made. Family was aware and notified. FNP was notified. 7/15/25 at 8:36 AM LVN EE documented that Resident #1 appeared to be in no pain and monitoring was conducted. 7/15/25 at 8:37 AM LVN EE documented that Resident #1 had no signs or symptoms of distress noted, resident in good spirits.7/15/25 at 10:13 PM LVN BB documented that Resident #1 had no signs or symptoms of distress and did not complain of any pain.During an interview on 8/14/25 at 12:31 PM, Resident #1 could not recall the incident that occurred between she and Resident #2. She could not identify her last roommate by name. She stated she could not remember if she was afraid on 7/11/25. She could not remember how long she had been in the room that she was and why she had moved. She reported that she felt safe at the facility. Resident #2 Record review of Resident #2's face sheet, dated 8/14/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include intermittent explosive disorder (mental disorder characterized by outburst of anger or violence), anxiety (increased worry) and dementia (memory loss). Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section E did not reveal any coded behaviors.Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: Section E Behavior Resident #2 had other behavioral symptoms not directed towards others.Resident #2's care plan, dated 7/14/25 revealed the following:Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had potential to demonstrate physical behaviors. (initiated 7/4/25) The goal was for Resident #2 to demonstrate effective coping skills. Interventions included staff analyzing key times, places, circumstances, triggers, and what de-escalates behavior and document. Staff should assess and address sensory deficits and notify the charge nurse of any physically abusive behaviors. When Resident #2 becomes agitated staff should intervene before agitation escalates. Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had a behavior problem related to being verbally aggressive to staff and other residents. (initiated 7/14/25) The goal was for Resident #2 to not have episodes of being verbally aggressive. Interventions included anticipate the needs of Resident #2. Staff should provide opportunity for positive interaction. Consultation with psychiatry will be made if needed. Staff should also intervene as necessary to protect the rights and safety of others. Staff will also monitor behavior episode of Resident #2. Record review of Resident #2's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #2 and any other residents on 7/11/25.7/13/25 at 9:11 PM the DON documented Resident #2 had a behavior (verbal, resident to resident alleged behavior). Resident #2 scolded her roommate (Resident #1) with curse words to clean up her mess in the bathroom. 1:1 mentoring supervision implemented. Consulted FNP for new orders of hydroxyzine 50 mg PO Q4 hours prn. Recommended to conduct room swap. Resident #2 stated we get along good. Resident #2 stated she worried about her roommate because she sleeps all day and does not sleep much. Attempted to contact Resident #2's family. 7/14/25 at 8:20 AM the DON documented late entry: Informed by administrator the resident's (unspecified in this progress note) roommate's family informed her the CNA (unspecified in this progress note) told them Resident #2 was cursing at her roommate and telling her to clean up after herself in the bathroom. Resident #2 was immediately place on one-on-one observation. Consulted psych provider for any new orders/recommendations. New order to start hydroxyzine 50 mg prn Q4 hours for anxiety/agitation. Performed a roommate swap and may d/c one-on-one monitoring but ensure frequent monitoring as the resident was not physically aggressive. Attempted to notify Family Member FF multiple times. D/c one-on-one supervision. Resident #2 currently does not have a roommate currently.07/15/25 at 10:18 AM the SW documented that she received notification from the administration that a referral to the behavioral center was needed. The SW notified Family Member FF, and he agreed to the referral and the referral was completed. 07/15/25 at 10:24 AM LVN EE documented no verbal behaviors noted, and Resident #2 was in good spirits. 07/15/25 at 10:29 PM LVN BB documented Resident #2 was quiet without negative behaviors, toward resident or staff. 07/16/25 at 8:57 AM LVN EE documented Resident #2 had no behaviors. 07/16/25 at 8:57 PM LVN B documented no behaviors reported during her shift. 07/17/25 at 2:57 PM The SW documented that the referral for Resident #2 was denied due to Resident #2's insurance being out of network. During an interview on 8/14/25 at 12:33 PM, Resident #2 stated she does not remember why her last roommate moved. She stated she got along well with her last roommate. She could not identify her last roommate by name. She could not report if she had an incident with Resident #1 on 7/11/25. During an interview on 8/14/25 at 9:31 AM, CNA A stated she did not have a calendar in front of her but believed the incident occurred on 7/11/25. She stated she worked the night shift (6:00 PM- 6:00 AM). She stated on that day (7/11/25) her partner that she worked with that day called in late. She stated she and LVN B were the only ones on the locked female unit. She stated around 7:00 PM or 7:30 PM while LVN B was attending to another resident next door to Resident #1 and Resident #2 they (CNA A and LVN B) heard Resident #2 yell a loud and clear Get your mother fucking ass in that God Damn bathroom and clean that shit up! CNA A stated she and LVN B looked at each other. CNA A stated LVN B asked her Who is she (Resident #2) hollering at? CNA A stated LVN B instructed her (CNA A) to go and look. CNA A stated when she stepped into Resident #1 and Resident #2's room she observed Resident #1 standing in front of Resident #2 and the look on Resident #1's face gave her (CNA A) the impression that she was scared. CNA A stated she motioned for Resident #1 to come with her. CNA A stated she took Resident #1 to where LVN B was and during this time LVN B then goes to Resident #2. CNA A stated she and Resident #1 stood outside the room where Resident #2 and LVN B were. CNA A stated LVN B asked Resident #2 what was going on and Resident #2 voiced her complaint about Resident #1 pissing on the bathroom floor. She stated LVN B instructed Resident #2 that if it happened again, she needed to call staff for help. CNA A stated she went to get a towel to clean up the urine in the bathroom and while she was doing this Resident #1 followed LVN B. CNA A stated Resident #2 yelled at her Don't clean up that shit! This is why she (Resident #1) don't learn because y'all baby her (Resident #1)! CNA A stated Resident #1 was afraid and did not go back to the room with Resident #2 for majority of the night. CNA A stated Resident #1 did not go to bed until Resident #2 was asleep. CNA A stated she was under the impression that since LVN B witnessed the incident along with her that she would report it to the abuse coordinator, document and notify the family. CNA A stated a couple of days later (unsure of the exact date), Resident #1's family came to the facility and in passing the family asked why is it that when they have come in Resident #1 is not in her bed and sometimes is found in other resident's bed. CNA A stated she told them that it was most likely because she (Resident #1) was afraid of her roommate (Resident #2). She stated that immediately once she mentioned the incident to Family Member CC, he became upset and exclaimed no one told him about the incident. She stated that LVN B was upset with her and told her at that time to complete a report. She stated unsure of the date the following Monday she was suspended because she failed to report the incident. CNA A stated she did not feel it was right that she was suspended for failure to report when LVN B also heard the incident and was present. CNA A stated that the ADM told her that LVN B may have misheard what happened. CNA A stated this was not the case because Resident #2 said what she said very loud, and they were next door to their room. CNA A stated Resident #1 slept in the same room with Resident #2 the night of the incident. CNA A stated she was told that Resident #1 was moved out of the room only after Resident #1's family complained. CNA A stated Resident #2 had a history of aggression and that she had expressed concern in the past. CNA A stated Resident #2 had broken the facility door before and was an exceptionally large lady in comparison to Resident #1. She stated although she did not believe Resident #2 physically hit Resident #1, she believed that Resident #1 was afraid because she would not go back in her room the night of the incident. She stated she and other staff reported to LVN B that even they (staff) were afraid of Resident #2. CNA A stated no other incidents had occurred between Resident #1 and Resident #2 since 7/11/25 but she could not attest for any time after she was suspended. She stated she was trained that if she suspects or witness abuse, she was to report abuse to her chain of command, and this would have been LVN B. She stated that being a CNA for over 25 years this was the way it has always been. She stated that the ADM stated at the time of her suspension that she was supposed to report the incident to her (the ADM). CNA A stated the nurses were responsible for reporting incidents to the family. CNA A stated the night of the incident Resident #1 did not have any injuries that she could visibly see. During an interview on 8/14/25 at 10:32 AM, CNA C stated she had never worked the female locked unit. She stated she had guarded the door once when the doors were not working. She stated she had not worked directly with Resident #1 and Resident #2. During an interview on 8/14/25 at 10:43 AM, CNA D stated she did not have any information regarding the verbal incident between Resident #1 and Resident #2 that occurred on 07/11/25. She stated she is unaware if any incidents had occurred since 7/11/25. During an interview on 8/14/25 at 11:09 AM, CNA E stated she did not have any firsthand information about the verbal incident that occurred on 7/11/25 between Resident #1 and Resident #2. She stated Resident #1 and Resident #2 had never had issues before 7/11/25 or since 7/11/25. She stated Resident #2 rarely has behaviors. She stated Resident #1 has no behaviors but will ask questions over and over. During an interview on 8/14/25 at 11:24 AM, CNA F stated she did not have any firsthand information about Resident #1's and Resident #2's verbal altercation that occurred on 7/11/25. She stated there had been no additional altercations between Resident #1 and Resident #2. She stated Resident #1 had an issue where she wanted to leave the unit but never had any altercations with residents in the unit. During an interview on 8/14/25 at 11:35 AM, CNA G stated she does not work the female unit and did not have any information regarding the incident that occurred on 7/11/25 between Resident #1 and Resident #2. During an interview on 8/14/25 at 11:45 AM, CNA H stated although she works the female locked unit at times, she did not have any information regarding the verbal altercation that occurred between Resident #1 and Resident #2. She stated she did not have any information about Resident #1 and Resident #2's behaviors as she had not worked the female locked unit in a while. During an interview on 8/14/25 at 11:55 AM, LVN I stated he did not have any firsthand information about the verbal altercation that occurred on 7/11/25 between Resident #1 and Resident #2. He stated Resident #1 and Resident #2 did not have a history of verbal altercations and there had been no incidents since 7/11/25. He stated Resident #1 was pleasantly confused. He stated she would wander but no other behaviors. He stated in the past Resident #2 had behaviors that included hoarding briefs. He stated in the past on an unknown date she (Resident #2) broke the female locked unit door but was sent to a behavior unit because of that behavior. He stated the facility manages Resident #2's behavior well through close monitoring. During an interview on 8/14/25 at 12:11 PM, LVN J stated she did not have any firsthand information about Resident #1 and Resident #2's verbal altercation that occurred on 7/11/25 as she did not work the female locked unit on that date. She stated she did not have any additional information regarding Resident #2 or Resident #1 behaviors. During an interview on 8/14/25 at 1:04 PM, CNA K stated she did not have firsthand information regarding Resident #1 and Resident #2 verbal altercation that occurred on 7/11/25. She stated she had worked with both residents before and after 7/11/25. She stated the two had never had any issues before or after. She stated Resident #2 never comes out of her room. She stated Resident #1 can be active at times. She stated neither resident has ever had significant behaviors in her presence. Interviews conducted on 8/14/25 between 10:32 AM-1:04 PM, revealed that daytime staff (CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, LVN I, LVN J and CNA K) had been trained on the facility's abuse policy. The staff were able to identify the abuse coordinator, and stated if they suspected or witnessed abuse, they would report directly to the abuse coordinator. During their interview staff was able to report that apart of the suspicion or witnessing abuse they would protect the resident. During an interview on 8/14/25 at 2:33 PM, the ADM stated that she was unsure of the date and time but while at home one-night LVN B called her and explained that Resident #1's family was upset. She stated LVN B told her about the initial complaint from the family involved cleaning supplies and them (Family Member CC) having to clean the restroom. The ADM stated that she received a call from Family Member DD 30 minutes later who stated that the real reason that they (family) were upset was because Resident #1 had been abused and her roommate (Resident #2) was screaming at her (Resident #1). The ADM stated at the time Family Member DD notified her of Resident #2 screaming at Resident #1 she was unaware of the incident. She stated once Family Member DD notified her, she notified the DON, and the DON instructed for 1:1 to be started for Resident #2 to LVN B. The ADM stated that LVN B stated she was unaware of any incidents of abuse that involved Resident #1 and Resident #2. She (the ADM) stated that she started her abuse process. The ADM stated LVN B reported that she (LVN B) heard yelling one night (date was not specified) and LVN B instructed CNA A to see what happened. The ADM stated LVN B reported to her that CNA A never reported to her that Resident #2 was yelling at Resident #1. The ADM stated Resident #2 had a history of yelling at staff. The ADM stated she immediately suspended CNA A for not reporting directly to her. She stated she interviewed CNA A and CNA stated she did tell Family Member CC about the incident between Resident #1 and Resident #2. The ADM stated she asked CNA A why she did not report the incident directly to her as the abuse coordinator as she had been trained and CNA A response was my bad. During an interview on 8/15/25 at 12:15 PM, the ADM stated that she was unsure of the exact date of the incident between Resident #1 and Resident #2, but voiced that she was notified of the incident on 7/13/25 by Family Member DD. The ADM stated she reported the incident to HHSC on 7/13/25 at 11:05 PM. She stated Resident #2 was placed on 1:1 supervision as soon as she was notified of the incident on 7/13/25. She stated Resident #1 was not moved out of the room with Resident #2 because of bed availability. She stated room moves had to be made before she could move Resident #1 out of the room with Resident #2. The ADM stated Resident #1 shared the same bedroom with Resident #2 after the incident up until she was notified on 7/13/25. The ADM no additional incidents had occurred between Resident #1 and Resident #2. She stated she suspended CNA A on 7/14/25 and the last date CNA A had been in the facility was on the morning of her shift ended on 7/14/25. She started safe surveys were conducted on the female locked unit and there were no findings. She stated after consulting with the corporate office and gaining approval she terminated CNA A for failure to report ANE. She stated they started re-education on the facility's abuse policy and by 7/14/25 100 percent of her staff had been trained on the facility's abuse policy. The ADM stated she was sure all staff had been trained because the day they started re-education it was the facility's pay day and each staff that came in had to pick up their check. They re-educated and quizzed the staff verbally on the expectations. She stated staff had always been trained to report to her as the abuse coordinator. She stated Resident #2 was referred to psychiatric services for the incident.During an interview on 8/15/25 at 12:20 PM, the DON stated that on 07/09/25 Resident #2 had a recent change in medication where she had started Depakote. She stated because of the incident between Resident #1 and Resident #2 it was decided to continue to monitor the newly change medication and they added a PRN medication (Hydroxyzine). The ADM, DON, regional Nurse Consultant and Director of Operations were notified on 7/15/25 at 4:08 PM and a PNC IJ situation was identified due to the above failures and the IJ template and 3-strike letter was provided.Interviews conducted on 8/15/25 between 4:31 PM-6:16 PM, revealed that administration, daytime and nighttime staff (the DM, MDS Coordinator, ADON, HR, the Maintenance Supervisor, DS L, [NAME] M, LVN N, LVN O, CNA P, MA Q, CNA R, CNA S, RN T, CNA U, MA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, and LVN BB) had been trained on the facility's abuse policy recently (within the past 30-60 days). The staff voiced they had been trained by the ADM, DON and or the ADON. They stated that they were given the opportunity to ask questions if they needed to. They were all able to identify the abuse coordinator as the ADM and that they needed to report all suspected or witnessed abuse to the ADM. They all were able to voice that they would not assume that an incident had been reported but would report the incident as it was their responsibility. They all were able to report that protection of the resident(s) involved was a part of following the abuse protocol for the facility. They all were able to report that if they did not see any protection interventions put in place that they would follow up with management and or the abuse coordinator. All nurses interviewed were able to report that it was their responsibility to notify family and or responsible party of any significant events involving the residents that resided at the facility. During an interview on 8/15/25 at 6:18 PM, Family Member CC stated they were not notified of the incident that occurred with Resident #1 and Resident #2 at the time of the incident. Family Member CC stated CNA A notified them that Resident #1 was afraid of her roommate (Resident #2). Family Member CC stated he had not observed any incidents between Resident #1 and Resident #2. He stated that they (he and his family) were incredibly pleased with how the facility responded to them reporting their concerns about Resident #1. Family Member CC stated as soon as they reported the incident the facility staff moved Resident #1. Family Member CC stated there had been no incidents since the incident. Family member CC stated that he was unsure if Resident #1 was afraid, but they (he and the family) had concerns that Resident #1 was sleeping in other resident's beds because she had a UTI. He stated when he asked CNA A about what she thought regarding Resident #1 sleeping in other's beds CNA disclosed the incident. He stated he honestly believed CNA was trying to console them because they had other concerns within the same night. He stated since the incident between Resident #1 and Resident #2 the facility staff have done so well notifying them (he and family). During an interview on 8/15/25 at 5:15 PM, the ADM stated regarding the failure to prevent abuse she had been trained on the facility's policy. She stated they review the abuse policy routinely. She stated the purpose of the policy was to protect the residents and ensure they investigate all allegations of abuse. The ADM stated when the allegation was reported to her on 7/13/25 she did investigate and found that CNA A failed to report timely. The ADM stated when she interviewed CNA A, she stated CNA A stated she thought LVN B had reported it. The ADM stated she reminded CNA A at that time it was her responsibility and CNA A's response was my bad. The ADM stated the potential negative outcome for not preventing abuse was residents could endure harm. The ADM stated she could not confirm if Resident #1 was abused. The ADM stated she had no indication that Resident #1 was harmed or was withdrawn. She stated after the incident no staff reported any changes. The ADM stated she was unaware that Resident #2 had yelled at Resident #1. She stated she became aware of the incident on 7/13/25 when the family called her. The ADM stated the system to monitor residents and ensuring they are not abused was re-educating staff, making rounds, and talking to residents and family about abuse. She stated staff are trained upon hire, annually and when there is an incident. The ADM stated she had never observed Resident #2 be aggressive to Resident #1 or any other residents. The ADM stated she expected facility staff to prevent abuse for all residents. The ADM stated all staff are responsible for preventing abuse. The ADM stated the reason abuse was not prevented in the incident involving Resident #1 and Resident #2 was because she was unaware of the incident as it was not reported to her by CNA A. The ADM stated she was unaware that Resident #2 was treating Resident #1 in any way that was negative. The ADM stated regarding the failure to follow the facility's abuse policy that she had been trained on the facility policy and it is routine that they go over the abuse policy. She stated the overall potential negative outcome for not following the facility's abuse policy was the residents would not be free from abuse in their own home. The ADM stated she was unaware that the facility's ANE policy was not being followed. She stated she became aware on 7/13/25 when Resident #1's family called her. The ADM stated the facility's system to ensure that the facility ANE policy (specifically ANE was reported to the appropriate parties (HHSC and abuse coordinator), protection measures were put in place and family was notified) was being followed was through staff education, re-education, routine rounds and talking to staff. The ADM stated she and all her staff had been trained on the facility's ANE policy (specifically ANE was reported to the appropriate parties (HHSC and abuse coordinator), protection measures were put in place and family was notified) and their specific roles as it related to the policy. The ADM stated she expected all staff to follow the abuse policy. Specifically, the ADM stated she expected family to be notified of incidents of ANE, the abuse coordinator to be notified immediately if they suspect or witness abuse, incidents of ANE to be reported to HHSC and protective measures to protect residents should be implemented. The ADM stated everyone was responsible for following the abuse policy. The ADM stated more specifically the nursing staff, DON or the ADM was responsible for family notifications. The ADM stated all staff was responsible for reporting to the abuse coordinator immediately. The ADM stated she and the DON was responsible for reporting incidents to HHSC. The ADM stated once they were notified, they were responsible for implementing protective measures, but all staff had been trained to ensure resident safety. The ADM stated the reason the facility ANE policy was not followed was because CNA A did not report the details of the incident between Resident #1 and Resident #2 to LVN B. The ADM stated the potential negative outcome for not notifying family was the family would not be aware of issues and they are supposed to be aware of issues concerning their resident. The ADM stated if CNA A would have notified the LVN B then LVN B could have notified Resident #1's family. The ADM stated the reason Resident #1's family was not notified was because CNA A did not report the details of the incident to LVN B. The ADM stated the potential negative outcome for not reporting to the abuse coordinator was the abuse coordinator would not know. The ADM stated with the abuse coordinator not knowing of an incident then they would not be able to report to HHSC timely to HHSC. The ADM stated the reason the incident was not reported to HHSC timely was because CNA A did not report to the incident to LVN B or to her timely. The ADM stated the potential negative outcome for not reporting to HHSC would be a thorough investigation may not be conducted. The ADM stated the reason that the incident was not reported to HHSC timely was because CNA A did not report the details to LVN B or to her as the abuse coordinator. The ADM stated the potential negative outcome for not implementing protective measures for a resident after an incident would be resident safety could be affected. The ADM stated protective measures are put in place to ensure that the resident is safe. The ADM additionally stated that she also ensures that protective measures were put in place by initiating 1:1 supervision until other protective measures can be put in place. The ADM stated protective measures were not put in place for Resident #1 because CNA A did not report the incident details to LVN B. During an interview on 8/15/25 at 5:42 PM, the DON stated regarding the failure to prevent abuse that she was familiar with the facility's ANE policy. The DON stated the purpose of pr[TRUN

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Abuse Coordinator for 2 of 7 residents (Resident #1, and #2) reviewed for abuse. CNA A failed to report the allegation of abuse involving Resident #1 and Resident #2, to the abuse Coordinator (ADM) on 7/11/25 when she heard Resident #2 verbally assault Resident #1 between 7:00 PM and 7:30 PM.LVN B failed to report the allegation of abuse involving Resident #1 and Resident #2, to the abuse Coordinator (ADM) on 7/11/25 when she heard Resident #2 verbally assault Resident #1 between 7:00 PM and 7:30 PM.The Abuse Coordinator (ADM) failed to follow the facility's abuse policy by not reporting to HHSC verbal abuse involving Resident #1 and Resident #2 that occurred on 7/11/25 between 7:00 PM and 7:30 PM.The noncompliance was identified as PNC. The IJ began on 07/11/25 and ended on 7/14/25. The facility had corrected the noncompliance before the survey began.These failures could place residents as risk for abuse and neglect. Findings included: Resident #1 Record review of Resident #1's face sheet, 8/14/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), schizoaffective disorder (mental disorder), anxiety (increased worry), insomnia (difficulty sleeping), major depressive disorder (increase sadness) and UTI (infection in the urinary system). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Record review of Resident #1's care plan, dated 7/14/25, revealed the following:Resident #1 had a focus for elopement and wandering specifically that she wandered aimlessly (date initiated 8/14/25). The goal was for Resident #1 to remain safe within the facility unless accompanied by a staff or authorized person. Interventions included distracting resident from wandering by offering pleasant diversions and supervising closely and make regular compliance rounds. Resident #1 had a focus for coping, specifically Resident #1 had a tough time coping with a roommate as roommate might have been verbally aggressive towards Resident #1 (date initiated 7/14/25). The goal was for Resident #1 to feel comfortable in a safe living environment. Interventions included staff would listen to Resident #1's concerns. Staff would monitor if Resident #1 were unable to cope with roommate and the social worker would find a new roommate if applicable. Record review of Resident #1's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #1 and any other residents on 7/11/25.07/13/25 at 9:11 PM LVN B documented: family report a CNA reported to them Resident #1's roommate was cursing at her and telling her to clean up after herself in the bathroom. Initial treatment included skin assessment; roommate placed on 1:1 monitoring supervision. Medical doctor and nurse practitioner notified. Responsible party was notified. 07/13/25 at 10:37 PM LVN B documented skin assessment conducted with no negative findings. 07/14/25 at 2:58 AM LVN B documented trauma assessment conducted. There were no negative findings or experiences documented or found. Resident #1 did not express fear or anger. 7/14/25 at 9:36 PM the DON documented a late entry indicating Resident #1's family reported to administration that the CNA (unidentified in the progress note) told them Resident #1's roommate was cursing at Resident #1 and telling her to clean up after herself in the bathroom. Resident #1's roommate was placed on one-to-one monitoring. Skin Assessment performed on Resident #1. A room swap was made. Family was aware and notified. FNP was notified. 7/15/25 at 8:36 AM LVN EE documented that Resident #1 appeared to be in no pain and monitoring was conducted. 7/15/25 at 8:37 AM LVN EE documented that Resident #1 had no signs or symptoms of distress noted, resident in good spirits.7/15/25 at 10:13 PM LVN BB documented that Resident #1 had no signs or symptoms of distress and did not complain of any pain.During an interview on 8/14/25 at 12:31 PM, Resident #1 could not recall the incident that occurred between she and Resident #2. She could not identify her last roommate by name. She stated she could not remember if she was afraid on 7/11/25. She could not remember how long she had been in the room that she was and why she had moved. She reported that she felt safe at the facility. Resident #2 Record review of Resident #2's face sheet, dated 8/14/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include intermittent explosive disorder (mental disorder characterized by outburst of anger or violence), anxiety (increased worry) and dementia (memory loss). Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section E did not reveal any coded behaviors.Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: Section E Behavior Resident #2 had other behavioral symptoms not directed towards others.Resident #2's care plan, dated 7/14/25 revealed the following:Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had potential to demonstrate physical behaviors. (initiated 7/4/25) The goal was for Resident #2 to demonstrate effective coping skills. Interventions included staff analyzing key times, places, circumstances, triggers, and what de-escalates behavior and document. Staff should assess and address sensory deficits and notify the charge nurse of any physically abusive behaviors. When Resident #2 becomes agitated staff should intervene before agitation escalates. Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had a behavior problem related to being verbally aggressive to staff and other residents. (initiated 7/14/25) The goal was for Resident #2 to not have episodes of being verbally aggressive. Interventions included anticipate the needs of Resident #2. Staff should provide opportunity for positive interaction. Consultation with psychiatry will be made if needed. Staff should also intervene as necessary to protect the rights and safety of others. Staff will also monitor behavior episode of Resident #2. Record review of Resident #2's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #2 and any other residents on 7/11/25.7/13/25 at 9:11 PM the DON documented Resident #2 had a behavior (verbal, resident to resident alleged behavior). Resident #2 scolded her roommate (Resident #1) with curse words to clean up her mess in the bathroom. 1:1 mentoring supervision implemented. Consulted FNP for new orders of hydroxyzine 50 mg PO Q4 hours prn. Recommended to conduct room swap. Resident #2 stated we get along good. Resident #2 stated she worried about her roommate because she sleeps all day and does not sleep much. Attempted to contact Resident #2's family. 7/14/25 at 8:20 AM the DON documented late entry: Informed by administrator the resident's (unspecified in this progress note) roommate's family informed her the CNA (unspecified in this progress note) told them Resident #2 was cursing at her roommate and telling her to clean up after herself in the bathroom. Resident #2 was immediately place on one-on-one observation. Consulted psych provider for any new orders/recommendations. New order to start hydroxyzine 50 mg prn Q4 hours for anxiety/agitation. Performed a roommate swap and may d/c one-on-one monitoring but ensure frequent monitoring as the resident was not physically aggressive. Attempted to notify Family Member FF multiple times. D/c one-on-one supervision. Resident #2 currently does not have a roommate currently.07/15/25 at 10:18 AM the SW documented that she received notification from the administration that a referral to the behavioral center was needed. The SW notified Family Member FF, and he agreed to the referral and the referral was completed. 07/15/25 at 10:24 AM LVN EE documented no verbal behaviors noted, and Resident #2 was in good spirits. 07/15/25 at 10:29 PM LVN BB documented Resident #2 was quiet without negative behaviors, toward resident or staff. 07/16/25 at 8:57 AM LVN EE documented Resident #2 had no behaviors. 07/16/25 at 8:57 PM LVN B documented no behaviors reported during her shift. 07/17/25 at 2:57 PM The SW documented that the referral for Resident #2 was denied due to Resident #2's insurance being out of network. During an interview on 8/14/25 at 12:33 PM, Resident #2 stated she does not remember why her last roommate moved. She stated she got along well with her last roommate. She could not identify her last roommate by name. She could not report if she had an incident with Resident #1 on 7/11/25. During an interview on 8/14/25 at 9:31 AM, CNA A stated she did not have a calendar in front of her but believed the incident occurred on 7/11/25. She stated she worked the night shift (6:00 PM- 6:00 AM). She stated on that day (7/11/25) her partner that she worked with that day called in late. She stated she and LVN B were the only ones on the locked female unit. She stated around 7:00 PM or 7:30 PM while LVN B was attending to another resident next door to Resident #1 and Resident #2 they (CNA A and LVN B) heard Resident #2 yell a loud and clear Get your mother fucking ass in that God Damn bathroom and clean that shit up! CNA A stated she and LVN B looked at each other. CNA A stated LVN B asked her Who is she (Resident #2) hollering at? CNA A stated LVN B instructed her (CNA A) to go and look. CNA A stated when she stepped into Resident #1 and Resident #2's room she observed Resident #1 standing in front of Resident #2 and the look on Resident #1's face gave her (CNA A) the impression that she was scared. CNA A stated she motioned for Resident #1 to come with her. CNA A stated she took Resident #1 to where LVN B was and during this time LVN B then goes to Resident #2. CNA A stated she and Resident #1 stood outside the room where Resident #2 and LVN B were. CNA A stated LVN B asked Resident #2 what was going on and Resident #2 voiced her complaint about Resident #1 pissing on the bathroom floor. She stated LVN B instructed Resident #2 that if it happened again, she needed to call staff for help. CNA A stated she went to get a towel to clean up the urine in the bathroom and while she was doing this Resident #1 followed LVN B. CNA A stated Resident #2 yelled at her Don't clean up that shit! This is why she (Resident #1) don't learn because y'all baby her (Resident #1)! CNA A stated Resident #1 was afraid and did not go back to the room with Resident #2 for majority of the night. CNA A stated Resident #1 did not go to bed until Resident #2 was asleep. CNA A stated she was under the impression that since LVN B witnessed the incident along with her that she would report it to the abuse coordinator, document and notify the family. CNA A stated a couple of days later (unsure of the exact date), Resident #1's family came to the facility and in passing the family asked why is it that when they have come in Resident #1 is not in her bed and sometimes is found in other resident's bed. CNA A stated she told them that it was most likely because she (Resident #1) was afraid of her roommate (Resident #2). She stated that immediately once she mentioned the incident to Family Member CC, he became upset and exclaimed no one told him about the incident. She stated that LVN B was upset with her and told her at that time to complete a report. She stated unsure of the date the following Monday she was suspended because she failed to report the incident. CNA A stated she did not feel it was right that she was suspended for failure to report when LVN B also heard the incident and was present. CNA A stated that the ADM told her that LVN B may have misheard what happened. CNA A stated this was not the case because Resident #2 said what she said very loud, and they were next door to their room. CNA A stated Resident #1 slept in the same room with Resident #2 the night of the incident. CNA A stated she was told that Resident #1 was moved out of the room only after Resident #1's family complained. CNA A stated Resident #2 had a history of aggression and that she had expressed concern in the past. CNA A stated Resident #2 had broken the facility door before and was an exceptionally large lady in comparison to Resident #1. She stated although she did not believe Resident #2 physically hit Resident #1, she believed that Resident #1 was afraid because she would not go back in her room the night of the incident. She stated she and other staff reported to LVN B that even they (staff) were afraid of Resident #2. CNA A stated no other incidents had occurred between Resident #1 and Resident #2 since 7/11/25 but she could not attest for any time after she was suspended. She stated she was trained that if she suspects or witness abuse, she was to report abuse to her chain of command, and this would have been LVN B. She stated that being a CNA for over 25 years this was the way it has always been. She stated that the ADM stated at the time of her suspension that she was supposed to report the incident to her (the ADM). CNA A stated the nurses were responsible for reporting incidents to the family. CNA A stated the night of the incident Resident #1 did not have any injuries that she could visibly see. Interviews conducted on 8/14/25 between 10:32 AM-1:04 PM, revealed that day time staff (CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, LVN I, LVN J and CNA K) had been trained on the facility's abuse policy. The staff were able to identify the abuse coordinator, and stated if they suspected or witnessed abuse, they would report directly to the abuse coordinator. During their interview staff was able to report that apart of the suspicion or witnessing abuse they would protect the resident. During an interview on 8/14/25 at 2:33 PM, the ADM stated that she was unsure of the date and time but while at home one-night LVN B called her and explained that Resident #1's family was upset. She stated LVN B told her about the initial complaint from the family involved cleaning supplies and them (Family Member CC) having to clean the restroom. The ADM stated that she received a call from Family Member DD 30 minutes later who stated that the real reason that they (family) were upset was because Resident #1 had been abused and her roommate (Resident #2) was screaming at her (Resident #1). The ADM stated at the time Family Member DD notified her of Resident #2 screaming at Resident #1 she was unaware of the incident. She stated once Family Member DD notified her, she notified the DON, and the DON instructed for 1:1 to be started for Resident #2 to LVN B. The ADM stated that LVN B stated she was unaware of any incidents of abuse that involved Resident #1 and Resident #2. She stated that she started her abuse process and notified HHSC the same day the family notified her. The ADM, DON, regional Nurse Consultant and Director of Operations were notified on 7/15/25 at 4:08 PM and a PNC IJ situation was identified due to the above failures and the IJ template and 3-strike letter was provided.Interviews conducted on 8/15/25 between 4:31 PM-6:16 PM, revealed that administration, daytime and nighttime staff (the DM, MDS Coordinator, ADON, HR, the Maintenance Supervisor, DS L, [NAME] M, LVN N, LVN O, CNA P, MA Q, CNA R, CNA S, RN T, CNA U, MA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, and LVN BB) had been trained on the facility's abuse policy recently (within the past 30-60 days). The staff voiced they had been trained by the ADM, DON and or the ADON. They stated that they were given the opportunity to ask questions if they needed to. They were all able to identify the abuse coordinator as the ADM and that they needed to report all suspected or witnessed abuse to the ADM. They all were able to voice that they would not assume that an incident had been reported but would report the incident as it was their responsibility. All staff interviewed voiced that they were comfortable, confident in their role carrying out the facility's expectation regarding the facility's abuse policy and requirements. During an interview on 8/15/25 at 12:15 PM, the ADM stated that she was unsure of the exact date of the incident between Resident #1 and Resident #2, but voiced that she was notified of the incident on 7/13/25 by Family Member DD. The ADM stated she reported the incident to HHSC on 7/13/25 at 11:05 PM. The ADM stated she was sure all staff had been trained because the day they started re-education it was the facility's pay day and each staff that came in had to pick up their check. They re-educated and quizzed the staff verbally on the expectations. She stated staff had always been trained to report to her as the abuse coordinator. She stated Resident #2 was referred to psychiatric services for the incident.During an interview on 8/15/25 at 6:18 PM, Family Member CC stated they were not notified of the incident that occurred with Resident #1 and Resident #2 at the time of the incident. Family Member CC stated CNA A notified them that Resident #1 was afraid of her roommate (Resident #2). Family Member CC stated he had not observed any incidents between Resident #1 and Resident #2. He stated that they (he and his family) were incredibly pleased with how the facility responded to them reporting their concerns about Resident #1. Family Member CC stated as soon as they reported the incident the facility staff moved Resident #1. Family Member CC stated there had been no incidents since the incident. Family member CC stated that he was unsure if Resident #1 was afraid, but they (he and the family) had concerns that Resident #1 was sleeping in other resident's beds because she had a UTI. He stated when he asked CNA A about what she thought regarding Resident #1 sleeping in other's beds CNA disclosed the incident. He stated he honestly believed CNA was trying to console them because they had other concerns within the same night. He stated since the incident between Resident #1 and Resident #2 the facility staff have done so well notifying them (he and family). During an interview on 8/15/25 at 5:15 PM, the ADM stated the facility's system to ensure that the facility ANE policy (specifically ANE was reported to the appropriate parties (HHSC and abuse coordinator) and family was notified) was being followed was through staff education, re-education, routine rounds and talking to staff. The ADM stated she and all her staff had been trained on the facility's ANE policy (specifically ANE was reported to the appropriate parties (HHSC and abuse coordinator), and family was notified) and their specific roles as it related to the policy. The ADM stated she expected all staff to follow the abuse policy. Specifically, the ADM stated she expected family to be notified of incidents of ANE, the abuse coordinator to be notified immediately if they suspect or witness abuse and incidents of ANE to be reported to HHSC. The ADM stated more specifically the nursing staff, DON or the ADM was responsible for family notifications. The ADM stated all staff was responsible for reporting to the abuse coordinator immediately. The ADM stated she and the DON was responsible for reporting incidents to HHSC. The ADM stated the potential negative outcome for not notifying family was the family would not be aware of issues and they are supposed to be aware of issues concerning their resident. The ADM stated if CNA A would have notified the LVN B then LVN B could have notified Resident #1's family. The ADM stated the reason Resident #1's family was not notified was because CNA A did not report the details of the incident to LVN B. The ADM stated the potential negative outcome for not reporting to the abuse coordinator was the abuse coordinator would not know. The ADM stated with the abuse coordinator not knowing of an incident then they would not be able to report to HHSC timely to HHSC. The ADM stated the reason the incident was not reported to HHSC timely was because CNA A did not report to the incident to LVN B or to her timely. The ADM stated the potential negative outcome for not reporting to HHSC would be a thorough investigation may not be conducted. The ADM stated the reason that the incident was not reported to HHSC timely was because CNA A did not report the details to LVN B or to her as the abuse coordinator. During an interview on 8/15/25 at 5:42 PM, the DON stated the system to monitor ANE was reported to the appropriate parties (HHSC and abuse coordinator), and family was notifications was inservicing and educating staff on the policy. The DON stated they teach the staff over and over to follow the abuse policy which included reporting and family notifications. The DON stated she reviews documentation to also ensure that the policy was being followed. The DON stated that she had been trained on the facility's expectation that ANE was reported to the appropriate parties (HHSC and abuse coordinator), and family notifications as well as all her staff. The DON stated she expected that all staff to follow the expectation that ANE was reported to the appropriate parties (HHSC and abuse coordinator), and family notifications were made. The DON stated specifically for family notifications she expected family to be notified of all things that had to do with the residents. The DON stated that she expected for family to be notified of all incidents and any changes. The DON stated expected that the abuse coordinator should be notified immediately of any suspicions of ANE so that the proper steps are taken and followed. The DON stated that she expected HHSC to notified timely according to their policy so the proper investigations can be initiated. The DON stated whichever staff witnessed the incident was responsible for reporting to the abuse coordinator. The DON stated the nurse involved in the incident was responsible for notifying the family, but this could only be done after the person reported the incident to the nurse. The DON stated the abuse coordinator was responsible for notifying HHSC. The DON stated that the reason ANE was not reported to the appropriate parties (HHSC and abuse coordinator) was because CNA A did not report the incident between Resident #1 and Resident #2 to LVN B and the abuse coordinator. The DON stated that the potential negative outcome for not notifying family was the family would not bee aware of what was going on with the resident. The DON stated it was improper for notifications not to be done. The DON stated the reason the family was not notified was because CNA A did not notify LVN B or the abuse coordinator. The DON stated the potential negative outcome of not reporting to the abuse coordinator immediately was the situation with the resident would not be addressed and the residents would be at risk for harm. The DON was unaware that Resident #1's family had not been notified. The DON stated the reason the abuse coordinator was not notified was because CNA A did not notify LVN B or her. The DON stated the potential negative outcome of not reporting to HHSC timely was the facility would not be following the proper procedures. The DON stated that potentially the incident would not be investigated, and safety could not be ensured. The DON stated she was unaware that HHSC had not been notified because she was unaware of the incident until it was reported on 7/13/25. The DON stated the reason HHSC was not notified was because CNA A did not notify LVN B or the abuse coordinator. During an interview on 8/15/25 at 8:45 PM, LVN B stated she was unsure of the exact date of the incident that occurred between Resident #1 and Resident #2. LVN B stated that she was in the last room at the end of the hallway assisting another resident. She stated CNA A heard one of the residents raise their voice. She stated she asked CNA A which resident raised their voice and was told by CNA A that it was Resident #2 and Resident #1. LVN B stated CNA A told her that Resident #2 was raising her voice at Resident #1. LVN B stated she voiced to Resident #2 that she does not need to raise her voice. LVN B stated that was it and she left Resident #2 in her room. LVN B stated 5 minutes later both residents could not remember the incident. LVN B stated she does not know what specifically Resident #2 said to Resident #1. She stated CNA A did not specify what was said but only stated Resident #2 was yelling at Resident #1 because there was piss on the floor. LVN B stated she did not suspect abuse because normally Resident #2 was loud resident and that was the way she talked. She stated working on the locked unit residents have behaviors and she considered Resident #2 yelling as one of her behaviors and she needed redirection. LVN B stated Resident #1 did not appear afraid to her. LVN B stated Resident #1 went back to her room within an hour of the incident. LVN B stated that CNA A did not report to her or indicate that Resident #1 was afraid. LVN B stated after the incident between Resident #1 and Resident #2 she never had a discussion with Resident #1's family nor did she discuss the incident any further with CNA A. LVN B stated that had not been any other incidents since the verbal incident between Resident #1 and Resident #2 nor had there been any incidents before. LVN B stated CNA A reported to the Resident #1's family that Resident #1 felt threatened by Resident #2 and that is what caused them to call the ADM. She stated when they called the ADM, she was instructed to place Resident #2 on 1:1 supervision. LVN B stated she did not report the incident to the abuse coordinator because she felt it was a nursing judgement call to redirect Resident #2. LVN B stated she did not notify the family of the incident but could not give a reason as to why because she could not remember what was going on that day to be able to give the investigator accurate information. LVN B stated an incident of the same nature involving Resident #1 and Resident #2 would have been an incident that she would notify family of. She stated she did not document the incident in either resident's progress notes. LVN B stated she could not give the investigator a reason because she could not recall specifically what went on that day that would potentially hinder her in documenting. LVN B stated she had been trained on the facility's abuse policy recently (within the past 30-60 days) by the ADM, DON and ADON. LVN B was able to identify the abuse coordinator as the ADM and that she needed to report all suspected or witnessed abuse to the ADM. She stated that she would not assume that an incident had been reported but would report the incident as it was her responsibility. She stated that protection of the resident(s) involved was a part of following the abuse protocol for the facility. She stated if she did not see any protection interventions put in place that she would follow up with management and or the abuse coordinator. LVN B stated Resident #1 and Resident #2 shared the same room after the incident up until she was instructed to place Resident #2 on 1:1 supervision. LVN B stated no other incidents occurred with Resident #1 and Resident #2 after the verbal incident on the unknown date that she was aware of. LVN B stated it was her responsibility to notify family and or responsible party of any significant events involving the residents that resided at the facility. She stated before the incident that occurred with Resident #1 and Resident #2, she had received training on the facility's ANE policy.During the investigation held on 8/14/25-8/15/25 there were no observation of any interactions between Resident #1 and Resident #2. Resident #1 and Resident #2 were observed in their separate rooms during the visit. Record review of the facility's Form 3614 (Provider Investigation Report), dated 7/17/25, revealed:Incident Date: 7/11/25Person(s) or Resident(s) involved:Resident #1 Alleged Perpetrator: None listed.Witnesses:CNA ADescription of the Allegation: Resident #1's roommate cusses at her and tries to make her clean up the bathroom. Assessment:7/13/25: Resident has no injuries. Provider Response: Resident #2 was placed on one-to-one monitoring immediately upon receiving report from Resident #1's family. Resident #1 was assessed for any injuries-none noted. Physician notified. Family, physician and psychiatry notified for Resident #2.Investigation Summary: Resident #1's family reported to LVN B, that they had been finding Resident #1 bathroom with bowel and urine on the floor and they had been bringing toilet paper because she had not had toilet paper and sometimes paper towels. LVN B notified the ADM via phone of the concern. The ADM later received a call from Family Member B stating what family had reported and added that Resident #2 had been yelling and cussing at Resident #1. LVN B was aware that one evening she heard raised voices and sent CNA A to see what was going on but nothing was ever reported to LVN B about cussing or demanding residents to het on her knees and clean up the bathroom. CNA A was suspended pending investigation and will be terminated for failure to report. Both residents lack capacity to make informed decisions. Room changes were done, and Resident #2 remained one to one until the room changes were done. Referral was made to the behavior center for Resident #2. No issues since Resident #2 does not have a roommate. Facility Investigation Findings: UnconfirmedProvider Action Taken Post-Investigation: Continue to monitor resident and re-education with staff on abuse, neglect and reporting procedures.Record review of CNA A's witness statement, dated 7/14/25, revealed: I was in the room talking to my nurse, LVN B, when I heard Resident #2 yelling and cussing, saying Get your fucking ass in that goddamn bathroom and clean up that mess right now. I'm sick of this shit. LVN B had asked me to go see who she was talking to. I walked to the door and saw Resident #1 standing in front of Resident #2. I motioned for Resident #1 to come out in the hall. I then told LVN B she was talking to Resident #1. LVN B then asked Resident #2 what was going on and Resident #2 stated Resident #1 had peed on the bathroom floor and had done it before, and she wanted her to clean it up. LVN B told Resident #2 that Resident #1 could not do that because she could fall. I had went to get a towel to clean up the urine and Resident #2 stated to me that Resident #1 needed to get on her hands and knees and clean that shit up because she was tired of her doing that. I had advised Resident #2 that Resident #1 was not able to do so. I told Resident #2 if it happened again for her to let me or any aide that is on the hall and we would clean it up. Resident #2 then told me as long as we keep babying her and not making her clean up her mess then she would never stop. I walked out of the room and nothing more was said. Record review of Resident #2's 1:1 monitoring supervision sheet, dated 7/13/25-, revealed:Resident #2 was on 1:1 monitoring from 7/13/25 at 9:49 PM until 7/14/25 at 4:45 AM.Record review of CNA Record review of staff (LVN BB), undated, witness statements that revealed they had never observed Resident #2 being mean or rude to Resident #1.Record review of staff (CNA Z) written statement, undated, revealed she was not sure of the date, but she heard Resident #2 tell Resident #1 tell Resident #1 to clean up the bathroom, or she would make her and then she would kick her butt. The statement stated Resident #2 told Resident #1 she knew what she was doing. Record review of staff (CNA HH), dated 7/14/25, witness statements that revealed they had never observed Resident #2 being mean or rude to Resident #1.Record review of LVN B's written statement, dated, 7/16/25, revealed she (LVN B) was in the room assisting another resident in the restroom

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment for 2 of 7 residents (Resident #1, #2) reviewed for abuse.The facility failed to immediately implement protective measures to protect Resident #1 from Resident #2 after a verbal abuse incident occurred on 7/11/25 between 7:00 PM and 7:30 PM.The noncompliance was identified as PNC. The IJ began on 07/11/25 and ended on 7/14/25. The facility had corrected the noncompliance before the survey began.These failures could place residents as risk for further abuse to include emotional and physical.Findings Included: Resident #1 Record review of Resident #1's face sheet, 8/14/25, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), schizoaffective disorder (mental disorder), anxiety (increased worry), insomnia (difficulty sleeping), major depressive disorder (increase sadness) and UTI (infection in the urinary system). Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident's cognition was severely impaired. Record review of Resident #1's care plan, dated 7/14/25, revealed the following:Resident #1 had a focus for elopement and wandering specifically that she wandered aimlessly (date initiated 8/14/25). The goal was for Resident #1 to remain safe within the facility unless accompanied by a staff or authorized person. Interventions included distracting resident from wandering by offering pleasant diversions and supervising closely and make regular compliance rounds. Resident #1 had a focus for coping, specifically Resident #1 had a tough time coping with a roommate as roommate might have been verbally aggressive towards Resident #1 (date initiated 7/14/25). The goal was for Resident #1 to feel comfortable in a safe living environment. Interventions included staff would listen to Resident #1's concerns. Staff would monitor if Resident #1 were unable to cope with roommate and the social worker would find a new roommate if applicable. Record review of Resident #1's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #1 and any other residents on 7/11/25.07/13/25 at 9:11 PM LVN B documented: family report a CNA reported to them Resident #1's roommate was cursing at her and telling her to clean up after herself in the bathroom. Initial treatment included skin assessment; roommate placed on 1:1 monitoring supervision. Medical doctor and nurse practitioner notified. Responsible party was notified. 07/13/25 at 10:37 PM LVN B documented skin assessment conducted with no negative findings. 07/14/25 at 2:58 AM LVN B documented trauma assessment conducted. There were no negative findings or experiences documented or found. Resident #1 did not express fear or anger. 7/14/25 at 9:36 PM the DON documented a late entry indicating Resident #1's family reported to administration that the CNA (unidentified in the progress note) told them Resident #1's roommate was cursing at Resident #1 and telling her to clean up after herself in the bathroom. Resident #1's roommate was placed on one-to-one monitoring. Skin Assessment performed on Resident #1. A room swap was made. Family was aware and notified. FNP was notified. 7/15/25 at 8:36 AM LVN EE documented that Resident #1 appeared to be in no pain and monitoring was conducted. 7/15/25 at 8:37 AM LVN EE documented that Resident #1 had no signs or symptoms of distress noted, resident in good spirits.7/15/25 at 10:13 PM LVN BB documented that Resident #1 had no signs or symptoms of distress and did not complain of any pain.During an interview on 8/14/25 at 12:31 PM, Resident #1 could not recall the incident that occurred between she and Resident #2. She could not identify her last roommate by name. She stated she could not remember if she was afraid on 7/11/25. She could not remember how long she had been in the room that she was and why she had moved. She reported that she felt safe at the facility. Resident #2 Record review of Resident #2's face sheet, dated 8/14/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include intermittent explosive disorder (mental disorder characterized by outburst of anger or violence), anxiety (increased worry) and dementia (memory loss). Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section E did not reveal any coded behaviors.Record review of Resident #2's Quarterly Minimum Data Set, dated [DATE], revealed: Section E Behavior Resident #2 had other behavioral symptoms not directed towards others.Resident #2's care plan, dated 7/14/25 revealed the following:Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had potential to demonstrate physical behaviors. (initiated 7/4/25) The goal was for Resident #2 to demonstrate effective coping skills. Interventions included staff analyzing key times, places, circumstances, triggers, and what de-escalates behavior and document. Staff should assess and address sensory deficits and notify the charge nurse of any physically abusive behaviors. When Resident #2 becomes agitated staff should intervene before agitation escalates. Resident #2 had a focus for behavioral symptoms specifically that Resident #2 had a behavior problem related to being verbally aggressive to staff and other residents. (initiated 7/14/25) The goal was for Resident #2 to not have episodes of being verbally aggressive. Interventions included anticipate the needs of Resident #2. Staff should provide opportunity for positive interaction. Consultation with psychiatry will be made if needed. Staff should also intervene as necessary to protect the rights and safety of others. Staff will also monitor behavior episode of Resident #2. Record review of Resident #2's progress notes, dated 5/13/25-8/14/25, revealed: No incidents documented involving Resident #2 and any other residents on 7/11/25.7/13/25 at 9:11 PM the DON documented Resident #2 had a behavior (verbal, resident to resident alleged behavior). Resident #2 scolded her roommate (Resident #1) with curse words to clean up her mess in the bathroom. 1:1 mentoring supervision implemented. Consulted FNP for new orders of hydroxyzine 50 mg PO Q4 hours prn. Recommended to conduct room swap. Resident #2 stated we get along good. Resident #2 stated she worried about her roommate because she sleeps all day and does not sleep much. Attempted to contact Resident #2's family. 7/14/25 at 8:20 AM the DON documented late entry: Informed by administrator the resident's (unspecified in this progress note) roommate's family informed her the CNA (unspecified in this progress note) told them Resident #2 was cursing at her roommate and telling her to clean up after herself in the bathroom. Resident #2 was immediately place on one-on-one observation. Consulted psych provider for any new orders/recommendations. New order to start hydroxyzine 50 mg prn Q4 hours for anxiety/agitation. Performed a roommate swap and may d/c one-on-one monitoring but ensure frequent monitoring as the resident was not physically aggressive. Attempted to notify Family Member FF multiple times. D/c one-on-one supervision. Resident #2 currently does not have a roommate currently.07/15/25 at 10:18 AM the SW documented that she received notification from the administration that a referral to the behavioral center was needed. The SW notified Family Member FF, and he agreed to the referral and the referral was completed. 07/15/25 at 10:24 AM LVN EE documented no verbal behaviors noted, and Resident #2 was in good spirits. 07/15/25 at 10:29 PM LVN BB documented Resident #2 was quiet without negative behaviors, toward resident or staff. 07/16/25 at 8:57 AM LVN EE documented Resident #2 had no behaviors. 07/16/25 at 8:57 PM LVN B documented no behaviors reported during her shift. 07/17/25 at 2:57 PM The SW documented that the referral for Resident #2 was denied due to Resident #2's insurance being out of network. During an interview on 8/14/25 at 12:33 PM, Resident #2 stated she does not remember why her last roommate moved. She stated she got along well with her last roommate. She could not identify her last roommate by name. She could not report if she had an incident with Resident #1 on 7/11/25. During an interview on 8/14/25 at 9:31 AM, CNA A stated she did not have a calendar in front of her but believed the incident occurred on 7/11/25. She stated she worked the night shift (6:00 PM- 6:00 AM). She stated on that day (7/11/25) her partner that she worked with that day called in late. She stated she and LVN B were the only ones on the locked female unit. She stated around 7:00 PM or 7:30 PM while LVN B was attending to another resident next door to Resident #1 and Resident #2 they (CNA A and LVN B) heard Resident #2 yell a loud and clear Get your mother fucking ass in that God Damn bathroom and clean that shit up! CNA A stated she and LVN B looked at each other. CNA A stated LVN B asked her Who is she (Resident #2) hollering at? CNA A stated LVN B instructed her (CNA A) to go and look. CNA A stated when she stepped into Resident #1 and Resident #2's room she observed Resident #1 standing in front of Resident #2 and the look on Resident #1's face gave her (CNA A) the impression that she was scared. CNA A stated she motioned for Resident #1 to come with her. CNA A stated she took Resident #1 to where LVN B was and during this time LVN B then goes to Resident #2. CNA A stated she and Resident #1 stood outside the room where Resident #2 and LVN B were. CNA A stated LVN B asked Resident #2 what was going on and Resident #2 voiced her complaint about Resident #1 pissing on the bathroom floor. She stated LVN B instructed Resident #2 that if it happened again, she needed to call staff for help. CNA A stated she went to get a towel to clean up the urine in the bathroom and while she was doing this Resident #1 followed LVN B. CNA A stated Resident #2 yelled at her Don't clean up that shit! This is why she (Resident #1) don't learn because y'all baby her (Resident #1)! CNA A stated Resident #1 was afraid and did not go back to the room with Resident #2 for majority of the night. CNA A stated Resident #1 did not go to bed until Resident #2 was asleep. CNA A stated she was under the impression that since LVN B witnessed the incident along with her that she would report it to the abuse coordinator, document and notify the family. CNA A stated a couple of days later (unsure of the exact date), Resident #1's family came to the facility and in passing the family asked why is it that when they have come in Resident #1 is not in her bed and sometimes is found in other resident's bed. CNA A stated she told them that it was most likely because she (Resident #1) was afraid of her roommate (Resident #2). She stated that immediately once she mentioned the incident to Family Member CC, he became upset and exclaimed no one told him about the incident. She stated that LVN B was upset with her and told her at that time to complete a report. She stated unsure of the date the following Monday she was suspended because she failed to report the incident. CNA A stated she did not feel it was right that she was suspended for failure to report when LVN B also heard the incident and was present. CNA A stated that the ADM told her that LVN B may have misheard what happened. CNA A stated this was not the case because Resident #2 said what she said very loud, and they were next door to their room. CNA A stated Resident #1 slept in the same room with Resident #2 the night of the incident. CNA A stated she was told that Resident #1 was moved out of the room only after Resident #1's family complained. CNA A stated Resident #2 had a history of aggression and that she had expressed concern in the past. CNA A stated Resident #2 had broken the facility door before and was an exceptionally large lady in comparison to Resident #1. She stated although she did not believe Resident #2 physically hit Resident #1, she believed that Resident #1 was afraid because she would not go back in her room the night of the incident. She stated she and other staff reported to LVN B that even they (staff) were afraid of Resident #2. CNA A stated no other incidents had occurred between Resident #1 and Resident #2 since 7/11/25 but she could not attest for any time after she was suspended. She stated she was trained that if she suspects or witness abuse, she was to report abuse to her chain of command, and this would have been LVN B. She stated that being a CNA for over 25 years this was the way it has always been. She stated that the ADM stated at the time of her suspension that she was supposed to report the incident to her (the ADM). CNA A stated the nurses were responsible for reporting incidents to the family. CNA A stated the night of the incident Resident #1 did not have any injuries that she could visibly see. During an interview on 8/14/25 at 10:32 AM, CNA C stated she had never worked the female locked unit. She stated she had guarded the door once when the doors were not working. She stated she had not worked directly with Resident #1 and Resident #2. During an interview on 8/14/25 at 10:43 AM, CNA D stated she did not have any information regarding the verbal incident between Resident #1 and Resident #2 that occurred on 07/11/25. She stated she is unaware if any incidents had occurred since 7/11/25. During an interview on 8/14/25 at 11:09 AM, CNA E stated she did not have any firsthand information about the verbal incident that occurred on 7/11/25 between Resident #1 and Resident #2. She stated Resident #1 and Resident #2 had never had issues before 7/11/25 or since 7/11/25. She stated Resident #2 rarely has behaviors. She stated Resident #1 has no behaviors but will ask questions over and over. During an interview on 8/14/25 at 11:24 AM, CNA F stated she did not have any firsthand information about Resident #1's and Resident #2's verbal altercation that occurred on 7/11/25. She stated there had been no additional altercations between Resident #1 and Resident #2. She stated Resident #1 had an issue where she wanted to leave the unit but never had any altercations with residents in the unit. During an interview on 8/14/25 at 11:35 AM, CNA G stated she does not work the female unit and did not have any information regarding the incident that occurred on 7/11/25 between Resident #1 and Resident #2. During an interview on 8/14/25 at 11:45 AM, CNA H stated although she works the female locked unit at times, she did not have any information regarding the verbal altercation that occurred between Resident #1 and Resident #2. She stated she did not have any information about Resident #1 and Resident #2's behaviors as she had not worked the female locked unit in a while. During an interview on 8/14/25 at 11:55 AM, LVN I stated he did not have any firsthand information about the verbal altercation that occurred on 7/11/25 between Resident #1 and Resident #2. He stated Resident #1 and Resident #2 did not have a history of verbal altercations and there had been no incidents since 7/11/25. He stated Resident #1 was pleasantly confused. He stated she would wander but no other behaviors. He stated in the past Resident #2 had behaviors that included hoarding briefs. He stated in the past on an unknown date she (Resident #2) broke the female locked unit door but was sent to a behavior unit because of that behavior. He stated the facility manages Resident #2's behavior well through close monitoring. During an interview on 8/14/25 at 12:11 PM, LVN J stated she did not have any firsthand information about Resident #1 and Resident #2's verbal altercation that occurred on 7/11/25 as she did not work the female locked unit on that date. She stated she did not have any additional information regarding Resident #2 or Resident #1 behaviors. During an interview on 8/14/25 at 1:04 PM, CNA K stated she did not have firsthand information regarding Resident #1 and Resident #2 verbal altercation that occurred on 7/11/25. She stated she had worked with both residents before and after 7/11/25. She stated the two had never had any issues before or after. She stated Resident #2 never comes out of her room. She stated Resident #1 can be active at times. She stated neither resident has ever had significant behaviors in her presence. Interviews conducted on 8/14/25 between 10:32 AM-1:04 PM, revealed that daytime staff (CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, LVN I, LVN J and CNA K) had been trained on the facility's abuse policy. The staff were able to identify the abuse coordinator, and stated if they suspected or witnessed abuse, they would report directly to the abuse coordinator. During their interview staff was able to report that apart of the suspicion or witnessing abuse they would protect the resident. During an interview on 8/14/25 at 2:33 PM, the ADM stated that she was unsure of the date and time but while at home one-night LVN B called her and explained that Resident #1's family was upset. She stated LVN B told her about the initial complaint from the family involved cleaning supplies and them (Family Member CC) having to clean the restroom. The ADM stated that she received a call from Family Member DD 30 minutes later who stated that the real reason that they (family) were upset was because Resident #1 had been abused and her roommate (Resident #2) was screaming at her (Resident #1). The ADM stated at the time Family Member DD notified her of Resident #2 screaming at Resident #1 she was unaware of the incident. She stated once Family Member DD notified her, she notified the DON, and the DON instructed for 1:1 to be started for Resident #2 to LVN B. The ADM stated that LVN B stated she was unaware of any incidents of abuse that involved Resident #1 and Resident #2. She (the ADM) stated that she started her abuse process. The ADM stated LVN B reported to her that she (LVN B) heard yelling one night (date was not specified) and LVN B instructed CNA A to see what happened. The ADM stated LVN B reported to her that CNA A never reported to her that Resident #2 was yelling at Resident #1. The ADM stated Resident #2 had a history of yelling at staff. The ADM stated she move Resident #1 away from Resident #2 on 7/14/25. The ADM could not specifically state when the incident between the two residents happened but that she became aware of the incident on 7/13/25. During an interview on 8/15/25 at 12:15 PM, the ADM stated that she was unsure of the exact date of the incident between Resident #1 and Resident #2, but voiced that she was notified of the incident on 7/13/25 by Family Member DD. She stated Resident #2 was placed on 1:1 supervision as soon as she was notified of the incident on 7/13/25. She stated Resident #1 was not moved out of the room with Resident #2 because of bed availability. She stated room moves had to be made before she could move Resident #1 out of the room with Resident #2. The ADM stated Resident #1 shared the same bedroom with Resident #2 after the incident up until she was notified on 7/13/25. The ADM no additional incidents had occurred between Resident #1 and Resident #2. She started safe surveys were conducted on the female locked unit and there were no findings. She stated they started re-education on the facility's abuse policy and by 7/14/25 100 percent of her staff had been trained on the facility's abuse policy. The ADM stated she was sure all staff had been trained because the day they started re-education it was the facility's pay day and each staff that came in had to pick up their check. They re-educated and quizzed the staff verbally on the expectations. She stated Resident #2 was referred to psychiatric services for the incident.During an interview on 8/15/25 at 12:20 PM, the DON stated that on 07/09/25 Resident #2 had a recent change in medication where she had started Depakote. She stated because of the incident between Resident #1 and Resident #2 it was decided to continue to monitor the newly change medication and they added a PRN medication (Hydroxyzine). The ADM, DON, regional Nurse Consultant and Director of Operations were notified on 7/15/25 at 4:08 PM and a PNC IJ situation was identified due to the above failures and the IJ template and 3-strike letter was provided.Interviews conducted on 8/15/25 between 4:31 PM-6:16 PM, revealed that administration, daytime and nighttime staff (the DM, MDS Coordinator, ADON, HR, the Maintenance Supervisor, DS L, [NAME] M, LVN N, LVN O, CNA P, MA Q, CNA R, CNA S, RN T, CNA U, MA V, CNA W, CNA X, CNA Y, CNA Z, CNA AA, and LVN BB) had been trained on the facility's abuse policy recently (within the past 30-60 days). The staff voiced they had been trained by the ADM, DON and or the ADON. They stated that they were given the opportunity to ask questions if they needed to. They all were able to report that protection of the resident(s) involved was a part of following the abuse protocol for the facility. They all were able to report that if they did not see any protection interventions put in place that they would follow up with management and or the abuse coordinator. All nurses interviewed were able to report that it was their responsibility to notify family and or responsible party of any significant events involving the residents that resided at the facility. During an interview on 8/15/25 at 6:18 PM, Family Member CC stated they were not notified of the incident that occurred with Resident #1 and Resident #2 at the time of the incident. Family Member CC stated CNA A notified them that Resident #1 was afraid of her roommate (Resident #2). Family Member CC stated he had not observed any incidents between Resident #1 and Resident #2. He stated that they (he and his family) were incredibly pleased with how the facility responded to them reporting their concerns about Resident #1. Family Member CC stated as soon as they reported the incident the facility staff moved Resident #1. Family Member CC stated there had been no incidents since the incident. Family member CC stated that he was unsure if Resident #1 was afraid, but they (he and the family) had concerns that Resident #1 was sleeping in other resident's beds because she had a UTI. He stated when he asked CNA A about what she thought regarding Resident #1 sleeping in other's beds CNA disclosed the incident. He stated he honestly believed CNA was trying to console them because they had other concerns within the same night. He stated since the incident between Resident #1 and Resident #2 the facility staff have done so well notifying them (he and family). During an interview on 8/15/25 at 5:15 PM, the ADM stated the facility's system to ensure that protection measures were put in place was through staff education, re-education, routine rounds and talking to staff. The ADM stated she and all her staff had been trained on implementing protection measures for residents and their specific roles as it related to the facility's abuse policy. Specifically, the ADM stated she expected the abuse coordinator to be notified immediately if they suspect or witness abuse, and protective measures to protect residents should be implemented. The ADM stated once they were notified, they were responsible for implementing protective measures, but all staff had been trained to ensure resident safety. The ADM stated the potential negative outcome for not implementing protective measures for a resident after an incident would be resident safety could be affected. The ADM stated protective measures are put in place to ensure that the resident is safe. The ADM additionally stated that she also ensures that protective measures were put in place by initiating 1:1 supervision until other protective measures can be put in place. The ADM stated protective measures were not put in place for Resident #1 because CNA A did not report the incident details to LVN B. During an interview on 8/15/25 at 5:42 PM, the DON stated the system to monitor implementation of protection measures were through inservicing and educating staff on the abuse policy. The DON stated they teach the staff over and over to follow the abuse policy which included protecting the residents from abuse. The DON stated she reviews documentation to also ensure that the policy was being followed and that protection measures were put in place. The DON stated that she had been trained to implement protection measures for residents when there is a suspicion or witnessed abuse as well as all her staff. The DON stated she expected that all staff to implement protection measures for all residents that experienced abuse or potentially could experience abuse. The DON stated expected that the abuse coordinator should be notified immediately of any suspicions of ANE so that the proper steps are taken and followed. The DON stated she expected for protective measures to be put in place to protect residents so that the residents are always safe, and the proper additional interventions can be put in place and implemented. The DON stated all staff were responsible for implementing protective measures, but this could only be done if the incident was reported correctly. The DON stated the potential negative outcome of not implementing protective measures for residents was harm to the residents involved could occur. The DON stated she was unaware that protective measures were not implemented immediately because she was unaware of the incident. The DON stated the reason protective measures were not implemented at the time of the incident was because CNA A did not notify LVN B or the abuse coordinator. During an interview on 8/15/25 at 8:45 PM, LVN B stated she was unsure of the exact date of the incident that occurred between Resident #1 and Resident #2. LVN B stated that she was in the last room at the end of the hallway assisting another resident. She stated CNA A heard one of the residents raise their voice. She stated she asked CNA A which resident raised their voice and was told by CNA A that it was Resident #2 and Resident #1. LVN B stated CNA A told her that Resident #2 was raising her voice at Resident #1. LVN B stated she voiced to Resident #2 that she does not need to raise her voice. LVN B stated that was it and she left Resident #2 in her room. LVN B stated 5 minutes later both residents could not remember the incident. LVN B stated she does not know what specifically Resident #2 said to Resident #1. She stated CNA A did not specify what was said but only stated Resident #2 was yelling at Resident #1 because there was piss on the floor. LVN B stated she did not suspect abuse because normally Resident #2 was loud resident and that was the way she talked. She stated working on the locked unit residents have behaviors and she considered Resident #2 yelling as one of her behaviors and she needed redirection. LVN B stated Resident #1 did not appear afraid to her. LVN B stated Resident #1 went back to her room within an hour of the incident. LVN B stated that CNA A did not report to her or indicate that Resident #1 was afraid. LVN B stated after the incident between Resident #1 and Resident #2 she never had a discussion with Resident #1's family nor did she discuss the incident any further with CNA A. LVN B stated that had not been any other incidents since the verbal incident between Resident #1 and Resident #2 nor had there been any incidents before. LVN B stated CNA A reported to the Resident #1's family that Resident #1 felt threatened by Resident #2 and that is what caused them to call the ADM. She stated when they called the ADM, she was instructed to place Resident #2 on 1:1 supervision. LVN B stated she did not report the incident to the abuse coordinator because she felt it was a nursing judgement call to redirect Resident #2. LVN B stated she had been trained on the facility's abuse policy recently (within the past 30-60 days) by the ADM, DON and ADON. LVN B was able to identify the abuse coordinator as the ADM and that she needed to report all suspected or witnessed abuse to the ADM. She stated if she did not see any protection interventions put in place that she would follow up with management and or the abuse coordinator. LVN B stated Resident #1 and Resident #2 shared the same room after the incident up until she was instructed to place Resident #2 on 1:1 supervision. LVN B stated no other incidents occurred with Resident #1 and Resident #2 after the verbal incident on the unknown date that she was aware of. She stated before the incident that occurred with Resident #1 and Resident #2, she had received training on the facility's ANE policy.During the investigation held on 8/14/25-8/15/25 there were no observation of any interactions between Resident #1 and Resident #2. Resident #1 and Resident #2 were observed in their separate rooms during the visit. Record review of the facility's Form 3614 (Provider Investigation Report), dated 7/17/25, revealed:Incident Date: 7/11/25Person(s) or Resident(s) involved:Resident #1 Alleged Perpetrator: None listed.Witnesses:CNA ADescription of the Allegation: Resident #1's roommate cusses at her and tries to make her clean up the bathroom. Assessment:7/13/25: Resident has no injuries. Provider Response: Resident #2 was placed on one-to-one monitoring immediately upon receiving report from Resident #1's family. Resident #1 was assessed for any injuries-none noted. Physician notified. Family, physician and psychiatry notified for Resident #2.Investigation Summary: Resident #1's family reported to LVN B, that they had been finding Resident #1 bathroom with bowel and urine on the floor and they had been bringing toilet paper because she had not had toilet paper and sometimes paper towels. LVN B notified the ADM via phone of the concern. The ADM later received a call from Family Member B stating what family had reported and added that Resident #2 had been yelling and cussing at Resident #1. LVN B was aware that one evening she heard raised voices and sent CNA A to see what was going on but nothing was ever reported to LVN B about cussing or demanding residents to het on her knees and clean up the bathroom. CNA A was suspended pending investigation and will be terminated for failure to report. Both residents lack capacity to make informed decisions. Room changes were done, and Resident #2 remained one to one until the room changes were done. Referral was made to the behavior center for Resident #2. No issues since Resident #2 does not have a roommate. Facility Investigation Findings: UnconfirmedProvider Action Taken Post-Investigation: Continue to monitor resident and re-education with staff on abuse, neglect and reporting procedures.Record review of CNA A's witness statement, dated 7/14/25, revealed: I was in the room talking to my nurse, LVN B, when I heard Resident #2 yelling and cussing, saying Get your fucking ass in that goddamn bathroom and clean up that mess right now. I'm sick of this shit. LVN B had asked me to go see who she was talking to. I walked to the door and saw Resident #1 standing in front of Resident #2. I motioned for Resident #1 to come out in the hall. I then told LVN B she was talking to Resident #1. LVN B then asked Resident #2 what was going on and Resident #2 stated Resident #1 had peed on the bathroom floor and had done it before, and she wanted her to clean it up. LVN B told Resident #2 that Resident #1 could not do that because she could fall. I had went to get a towel to clean up the urine and Resident #2 stated to me that Resident #1 needed to get on her hands and knees and clean that shit up because she was tired of her doing that. I had advised Resident #2 that Resident #1 was not able to do so. I told Resident #2 if it happened again for her to let me or any aide that is on the hall and we would clean it up. Resident #2 then told me as long as we keep babying her and not making her clean up her mess then she would never stop. I walked out of the room and nothing more was said. Record review of Resident #2's 1:1 monitoring supervision sheet, dated 7/13/25-, revealed:Resident #2 was on 1:1 monitoring from 7/13/25 at 9:49 PM until 7/14/25 [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that 1 of 8 residents (Resident #1) reviewed for quality of care was offered a therapeutic diet when there is a nutritional problem, and the health care provider ordered a therapeutic diet.On 6/27/25 the facility did not ensure Resident #1 received her physician ordered NPO diet Enteral Feed diet (a method of providing nutrition directly into the gastrointestinal tract) when CNA provided Resident #1 with a plate of puree food (chili dog on a bun, sauerkraut, tater tots, diced onions, assorted gelatin; pureed). An IJ was identified on 07/02/25 at 2:50 PM. The IJ template was provided to the facility on [DATE] at 2:50 PM. While the IJ was removed on 7/03/25 at 9:23 AM, the facility remained out of compliance at a scope of no harm and a severity level of isolated because all staff had not been trained on 7/03/25.This failure put residents at risk for health complications related to nonadherence to diet order. Findings included:Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old-female was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include cerebral palsy, Aphagia (inability or refusal to swallow), unspecified severe protein malnutrition, major depressive disorder, diaphragmatic hernia without obstruction and partial intestinal obstruction (abdominal organs moved through a hole in the diaphragm and are experiencing partial blockage in the digestive tract), dysphasia (difficulty swallowing food or liquids), dysarthria (weaken muscles of neck), moderate intellectual disability, and GERD (gastro esophageal reflux disease).Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C - Brief Interview for Mental Status score revealed a score of 06, which indicated the resident's cognition was severely impaired. Section K - Swallowing/Nutritional Status revealed while a resident, she utilized a feeding tube and she received 51% or more of her total calories through tube feeding at a rate of 501 cc/daily. Section V - Care Area Assessment (CAA) Summary:CAA Results: 13. Feeding Tube Record review of Resident #1's Care plan dated 5/23/25, revealed:Nutritional StatusFOCUS: Resident #1 was NPO had a peg tube and received her nutrition per physician orders via peg tube. (initiated 9/23/24 revised on 5/16/25)GOAL: Resident #1 would maintain ideal weight and receive proper nutrition daily. (initiated 9/23/24 revised on 5/16/25)INTERVENTIONS: Follow orders for PEG Feedings. (initiated 5/16/25) Record review of Resident #1's Care plan dated,5/26/25, revealed:Nutritional StatusFOCUS: Resident #1 had a peg tube and received her nutrition orally (Regular diet, pureed texture, and nectar consistency fluids). (initiated 9/23/25 revised on 7/01/25)GOAL: Resident #1 will maintain ideal weight and receive proper nutrition daily. (initiated 9/23/25 revised on 7/01/25)INTERVENTIONS: Follow PEG Orders for feedings (initiated 6/16/25) Record review of Resident #1's physician orders, dated 6/27/25, revealed NPO diet, NPO texture, NPO consistency. order date 4/28/2025 and Enteral Feed every 12 hours IsoSource 1.5 50 ml/hr x (over) 22 hours off from 1900-2100 (7pm-9pm) .order date 6/15/2025. Record review of Resident #1's Progress Notes dated, 3/30/25-7/01/25, revealed:RN W documented on 6/27/25 at 1:24 PM The chest x-ray of [Resident #1] came in and [Resident #]1 has pulmonary edema, and pneumonia. Notified the results to RR, FNP who ordered IV Rocephin 1 g daily for 5 days. RN W documented on 6/28/25 at 1:30 AM [Resident #1] was given food by the day CNA (cannot specified) and chest x-ray taken due to that although it came negative but showed Resident #1 has pneumonia and is on Rocephin. RN W administered Resident #1's first dose.Record Review of Resident #1's hospital records dated 4/26/2025 revealed Resident #1 Peg evaluation, Aspiration pneumonia (a lung infection that develops when food, liquids, or other foreign materials are inhaled into the lungs, causing inflammation and infection), dysphagia, has failed swallow evaluations.Record Review of Resident #1's hospital records dated 4/27/2025 revealed Resident #1 underwent EGD (procedure that uses a camera to examine the esophagus) with PEG placement on 4/23.20 French PEG placement (a feeding tube that is 20 inch in diameter) was successfully completed. Record review of Resident #1 hospital discharge orders revealed Diet: NPO.hydration/water.125ml/q4hrs.continuous tube feeding.Jevity 1.2.rate 60. Record Review of Resident #1's Xray report, dated 6/19/25, revealed Subtle patchy opacity (a faint or indistinct area of increased density) is seen in the right upper lung and left lower lung. This could be due to pulmonary edema (a condition where fluid builds up in the lungs, making it difficult to breathe), atelectasis (Complete or partial collapse of a lung or a section (lobe) of a lung) and/or pneumonia (an infection that inflames the air sacs in one or both lungs).Record Review of Resident #1's Xray report, dated 6/27/25 revealed Subtle patchy opacity (a faint or indistinct area of increased density) is seen in the right upper lung and left lower lung. This could be due to pulmonary edema (a condition where fluid builds up in the lungs, making it difficult to breathe), atelectasis (Complete or partial collapse of a lung or a section (lobe) of a lung) and/or pneumonia (an infection that inflames the air sacs in one or both lungs).Record review of Resident #1's dietary ticket, dated 6/27/25, revealed: NPO/PureeBeverage texture: NectarDuring an interview on 7/1/25 at 3:41 PM, Resident #1 only answered yes and no questions. She answered yes to receiving a tray on 6/27/25, consuming the food on the tray in its entirety, to the food being good and being able to consume the food without complication. She answered no to being in any pain and she stated no when asked was she to receive a tray on 6/27/25. During interviews conducted on 07/01/25 at 9:00 AM, the ADM stated CNA A gave Resident #1 a tray that contained pureed food. She stated CNA C reported the incident to RN W on 6/27/25. The ADM stated after investigating the incident, she found that the vendor that was used for dietary needs was implementing a system update which made it impossible to print the dietary tickets for the facility. She stated the system to print the tickets had never been down before. She stated the vendor had to print the dietary tickets for the facility and when the tickets were printed, Resident #1's, who was actively in NPO status, because she received her nutrition via PEG tube, ticket was printed and included with the remainder of the facility resident dietary tickets. She stated initially CNA C assumed Resident #1 received regular textured food because CNA C knew other residents received regular textured food. The ADM stated that she spoke with CNA A who stated that the food that she served Resident #1 was pureed and described it as that slurpee stuff. The ADM stated when she interviewed CNA A, she inquired what happened and she was told by CNA A that she read the ticket and was surprised because Resident #1 did not usually get a tray. The ADM stated CNA A stated she consulted with CNA B and CNA B told CNA A to leave the tray for Resident #1. The ADM stated Resident #1 received her PEG tube at the end of the April 2025, and since then, Resident #1 had been crying because she wanted to eat. The ADM stated she reported the incident to state because CNA C stated it was negligent and Resident #1 should not have received a tray of food because she was NPO. During an interview conducted on 07/01/25 at 9:10 AM, the DON stated Resident #1 had a PEG tube in place on 6/27/25. The DON stated Resident #1 had the PEG placed in April 2025 due to ongoing stomach issues and she was experiencing pain. The DON stated Resident #1 also had a history of pneumonia. The DON stated ever since the PEG placement, Resident #1 had been crying because she wanted to eat. The DON stated when Resident #1 received a tray on 6/27/25 and RN W was notified, he (RN W) notified facility management, RR, the MD and ordered an x-ray. She stated RN W reported to her that the x-ray did not have any significant findings. The DON stated that she was told by RN W that there were signs of pneumonia, but it was lingering pneumonia from a previous diagnosis. The DON stated Rocephin was ordered, and the first dose was given that night. The DON stated there were no signs of aspiration. The DON stated since 6/27/25, the orders for Resident #1 were changed and Resident #1 was actively able to consume food orally. She stated when Resident #1 consumed her meal, a staff sat with her and a nurse was present during the meal. During an interview conducted on 07/01/25 at 11:25 AM, CNA A stated on 6/27/25 they (she and CNA B) were passing out trays. She stated she received the tray for Resident #1. She stated it was not whole food. She described the food as food that you slurped up and it looked like baby food. CNA A stated that she did not believe a nurse checked the trays before the resident trays were brought to the hall. CNA A stated she looked at the dietary ticket for Resident #1 and remember seeing her name on the ticket, but did not remember seeing anything else. She stated after she saw that Resident #1 had a tray, she consulted with CNA B, and she was told by CNA B to leave the tray with Resident #1. CNA A stated she left the tray, but did not see her consume the food on the tray. She stated she did not know if Resident #1 consumed the entire tray of food or not because their shift did not pick up the trays. She stated the potential negative outcome was Resident #1 could have choked or died. She stated her nurse would have been LVN L, but LVN L did not bring the resident trays to the hall. CNA A stated that the dietary staff (did not know which one) brought the trays on 6/27/25. CNA A stated she was a newer staff and had been employed at the facility for about three weeks. She stated she had only been a CNA for a brief time. She stated she did not realize Resident #1 receiving the tray of food was an issue until the ADM called her the following day (6/28/25) and asked her about the incident. CNA A stated she was told that when she returned, she was instructed to give a statement. CNA A stated she gave Resident #1 the food because she did not know Resident #1 could not have food. She was unaware that she had a PEG tube for her nutrition. She stated she later found out Resident #1 had a PEG tube when the ADM called her. She stated there were no other residents with PEG tube placements. She stated she did not contact or consult a nurse. She stated after consulting CNA B, she thought it was ok. She stated CNA B had been with the facility longer than her. CNA A stated she did not have access to the facility's EMR/PCC at the time of the incident (6/27/25). She stated she just received access not to long before the interview but did not remember the exact date. She stated the facility process of checking the trays was the nurse would check the trays in the dining room. She stated dietary staff brought the trays to the hall normally. She stated they (CNAs) checked the dietary ticket for the name and served the tray. She stated on 6/27/25, she was floating between halls and not assigned to any hall. She stated she had been trained that NPO meant nothing by mouth, and she would know if someone was NPO if the resident had a feeding tube.During interviews conducted on 07/01/25 at 12:18 PM, CNA B stated NPO meant the resident could not be fed by mouth. CNA B stated she was never officially told that Resident #1 was NPO, but she assumed she was because Resident #1 never received a tray since she had worked at the facility. She stated she had worked at the facility for at least a month. CNA B stated there were no other residents in the facility that were NPO status. CNA B stated she was unaware that Resident #1 received a tray on 6/27/25. She stated she found out about the incident on 6/28/25 when she was asked who gave Resident #1 a tray. She stated the night/evening staff picked up the tray and that was how they (nighttime staff) found it. CNA B stated she worked with CNA A on 6/27/25. She stated CNA A did not consult her (CNA B) about giving Resident #1 the tray. CNA B stated she could not recall telling CNA A anything about leaving the tray for Resident #1. She stated at the time of the incident she did not receive any additional training or instruction about Resident #1 or about any residents that could not eat. She stated they (staff that worked 6/28/25) were told that Resident #1 was not to receive a tray on 6/27/25. CNA B stated she was unsure if the tray was checked by a nurse on 6/26/25. She stated she could not remember who the nurse was on 6/26/25. She stated the facility process for administering the trays to the resident during mealtimes was the nurse should check the trays in the dining room but not the trays on the hall. CNA B stated she had never had any issues with the trays being wrong on the halls. She stated the staff from dietary brought the resident trays from dining room to the halls to serve to the residents that eat in their rooms. She stated it was different staff each time, but always dietary staff. During interviews conducted on 07/01/25 at 1:23 PM, DA P stated he had been trained that NPO was nothing by mouth. He stated he knew a resident was NPO based off the dietary ticket. He stated if a resident was NPO, they (residents) should not have a dietary ticket. He stated if the saw on a ticket conflicting information he was unsure what to do. He stated he was not present on 6/27/25 when Resident #1 received a tray. He stated the facility process for distributing resident trays was the nurse checked the tray. He stated they (dietary staff) was not to serve until a nurse was in the dining room. He stated the nurse was to take the trays to the hall for the residents that eat in their room. He stated in the dining room, the nurse checked the tray and handed it to the CAN and the CNA would then distribute to the residents. He stated he was unsure if the CNAs were checking in addition to the nurse checking. During interviews conducted on 07/01/25 at 12:18 PM, DA Q stated NPO was nothing by mouth. He stated they (dietary staff) knew when a resident was NPO because it should say it on the resident's dietary ticket. He stated if he saw a diet texture and NPO on a ticket he would contact a charge nurse so that they (dietary and clinical staff) could figure it out together. DA Q stated he was not working on 6/27/25 and was unaware that Resident #1 had a PEG tube. He stated the facility process for distributing trays to residents was the nurse would sometimes check the tray before. He stated the nurses sometimes were busy. He stated there were times when the CNA would grab the tray and go. He stated, the majority of the time, the nurse checked the tray before distribution. He stated the trays that went to the halls were checked half the time. He stated he was unsure what the nurses checked for on residents' trays. During interviews conducted on 07/01/25 at 1:51 PM, the DM stated NPO meant nothing by mouth and the dietary staff know because if there was a change, then the nurse would send the dietary department a communication form so that the dietary cards were updated. The DM stated whether they (residents) eat their food or not each resident should have a dietary card. She stated if the resident was NPO then they (residents) should not have a dietary card. She stated when they (dietary staff) print out the dietary cards Resident #1's card did not normally print out when they (dietary staff) printed them out. She stated she was unsure why when the vendor printed the dietary tickets for them (dietary staff) Resident #1 had a dietary card to print out. She stated on 6/27/25, during breakfast and lunch, she assisted the dietary staff with ensuring that all residents received the appropriate diet. She stated the vendor printed the tickets out for supper, she handed the dietary tickets to the dietary staff, and did not check the tickets for accuracy. She did not have a reason she did not check the tickets. She stated she did not think about checking the tickets for accuracy. She stated she left at 5:00 PM on 6/27/25 and was not present when the dietary staff prepared Resident #1 tray. She stated [NAME] T would have been the only staff that she would have thought that did not know that Resident #1 did not consume food orally. She stated DA R, and DA S would have known Resident #1 did not consume food orally because they had worked at the facility for a while. She stated once they (dietary staff) saw the ticket they (dietary staff) should have questioned the ticket. She stated the ticket first went to the cook who would place the entre on the plate. The DM stated that the cook was looking for the texture and should be checking the dietary ticket in its entirety. The DM stated then the plate goes to the first dietary aide who was added things such as vegetables and any other sides. The DM stated the first dietary aide was continuing the correct texture that was listed on the ticket and should also be checking the dietary ticket in its entirety. She stated each dietary staff would have had the opportunity to identify on Resident #1's ticket that she was NPO. The DM stated the dietary staff should have consulted with the charge nurse on 6/27/25 when they (dietary staff) observed a diet texture and the status of NPO listed. The DM stated then the last part of the plating process was the last/second dietary aide would add things such as drinks, bread, and desserts. They (dietary staff) would hand the tray to the nurse or place it on the cart for the tray to go to the hall. She stated the second dietary aide should also be checking the dietary ticket in its entirety. The DM stated Resident #1 had never received a tray while on NPO status. The DM stated they (the facility) had never had issues with their system before. She stated when she gave the dietary workers the dietary tickets, she was unaware Resident #1 had a ticket. The DM stated the potential negative outcome for serving Resident #1 a tray, when she was not supposed to, was that she could have choked, aspirated, and possibly died. The DM stated she was unsure if Resident #1's tray was checked on 6/27/25. The DM stated she expected the residents to receive the correct meal on their ticket and if they (residents) were not to have a meal, then they (residents) should not receive one. The DM stated she was never at the facility for dinner because she left at 5:00 PM daily. She stated she was present during breakfast and lunch, and she normally observed dietary staff checking the dietary tickets and nurses checking the trays before distribution to the residents. During interviews conducted on 07/01/25 at 2:37 PM, [NAME] T stated he worked on 6/27/25, but he did not know specifically who Resident #1 was until after she was served and management addressed them (dietary staff). He stated he was new and was at the beginning of the plating process. He stated after him the plate would go through, two other workers and then a CNA would check it. [NAME] T stated he did not remember reading Resident #1's ticket. He stated he normally looks at the texture but did not remember seeing NPO on Resident #1's ticket. [NAME] T stated he was told/trained by the DM that NPO meant that the resident could not receive anything by mouth and received their nutrition by tube. [NAME] T stated even if he had seen NPO he may not have done anything different because he was not made aware of the NPO status until after the incident. He stated he was trained on NPO and the incident the day after the incident before his shift started. He stated he recently learned that he was to look at the entire dietary ticket. [NAME] T stated he knew to ask questions if he needed to, and would, moving forward. [NAME] T stated he was still new and stated he honestly could not tell the difference between the CNAs or the nurses as he was a newer employee. [NAME] T stated he had only worked at the nursing facility for 2-3 weeks. During interviews conducted on 07/01/25 at 2:39 PM, LVN L stated she knew what NPO was and that it meant nothing by mouth. She stated she knew that a resident had the status of NPO when it was listed in the residents' chart. She stated they (facility staff) were also told during shift change if a person received a new order of NPO. She stated the staff would have access to NPO information in the EMR. LVN L stated she was unaware that Resident #1 had been given a tray by CNA A because she did not remember which CNAs worked on 6/27/25, and she was not told that Resident #1 received a tray. She stated on 6/28/25 she received the information during shift change in report from RN W. She stated RN W stated that Resident #1 received a tray. LVN L stated she did not monitor the dining room on 6/27/25 during dinner time. She stated she monitored breakfast, and Resident #1 did not receive a tray during breakfast on 6/27/25. She stated LVN O would have been the other nurse on duty. She stated she was unaware if he was in the dining room, or if the dining room trays were checked before the resident trays went to the hallway. She stated that there were only two nurses on duty, and they (LVN L and LVN O) were training other nurses that day. LVN L stated she had never seen Resident #1 consume food or receive a tray. LVN L stated she did not receive any specialized training because of the incident. She stated the facility process for distributing resident trays was once the tray came off the line, the nurse checked the ticket against the tray for accuracy. She stated the nurse was checking to make sure the resident had the correct diet texture. She stated then they (nurses) gave the tray to a CNA to distribute. LVN L stated the cook for that day was new and she remembered the system that dietary used was down, but she did not have much information about it. LVN L stated she was aware that Resident #1 had a PEG and was NPO. She stated Resident #1 had a PEG tube because she had stomach issues, but she was unsure of the details and specifics. She stated when she checked the ticket, she checked the dietary ticket in its entirety for the correct resident and diet details. During interviews conducted on 07/01/25 at 3:16 PM, DA R stated NPO meant the resident could not have anything by mouth. He stated they (dietary staff) knew when a resident was NPO because the nurses told them (dietary staff), and it would indicate the information on the dietary ticket. He stated he knew Resident #1 did not eat and knew who she was. DA R stated he was aware that Resident #1 was NPO. He stated he observed her ticket on 6/27/25 and saw she was to receive a pureed tray and that was why he was served one. DA R stated their cook (Cook T) was new but since he made the plate for Resident #1, he assumed that it was ok. DA R stated he was unsure if the trays were checked by a nurse but did not remember seeing a nurse. DA R stated the facility process in distributing trays was the nurse was to check the tray before it was served to the resident. He stated on 6/27/25, he took the tray to the Hall were Resident #1 resided and this was because they (dietary staff) did not see a nurse. He stated once he took the cart to the hall, it would have been the nurse's aides to serve the trays to the residents. He stated that when it was time to serve meals, the dietary staff announced the mealtime over the loudspeaker. He stated he had not received any additional training regarding the incident. He stated when he checked the dietary ticket, he looked at the ticket in its entirety. He stated he did not see the word NPO on the ticket on 6/27/25. During interviews conducted on 07/01/25 at 4:50 PM, RN W stated NPO meant nothing by mouth and the resident was not allowed to have anything by mouth. He stated that he knew a resident was NPO because of the MAR, EMR, or PCC. He stated he was aware that Resident #1 was NPO. RN W stated he worked the night shift on 6/27/25. He stated he was notified by CNA C that Resident #1 hit her call light for her tray to be picked up. RN W stated CNA C reported that the tray was empty when she picked up Resident #1's tray. RN W stated when he went to see Resident #1, he observed red Kool-Aid on her face. He stated he notified management, the MD, and the RR. He stated the MD ordered an x-ray. He stated the x-ray was completed and it showed that she had lingering pneumonia but no signs of aspiration. RN W stated Resident #1 had pneumonia in the past and had received treatment, so the MD ordered IV Rocephin and he administered the medication the night of 6/27/25. He stated when he started his shift on 6/27/25 at 6:00 PM, LVN L gave him report and it did not include any information about Resident #1 receiving a tray of food. RN W stated he would not have been responsible for any meal monitoring because when he arrived at the facility, dinner would have already started as it started at 5:00 PM. He stated the evening/night shift were only responsible for passing out snacks and picking up dinner trays if there were any left. He stated when he reported the incident to the DON, the DON told him she would educate the staff. RN W stated he immediately verbally educated his staff on what NPO was and the importance. During an interview on 7/01/2025 at 10:24am with Resident #1's Guardian, she stated she had received a call during the weekend and was told Resident #1 had been served a tray of food although she was NPO. She stated Resident #1 had been placed on NPO after a PEG placement due to recurrent GI issues and recurrent aspiration pneumonia. She stated Resident #1 had not had any food since she had the PEG tube placed and had a decrease in quality of life, but as of 6/30/2025, Resident #1 had the PEG tube removed by hospice and was allowed pleasure feedings. During an interview on 7/01/2025 at 4:51 pm with the MD, he stated he had been made aware of the incident that occurred on 6/27/2025 with Resident #1, and from his understanding, there had been no complications from the incident. He stated he expected the staff at the facility to follow the diet orders for each resident. He stated the potential negative outcome of Resident #1 receiving the incorrect diet could have been aspiration pneumonia). The MD stated Resident #1 had a diaphragmatic hernia and the PEG tube had been placed because Resident #1 was having reflux (referred to the backward flow of stomach contents into the esophagus), and there were concerns about possible aspiration. The MD stated he had spoken to the ADM (unknown date) and the ADM would be ensuring all the diet orders were reviewed for accuracy with the kitchen staff and with the floor staff. The MD stated after speaking with Resident #1's guardian, they decided Resident #1 would have the PEG tube removed.During interviews conducted on 07/02/25 at 12:55 PM, the DON stated if the vendor's system was to stop working again, the facility intended to address the issue by ensuring the dietary staff knew to report the issue to the DM, DON, and ADM. She stated once they (management staff) were notified, they (DON/ADM) would work with the DM and dietary staff comparing the diet orders in the EMR/PCC to what the dietary staff had. She stated on 6/27/25, there were two nurses on duty, and they (LVN L and LVN O) were training two new nurses. She stated if there were three nurses then they (nurses on duty) would have split the mealtimes equally (1 nurse per mealtime). She stated if there would have been two nurses then they (nurses on duty) should have had one meal monitoring per nurse and split the dinner meal to monitor. She stated the nurses should have communicated to ensure monitoring for dinner was conducted by a nurse on 6/27/25. She stated on 6/27/25, there was no specific nurse assigned to dinner mealtime monitoring. She stated the nurses that were on duty (not the nurses that were being trained) would have been responsible. She stated it would have been between LVN L and LVN O who would have been responsible for monitoring the dinner mealtime. She stated the facility process was that nurses assigned to certain halls had specific meals that they (nurses on duty) were responsible for. The DON stated on 6/27/25, Resident #1 should not have received a tray of food, and should not have had a dietary ticket. She stated at the time, the dietary or clinical staff noticed that Resident #1 received a dietary ticket or there was a discrepancy on her dietary ticket they (the dietary and clinical staff) should have notified the DM and or a charge nurse. The DON stated the DM should have checked the dietary tickets for accuracy before giving the dietary tickets to the dietary staff. The DON stated that she did not see Resident #1's dietary ticket, but was told by the DM that the ticket indicated Resident #1 was NPO and could receive a pureed diet texture. The DON stated when there was conflicting information, the staff had been trained to verify with a charge nurse. The DON stated Resident #1 was NPO on 6/27/25. The DON stated Resident #1 had her PEG tube placed in April 2025 because she had aspiration pneumonia in the past. It was determined that it was safest if she had the PEG placed. The DON stated Resident #1 had dysphasia. She stated Resident #1 was once on mechanical soft and because she was having difficulty swallowing, she was moved to pureed. The DON stated when Resident #1 would consume the mechanical soft, she would have increased coughing. The DON stated Resident #1 even vomited a few times. The DON stated all the staff had been trained by her, the ADM, and the DM except for some of the nighttime shift. She stated the nighttime shift would be trained before they (nighttime shift) were allowed to work their shift. The DON stated she was familiar with the facility's policies related to dietary services and residents receiving the correct prescribed therapeutic diet. She stated the purpose of having the correct diet and having a policy for therapeutic diet was for resident safety and to prevent choking. She stated the potential negative outcome for not following the policies, or ensuring the residents have the correct diet, was the resident could choke or aspirate. She stated that residents could potentially not receive the nutrition they (residents at the facility) needed and could experience weight loss. The DON stated, on 6/27/25, she was unaware that Resident #1 had received a tray of food while she was ordered to be NPO. She stated she was unaware that CNA A was not following the physician order for Resident #1. She stated the system to monitor or ensure that staff were following the physicians order for diets, was once the MD ordered the diet, then it was entered in the EMR/PCC. The nursing staff then reported the change to dietary via communication form. She stated the CNAs were informed because the information was accessible in the EMR/PCC. She stated she and her staff had been trained regarding residents receiving the correct diet per physicians' orders. She stated she expected for all staff to follow the physician orders and for all residents to receive their meal as ordered by the physician. The DON stated the reason Resident #1 received the tray when she was not supposed to was because the vendor generated a dietary ticket, and the tray was not checked. She stated the dietary staff, and clinical staff should have asked the nurse about any discrepancies. The DON confirmed that CNA A had access to the facility EMR/PCC as of 6/24/25. During interviews conducted on 07/02/25 at 2:50 PM, the ADM stated if the system that dietary used to print dietary tickets goes down again, they (the ADM, DON, and DM) would ensure to check all tickets printed from the vendor for accuracy. The ADM stated on 6/27/25 one of the charge nurses on duty would have been responsible for monitoring the dinner mealtime. She stated it would have been between LVN L and LVN O. The ADM stated that the nurses would have known who was responsible for the meal monitoring based off the scheduling system created by the DON and ADON. The ADM stated, on 6/27/25, what should have happened was at the moment the staff observed Resident #1 had a dietary ticket and that it had a diet texture and listed as NPO, they (the clinical and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #4) reviewed for elopement. The facility failed to supervise Resident #4 while he was outside smoking. When the gate opened on 12/05/2024, Resident #4 was able to exit through the gate and leave the grounds. An Immediate Jeopardy situation was determined to have existed on 12/05/2024. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance on 12/05/2024 before the beginning of the survey. This failure could place residents at risk for serious injury, harm, impairment, or death. Findings included: Record Review of Resident #4's facesheet dated 12/10/2024 revealed that Resident #4 was initially admitted to the facility on [DATE] with a readmission on [DATE]. Resident #4 had a medical history of neuroleptic induced parkinsonism (condition that occurs when antipsychotic drugs cause parkinsonism like symptoms such as tremors and rigidity ), dementia with behavioral disturbance (loss of thinking, remembering, and reasoning with behavioral changes including agitation, aggression, wandering, delusions, hallucinations, depression often impacting their quality of life), schizoaffective disorder bipolar type (is a rare mental illness that combines schizophrenia symptoms with bipolar disorder symptoms of highs and lows), amnestic disorder (memory loss), schizophrenia (mental health condition that affects everything from how you think to how you feel and behave), anxiety disorder (feeling of fear, dread, and uneasiness), mild intellectual disability (deficits in intellectual functions pertaining to abstract/theoretical thinking), extrapyramidal and movement disorder (a group of movement disorders that CNA occur as a side effect of certain drugs particularly antipsychotics ), ataxia (impaired coordination, CNA be due to damage to brain, nerves, or muscles), borderline intellectual functioning (difficulty adapting to changes or learning new skills), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #4's MDS dated [DATE] revealed, Section C- Cognitive patterns revealed a BIMS score of 00 which indicated Resident #4 had a severe cognitive impairment. Record review of Resident #4's care plan dated 07/22/2019 revealed focus: **MENS SECURE UNIT** Resident #4 is at risk for wandering due to cognitive loss and has exit seeking behavior related to parkinson's and dementia. He currently resides on the secured unit related to high risk of elopement. Revision on 07/13/2023. Goals: Resident #4 will not leave facility unattended through the review date. Date initiated 07/22/2019, revision on 10/31/2019, target date 12/29/2024. Interventions/Tasks: Assess for fall risk 11/14/2019. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date initiated 11/14/2019, revision on 11/14/2019. Identify pattern of wandering: is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it include the need for exercise? Intervene as appropriate. Date initiated, 07/22/2019. If Resident #4 is exit seeking, stay with him, and notify the charge nurse by calling out, sending another staff member, call system, etc. Date initiated 07/22/2019, revision 08/08/2019. Monitor for fatigue and weight loss. Date initiated 07/22/2019. Monitor for resident messing with his window in his room. Date initiated 10/10/2020. Resident #4 resides on the male secure unit. Date initiated 01/02/2020. Resident #4 will reside in the secure unit. Date initiated 12/06/2024. Focus: **Smoker Alert** Resident #4 is a smoker. Safe smoking assessment completed; Resident #4 able to safely smoke supervised. Smoking materials to be kept at the nurses station. Date initiated 7/22/2019, revision 12/06/2024. Goal: Will smoke in designated areas without occurrence of injury of the next 90 days. Date initiated 07/22/2019, revision on 10/31/2029. Target Date 12/29/2024. Interventions/Tasks: 1. Perform smoking assessment according to facility policy. Date initiated 08/06/2019. 2. Explain/Show where designated smoking areas are, and smoking times-repeat as needed. Date initiated 08/06/2019. 3. Monitor when smoking to assure resident safety. Date initiated 08/06/2019, revision on 12/06/2024. 4. Keep all smoking materials at nurses station. Date initiated 08/06/2019. 5. Gather all smoking supplies after smoking time is completed, he saves his cigarette butts to take to his room, assist him in disposing of them properly. Date initiated 10/23/202, revision 12/06/2024. Focus: Actual elopement or elopement attempt. Resident #4 was confused and wandered outside the facility unattended. Dated initiated 12/05/2024, revision on 12/06/2024. Goal: Will remain safe in the facility with no further elopements or elopement attempts, unless accompanied by staff or other authorized person through review date. Date initiated 12/06/2024. Target date 12/292024. Interventions/Tasks: Directly supervise resident while smoking. Date initiated 12/06/2024. Provide structural activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date initiated 12/05/2024. Distract Resident #4 from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, books. Date initiated, 12/05/2024. If Resident #4 is exit seeking, stay with the resident, and notify the charge nurse by calling out, sending another staff member, call system, etc. Date initiated 12/05/2024. Record review of Resident #4's elopement risk assessment dated [DATE] reveals Resident #4 is an elopement risk with a score of 25 out of 28. Elopement risk assessment dated [DATE] revealed a score of 27 out of 28 which reveals elopement risk. Record review of Resident #4's safe smoking assessment dated [DATE] revealed: A. Evaluation: 6. Resident #4 is unable to enter door code to get to designated smoke area. B. Summary: 2. This resident requires direct supervision while smoking. 5. Care Plan up to date or updated. Safe smoking assessment dated [DATE] revealed: A. Evaluation: 6. Resident #4 resides on the secure unit and is unable to access it independently. 12. Trouble using fine motor skills. B. Summary: 2. This resident requires direct supervision while smoking. 4. All smoking materials will be kept at the nurses station. 5. Care plan up to date or updated. 6. The evaluation has been discussed with the resident. Record review of progress notes for Resident #4 dated 12/05/2024 revealed: Event- Elopement/Attempted: Blood pressure 146/74, Temperature 97.8, Pulse 81, Respirations 22. Door exited: smoke door on D Hall. How long missing: unknown. Where was the resident discovered: off campus. Code Orange was initiated. Injuries: No. Cognition/Behavior at time of event: Cognitive impairment, paces, wanders. CNA's alerted nurse that resident was outside smoking and is now missing. Initial Treatment/New Orders: No. Resident Statement: I went for a walk. Physician and family notified. Interventions: Resident #4 placed back on the secure unit. During an interview on 12/11/2024 at 8:55 AM, the ADM stated that on Tuesday 12/03/2024, the facility became aware that the secured door on Hall A was not locked. The ADM reported that she called the repair company at that time, and they arrived that evening. ADM stated that the repair company was able to remotely tell them what to do to get the door back locked and secure. The repair company came back on Wednesday 12/04/2024 to continue to work and troubleshoot the problem. On Thursday 12/05/2024, ADM stated that the repairman was in her office at the time of the event. ADM stated that the worker was telling her that everything was secure at this time, but they would have to make arrangements for staff to monitor the Chapel door and two gates that evening because he was going to have to leave that circuit disengaged, due to him having to wait on a part that was being shipped. The worker reported that the Chapel Door circuit was losing voltage and affected two gates. During their conversation, RN called a Code Orange and reported that Resident #4 was missing. ADM reported that there were three staff on the unit when the incident happened. Resident #4 is the only resident that smokes on Hall D secured unit. The CNA A reported that the gate was closed when she let Resident #4 go out. ADM reported that she went to check the gate and reported that when it was disengaged it swung open. ADM stated that the Code Orange was called at 3:40 PM and the resident was located at 3:54 PM. ADM reported that HR located the resident in an alley, approximately a half a mile from the facility. ADM reported that the repair company basically replaced the whole system. ADM stated they had staff at the facility all weekend monitoring the doors and gates, and that she still had staff checking the doors, stating that she was no longer just going to rely on the system. ADM stated that the facility completed elopement assessments on every resident. ADM stated they had also changed their smoking policy to all residents have to have direct supervision when smoking. During an interview on 12/11/2024 at 10:00 AM, RN stated that on 12/05/2024 that she entered Hall D Secure Unit to check on the residents and to see if the CNA's needed anything. RN stated that when she got back there she sat down by CNA B, and then CNA A and HA came in from outside. RN stated that when HA was leaving she asked her to check on a resident that she thought was sick, and CNA A was checking on another resident that was up without assistance. RN stated she left the unit at that time, then a few minutes later, RN went back to the unit to tell CNA A and CNA C to get some clothes ready for a resident they were going to send out. RN stated around 3:40 PM that CNA C notified her that while she was on break, that one of the CNA' let Resident #4 go out and smoke, and now they cannot find him. RN stated she immediately called a Code Orange and made assignments. RN stated that she had not seen Resident #4 outside, and the staff did not report to her that he was outside. RN stated she thought CNA A and HA had just gone out to vape on their own. RN stated when they got Resident #4 back to the facility, that she completed a full head-to-toe assessment with no injuries noted. RN stated that Resident #4 reported he had just gone for a walk. RN stated she notified the family and reported that they were happy he was able to go for a walk and hoped he had enjoyed it. RN stated that they had immediate in-services, and now all smokers have to be directly supervised, and the care plans have been updated. During an interview on 12/11/2024 at 10:53 AM, HR stated that when she heard the Code Orange, she left her office to see who it was. HR stated after checking around the facility that she got in her car. HR stated that she knew Resident #4 did not like commotion or being around a lot of people and did not think he would stay around the main roads. HR stated that she drove around the back of the facility, where there is an open field that leads to a remote residential/business area. HR stated that she located Resident #4 shuffling down an alley. HR asked Resident #4 if he wanted to get in the car and go for a ride. HR stated that Resident #4 stated no and then swung a hand in a downward motion, indicating for her to go away. HR stated that she called the ADM who came to the area. HR stated that ADM got out and went to talk to Resident #4, asking him if he wanted to get a hamburger and a milkshake, Resident #4 stated he did. HR stated they were able to get him in the car, and they went to the drive through at a fast food establishment. HR stated that Resident #4 just wanted a coke. HR stated that Resident #4 indicated he was tired when they asked him how he was. HR stated that she googled the location, and it was 1.2 miles driving, but Resident #4 was probably only about half a mile the way he went. HR stated the staff have a secure app on their phones for communication, and notifications started coming in immediately. HR revealed that she had been in-serviced on the Code Orange, Elopement Protocol, and Supervised Smoking. Observation on 12/11/2024 at 11:20 AM, HR accompanied me to the main smoking area that is off of the main dining room. The Chapel is in the back left corner of the main dining room. HR had to put in the code to the side door for us to enter the smoking area. From the back of the fence, the gate to Unit D secured smoking area was able to be visualized and was closed. There is a large vacant field behind the facility, which leads to a residential/business section. HR verbalized and pointed out the road she was on while looking for Resident #4. During an interview on 12/11/2024 at 12:20 PM, the ADON stated the facility has been doing a lot of education and follow-up. ADON stated that CNA A is a brand new CNA. The ADON reported that CNA A got called away to assist with another resident. ADON stated that the department heads were at the facility all weekend checking doors and the gates. ADON also reported that facility staff are continuing to check the doors to be sure they are secured. During an interview on 12/11/2024 at 12:51 PM, CNA A stated that she has been certified for about a month and a half. CNA A stated that her residents are like her family, and that she was so glad that Resident #4 was not hurt. CNA A stated that she had just returned from her break, and that her partner, CNA C then left the unit for her break. CNA A stated Resident #4 was wanting to go smoke, but stated she did not have a lighter, then HA came on the unit and CNA A asked her if she had a lighter. CNA A stated that HA left the unit to find a lighter, and when she got back, CNA A asked HA if she wanted to hit her vape before she left. CNA A stated they went outside, and she lit Resident #4's cigarette. CNA A stated that Resident #4 likes to walk over and stand at the turtle sanctuary that is in the back corner of the secured smoking area. CNA A stated that she and the HA were standing by the door, then HA stated she needed to leave. CNA A asked Resident #4 if he was ready to come in, and he said he was not ready. CNA A stated that she told Resident #4 to come to the door when he was ready to come in, and that she would be watching for him. CNA A stated she knows the gate was closed when they were outside. CNA A stated that when they went back in, that HA was leaving and hollered at her to come help with a resident that was up without assistance. CNA A stated that when she heard that, it was just instinct to run to go assist so that resident did not fall. She also reported that HA had notified RN that she was concerned that another resident needed to be checked because HA thought he was sick. CNA A stated that after they got that resident in bed, she heard another resident holler out. CNA A stated she had to go assist him or he will go to the bathroom in the floor. CNA A stated by that time CNA C had returned from her break, and that the RN asked them to get some clothes packed for a resident they were going to send out. CNA A stated that when they were in that resident's room getting clothes packed, she looked out the window and did not see Resident #4. CNA A stated that she figured Resident #4 was at the door ready to come in, but when she got to the door, he was not there, and the gate was open. CNA stated she went out and looked out the gate and did not see him. CNA A went inside and told CNA C that she could not locate Resident #4. CNA A stated they looked in all the rooms and closets and could not find him. CNA C notified RN who then called the Code Orange and protocol started. CNA A stated that no one had told her they were working on the gates, otherwise, I would not have let him go outside. CNA A stated that when she was being trained and she was working on her hours, that staff would just let Resident #4 go out and smoke, stating that he will be ok, the gate is locked. CNA A stated that Resident #4 will never be outside alone again. CNA A revealed that she had been in-serviced on the Orange Code, Elopement Protocol, and Supervised Smoking. During an interview on 12/11/2024 at 3:21 PM, CNA B stated that she was told to go cover Unit D while CNA C went on her lunch break. CNA B stated that when she got back to the unit, she asked CNA A what she needed to do, and CNA A reported that she had just completed her rounds. CNA B stated that at that point she sat down in a chair just outside the common area. CNA B stated that Resident #4 was wanting a light. CNA B stated that HA came on the unit and was talking to CNA A, and then the RN came in the unit and CNA B stated she was talking to her. CNA B stated that she did not see Resident #4, CNA A, and HA go outside. CNA B stated that while she was talking to the RN, that the other two girls came in and they were all four talking. CNA B stated that when HA was leaving, that HA hollered for CNA A to come assist with a resident, and that HA also notified RN about a resident that she thought might be sick. CNA B stated she was walking off the unit because she saw that CNA C was back on the unit. CNA B stated she went to the nursing station to work on some documentation, and she had four residents to document on. CNA B stated that when the Code Orange was called she had one more resident to chart on. CNA B stated that she cleared her halls she was assigned to, then went outside. Stated she saw CNA A and CNA C outside by a fence, stating that CNA A looked really upset. Stated that the ADON came out and told them someone needed to go back to the unit. CNA C stated she did not want to leave CNA A alone. CNA B stated that she would stay with her, and then CNA A took off running. CNA B stated that she was following her, then she fell and did not CNA A any longer. CNA C stated at that point she went back into the facility, and when she got to the nursing station she heard that they had located Resident #4. CNA B stated that she has been in-serviced on elopement and resident supervision of residents while smoking. During observation on 12/11/2024 at 5:00 PM, Investigator left facility and drove the route that HR had reported she had taken to locate Resident #4. Observed a large vacant field behind the facility. The area contains a residential area, including an apartment complex, with a couple of places of business. Area was remote with no traffic during drive through. During an interview on 12/12/24 at 9:10 AM, ADM stated that Resident #4's care plan stated supervision, which meant that the resident was just to be visually seen, and they were observing from the windows. ADM stated staff have been in-serviced and all residents that smoke have to be directly supervised, meaning the staff have to be outside with the residents. If it is found out that a resident is not being directly supervised, it is automatic termination. ADM stated they have been making observations to make sure staff is complying. ADM stated that she guessed if she would have had someone at the doors and gates while the repair company was here, that this probably would not have happened. ADM stated that CNA C clocked back in on 12/05/2024 at 3:00 PM, and that HA had clocked out at 3:03 PM on 12/05/2024. ADM stated their policy for notifying the police is 30 minutes. ADM stated she was in the process of getting information on what Resident #4 was wearing so she could call them, but Resident #4 had been located prior to her making that call. During an interview on 12/12/2024 at 9:35 AM, the DON came into the Conference Room and had CNA C on the phone. Phone interview with CNA C revealed that on 12/05/2024, she had returned from her lunch break around 3:00 PM. CNA C stated she entered Unit D and she saw RN, CNA A, CNA B, and HA on the other end of the hall. CNA C stated that she had gotten about halfway down the hall when HA hollered for CNA A that a resident was walking without assistance. CNA C stated that CNA A came down the hall to assist with that resident, then another resident was hollering out and CNA A went to check on him. CNA C stated that the RN had instructed them to get some clothes ready for a resident they were sending out. CNA C stated as she and CNA A were getting clothes packed, that is when CNA A stated that Resident #4 was outside smoking, so CNA A went to go check on him. CNA C stated that she heard CNA A yelling he was not out there, stating CNA A was hysterical. CNA C stated she was trying to calm her down and voiced for them to check the closets in all the rooms, because Resident #4 likes to hide sometimes. CNA C stated that they could not locate Resident #4, so she notified RN. CNA C stated that CNA A was being pulled in all directions, and she was just trying to do the right thing. CNA C reported that when she was being trained on the unit, that the staff would let Resident #4 go out to smoke and was told to just keep an eye on him. CNA C stated that now all residents are direct supervision for smoking, and if staff fails to do that, it is automatic termination. CNA C voiced that Resident #4 paces often and he will shadowbox, stating he will swing at you. During an interview on 12/12/2024 at 2:40 PM, the DON stated that they were monitoring smoking times to make sure staff is directly supervising. If staff is found not to be directly supervising, that employee will be immediately terminated. DON reported that the ADM had sent surveys to all of the employees earlier regarding elopement protocol and supervision, stating they all answered correctly. During a phone interview on 12/12/2024 at 2:45 PM, HA stated that on 12/5/2024 that she was getting ready to leave the facility for the day. HA stated that CNA A and her are good friends, so she went back to Hall D secure unit to let her know that she was leaving. HA stated when she got to the unit that CNA A asked her if she had a lighter. HA stated she did not, so she went out of the unit to find a lighter. When she got back, CNA A asked her if she wanted to go out and hit her vape before she left. HA stated that she, CNA A, and Resident #4 stepped outside. CNA A lit Resident #4's cigarette and then he walked to where the turtles are. HA stated after a few minutes she told CNA A that she needed to go, so she stepped inside, and CNA A was asking Resident #4 if he was ready to go in, and he was not ready. HA stated her and CNA A went in, and she saw RN and CNA B sitting in chairs just outside the common area. HA stated when she was leaving she saw a resident who was walking without assistance and yelled for CNA A to come help. HA stated that she saw another resident that she thought might be sick, so she told the RN who went in to check on him. HA stated when they got the other resident settled back in bed, she left the unit. HA stated she was suspended, has been in-serviced on elopement, and direct supervision of residents when they are outside smoking. Observation on 12/12/2024 at 4:35 PM, Resident #4 ambulated out of his room. Investigator introduced self and asked how he was doing. Resident #4 made eye contact but did not engage in conversation. His stance appeared as if he was ready to bolt. Staff walked up and talked with Resident #4. Resident #4 pointed to medication cart and stated he wanted some water. Resident #4 with steady gait followed staff to get water. Observation on 12/11/24 at 8:45 AM front entrance door was locked. Investigator rang doorbell and staff member approached door to enter code. During an interview on 12/11/2024 at 9:50 AM, MDS Nurse revealed that she had been in-serviced on Code Orange drills, Elopement Protocol, and Supervised Smoking. MDS Nurse stated that she helped with the door watches. During an observation on 12/11/2024 at 11:47 AM, Investigator put in the code to Secure Hall D. The alarm sounded upon entering unit and stopped when the door was closed. The alarm goes off when entering and exiting the unit. Resident #4 was resting in bed with eyes closed. The door that goes out to the smoking area also requires a code, and it was working. During an observation on 12/11/2024 at 11:55 AM, Investigator put in the code to Secure Hall C. The alarm sounded upon entering unit and stopped when the door was closed. The alarm goes off when entering and exiting the unit. The same thing occurred when leaving the Secure Hall C unit. The door was working. Record review on 12/11/2024 reviewed the Plan of Correction: Interventions put into place to prevent reoccurrence dated 12/05/2024, the document Self-Reporting Protocol/ Ad Hoc QAPI- Missing Resident or Elopement, Elopement Prevention QA Check List dated 12/05/2024 at 4:30 PM, 6:30 PM, 9:30 PM. 12/06/24 at 1:00 PM and 5:45 PM. 12/7/2024 at 1:00 AM, 3:30 PM, 7:30 PM. 12/08/2024 2:30 PM. Record review of in-service: Smoking Policy: If resident is unsupervised while smoking it will be an automatic termination, dated 12/05/2024 with 57 staff member signatures. Record review of in-service: Elopement Response: Codes are on the back of name badge. If it is not, notify HR for a new name tag. Code Orange is called if an employee discover a resident is missing from the facility. Undated with 59 staff member signatures. The following policy reviewed: Smoking Policy, Resident admission Packet, revised 11/01/2017. Smoking policies must be formulated and adopted by the facility. The policies must comply with all applicable codes, regulations, and standards, including local ordinances. The facility is responsible for enforcement of smoking policies which must include at least the following provisions: 2. A safe smoking assessment will be done regularly for each resident who smokes. Smoking by resident classified as unsafe will be prohibited except when the resident will be directly supervised by facility personnel or visitors who are aware of the resident's limitations with smoking. 3. If the facility identifies the resident needs assistance/supervision and/or additional protective devices for smoking, the facility includes this information in the resident's care plan, and reviews and revises the plan periodically as needed. The following policy reviewed: Elopement prevention dated 2003, revised 10/27/2010. Policy Statement: Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. 1. Physical Plant: All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts. The following policy reviewed: Elopement Response dated 2003, revised 10/27/2010. Policy statement: Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented. Policy Interpretation and Implementation: 2. C. A resident must demonstrate a free willful intent to leave the facility without prior notification of staff or is a wandering, confused resident who leaves the facility unattended. 7. Post return resident evaluation and care: C. The facility will evaluate its elopement prevention program and all residents will be reassessed for elopement. The ADM was notified on 12/12/2024 at 11:45 AM, that a past non-compliance IJ situation had been identified to the above failures. It was determined these failures placed Resident #4, in an IJ situation on 12/05/2024. These failures have the potential to affect all residents residing in the Secure Unit. The facility implemented the following interventions to prevent reoccurrence: Medical Director was notified of the elopement on 12/05/2024 at 4:30 PM. All exit doors and gates were checked by the Administrator on 12/05/2024 at 4:45 PM for proper alarming and functioning. No issues were identified. Repair company was in the facility on 12/05/2024 to assess power voltage. Repair company returned to the facility on [DATE] to continue assessment and repairs around 8:00 AM and repairs were completed around 12:30 PM. On 12/05/2024 staff were posted at the exit doors and gates until repair company completed all repairs. Elopement risk assessments were completed on all residents. Staff were in-serviced on 12/05/2024 on elopement response protocol and smoking policy by DON/Designee. All staff not present will be in-serviced prior to their next scheduled shift by DON/Designee. On 12/05/2024 an AD Hoc QAPI meeting was held with the medical director, facility Administrator, Director of Nurses, and Social Services Director to review the plan of correction. Monitoring: On 12/06/2024 the facility will monitor exit and gates for functioning 5x per week for 4 weeks, and prn thereafter to identify any potential future failures. On 12/06/2024 the DON/Designee will monitor resident smoke breaks for staff supervision 5x a week for 4 weeks and, then prn thereafter. On 12/06/2024 the DON/Designee will monitor elopement risk assessments to ensure completion 5x per week for 4 weeks, then prn thereafter. Interviews, observations, and record reviews confirmed that staff have been in-serviced on direct supervision of residents who smoke and elopement protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to immediately inform the physician and/or Resident/Responsible Party (RP) when there was a need to alter treatment for 1 of 5 residents reviewed for notification of changes. (Residents #1) - The facility failed to notify the physician that Resident #1 had an elevated blood sugar of 501. An IJ was identified on 02/25/23 at 5:02 PM. The IJ template was provided to the facility on [DATE] at 5:05 PM. While the IJ was removed on 02/26/23 at 1:24 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of not having notifications made for health-related issues and could hinder resident treatment. Findings included: Review of Resident #1's face sheet revealed he was an [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of dementia and a secondary diagnosis of type 1 diabetes. Review of Resident #1's admission MDS, dated [DATE], revealed his BIMS was 09, suggesting that the resident's cognitive was moderately impaired. Review of Resident #1's 48-hour baseline care plan, dated 02/20/23, revealed that diabetes management had not been care planned. Review of Resident #1's physician's orders dated 02/27/23 revealed the following order was written on 02/17/23: HumaLOG Subcutaneous Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 59 Give OJ ; 60 - 150 = 0 units; 151 - 200 = 2 units; 201 -250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units; 451+ Call physician, subcutaneously four times a day for diabetes-related to Type 2 Diabetes Mellitus with unspecified diabetic retinopathy . Record Review of Resident #1's admission Medical Records, dated 02/15/22, listed diabetes mellitus and diabetic retinopathy as active problems and past medical problems. Record review of Resident #1's admission note, dated 02/18/23, revealed the resident had the a diagnosis of diabetes. Record Review of the Investigative worksheet for intake # 408693 revealed the following: On 2/23/23 [Resident #1] was eating feces and throwing up what appeared to be feces. [LVN H] got orders for a KUB, but the family requested he go out to be evaluated. [LVN H] canceled the KUB and called Non-Emergency transport resident to ER. After calling non-emergency transport,[ LVN H] got a blood sugar of 501 and did not administer insulin per sliding scale orders. [LVN H] reports she reported to EMS that he had a blood sugar of 501 and she had not administered insulin. It was reported that when he arrived to the ER his blood sugar was in the 700s but EMS reported 400s. Record review of Resident #1's progress notes dated 02/23/23, entered by LVN H, revealed the following: LVN H at 11:00 AM spoke with Resident #1's family about sending him out to the ER. LVN H checked Resident #1 blood sugar, and it was 501. The note reflected she reported to the transportation staff his blood sugar and that she had not given him insulin. The progress note reflected the MD Representative was notified that Resident #1 was going to the ER because the family wanted him to and that the KUB would be canceled. The progress note did not specifically indicate the MD Representative was notified of the blood sugar level of 501. Record review of Resident #1 Medication Administration Record, dated 02/25/23, revealed the Resident #1's blood sugar was documented as 149 on 02/23/23 at 07:00 AM which did not require any units of the sliding scale insulin to be given according to the physician's orders. Resident #1's blood sugar was documented as 501 on 02/23/23 at 11:00 AM. The record reflected no documented evidence Humalog subcutaneous solution 100 unit/ML was as administered. Record review of the MD standing order, dated 01/29/21, revealed the following documentation: 10. Sliding Scale insulin greater than 451 10 units , recheck in 30 minutes, if no significant improvement call the physician. On 02/25/23 at 2:31 PM an observation of 5 Humalog insulin injection 100/ml dated 02/21/23 for Resident #1 located in the medication storage room refrigerator. Attempted to obtain hospital records on the following dates and times: 03/01/23 at 4:15 PM and on 03/03/23 at 11:28 PM. An Interview was conducted on 02/25/23 at 10:39 AM LVN J said Resident #1 had not been at the facility for a long time. He said he came in the morning of the incident (02/23/23) to help with coverage. He said his blood sugar was 149 that morning when he checked it. He said Resident #1 did have behaviors where he was smearing feces between 6 AM and 7 AM that morning. He said he addressed the behavior by contacting the MD Representative and getting an order for a medication to calm him. LVN J said that his shift ended and that he left the facility at 8:45 AM. He said he completed all treatments for all of the resident's assigned to him. He said he gave report to the oncoming nurse. He said he specifically reported to LVN H about Reisdent #1's behaviors. He stated Resident #1 was calm and resting in bed when he left. He said Resident #1's blood sugar ran high 300 to 400 regularly. He said they normally had to give him his coverage (sliding scale insulin). He said it was important to always follow the sliding scale. He said there were times when they did not give insulin, but it was because they were following the sliding scales or an actual order from the physician. He said a potential negative outcome was a resident could go into a diabetic coma. He stated during that, the resident was at risk of organ failure and also at risk of becoming septic (the body's extreme response to infection). He said blood sugar was fragile because it could quickly transition either way. An Interview was conducted on 02/25/23 at 10:58 AM LVN I said she did not have any specific information regarding the incident with Resident #1 but that as a nurse the sliding scale is always followed. She said the MD is notified if a resident's blood sugar is above the parameters or below what is listed in the orders. She said when notifying the MD she should receive additional instructions to treat the information she reported. An Interview was conducted on 02/25/23 at 11:09 AM, the Administrator stated LVN H is new. She said she was told by LVN H on 02/24/23 that she did not give the insulin because Resident #1 had not eaten and was throwing up. When asked why she reported the incident as neglect, she said when the MD Representative called and reported that she had not been notified that Resident #1 blood sugar was 501 and the insulin should have been given, she took it that the MD representative was alleging that the resident had not been adequately taken care of. She said after interviewing LVN H, the nurse did well with notifying the family, the MD Representative, and the transport staff. She said she expected the nursing staff to follow all physician orders. An Interview was conducted on 02/25/23 at 11:57 AM the MD Representative said she was the MD's nurse and was the equivalent of notifying the doctor. She said LVN J called first on 02/23/23 (time not disclosed) and wanted an order for Ativan to settle him down because he was exhibiting behaviors. She said she was told he was digging in his brief and painting the walls with his feces. She said LVN H called her later on 02/23/23 (time not disclosed) and told her she thought he was vomiting feces, which sounded like a bowel obstruction . The MD Representative said LVN H never mentioned that Resident #1 had an elevated blood sugar. The MD Representative said she was concerned that LVN H called an ambulance agency and not EMS or 911. The MD Representative said if notified, she would have told LVN H to go by the sliding scale and notified the doctor about the elevated blood sugar. She said the facility had standing orders that instructed the staff to notify the MD if the blood sugar was outside the sliding scale parameters. She said Resident #1 would have continued to be confused without insulin administration. She said if a blood sugar exceeded 451, they were to give 10 units of short-acting insulin but was not for sure because she did not have the orders in front of her at the time of the interview. She stated there is a standing order at the facility. She stated none of that was done that she was aware of. When asked what the potential negative outcome would be for not administering the insulin to a resident with an elevated blood sugar, she said it was hard to answer because it can be different individually. She said some people lose consciousness or can experience metabolic acidosis due to diabetes. She said acidosis could affect several body parts, such as the kidneys and mental status. She said it could build up toxins in the body. She said the elevated blood sugar could have caused the vomiting. She said LVN H should have known to treat the blood sugar. She said the lack of insulin contributes to the admitting diagnosis. She said if they had given his insulin, that would have started the blood sugar coming down but doing nothing did not help the resident. The MD representative said that she was not notified about Resodent #1 blood sugar level until after his admission in the hospital. She said that she had limited access to the hospital medical recor and this is how she was aware that the resident's blood sugar was at 749 when he arrived at the hospital. An Interview was conducted on 02/25/23 at 1:57 PM, LVN H stated she had been a nurse since 1990 and had been trained in dealing with residents with diabetes. She said she took over Resident #1 from LVN J around 10:15 AM or 10:30 AM on 02/23/23 She stated she was told by LVN J that Resident #1 had been throwing up and had not had breakfast. She said LVN J reported Resident #1's blood sugar was 147 at 7:00 AM that day. LVN H said it was reported to her that Resident #1 vomit appeared like poop. She stated she observed Resident #1's vomit. She stated it was dark and resembled coffee grounds. She stated she notified Resident #1's family. She said the family wanted Resident #1 to go the ER. She said she checked Resident #1 insulin between 11:15 AM and 11:20 AM. She stated his blood sugar was 501. She stated she notified the MD Representative shortly after she checked the blood sugar. She stated she was still determining the exact time but believed it was 7 to 8 minutes after she took the resident blood sugar is when she called and notified the MD representative of Resident #1 blood sugar level. When asked what the representative said when she told her about the elevated blood sugar, she said the representative said, Oh, okay. She said she had already called the non-emergency transportation before she checked Resident #1 blood sugar. She said she is unsure why she called the non-emergency transportation vs. the emergency transportation. She said at that time she did not think it was an emergency. She said Resident #1 family was okay with her not giving the insulin. She said it seemed like the non-emergency transportation was taking a long time, so she called them twice. She said the resident waited 40- 45 minutes. She said she checked his blood sugar because the family had requested it, but because it would have been the scheduled time to check it. She said it was her decision not to administer the insulin. She said she was afraid that he would bottom out. She said Resident #1 had not had any food that day and that it concerned her. When asked to explain bottom out, she said that happens when a resident's blood sugar exceeds 60. She said the physician must be the one to determine whether insulin should be held if the resident's blood sugar is outside of the parameters of the sliding scale. She said she further told the MD Representative she was holding the insulin and canceling the KUB . She said she told the MD Representative she was sending Resident #1 out because of his vomiting and she had concerns about bowel obstruction. She stated when Resident #1 was picked up by the non-emergency transportation she told them he had a blood sugar level of 500 and that she had not given him the sliding scale insulin. She stated in hindsight that she should have given the insulin and at blood sugar levels of 501 and that was a dangerous level and should have been an emergent situation but that she did not call 911 because the non emergency transport said they were near the facility. Record review of the facility's policy, Glucometer, revised 02/13/2007, revealed the following documentation: Abnormal Results 1. Notify the physician if the blood glucose is outside of any physician-specific parameters and implement any new orders prescribed. Record review of the facility's policy, Guidelines for notifying Physicians of Clinical Problems , dated 02/2014, revealed the following: Overview These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record. When contacting the practitioner, especially at night and on weekends the nurse should have the following information available: 1. Detailed description of current issues or problems, including a chronological story story of symptoms and treatment to date, On 02/25/23 at 5:02 PM, the Administrator was notified that the facility would be placed in immediate jeopardy status due to failure to administer Resident #`1 sliding scale insulin when the resident blood sugar was outside the parameters . Record Review of the POR submitted by the Administrator revealed the following: 02/25/2023 Plan of Removal- Quality of Care Interventions: 100% blood sugar audit in progress Physician will be notified of all blood sugars outside the parameters The following in-services were initiated 02/24/2023 by Admin: Any nurse not present or in-serviced on 2/25/23 will not be allowed to assume their duties until in-serviced: o Following facility policy for hypoglycemia located in the Glucometer policy: o Following facility policy for hyperglycemia located in the Glucometer policy: o Staff in-service on utilization of SBARs and E-transfers (SBAR includes change of condition, notification to physician/family, and new orders if applicable) o Staff in-service on following physician orders and not deviating from orders unless directed by physician. · Notify the physician if the blood glucose is outside of any physician specific parameters and implement any new orders as prescribed. o In-Service nursing staff that any transport going to the emergency room will be 911. There will be no non emergent transports when going to the emergency room. · Abnormal Results-see glucometer policy · If the resident is unresponsive, notify emergency medical services. Notified Medical Director of IJ situation on 2/25/23 at 6:06 PM. Monitoring: ADMIN/ADON/Regional Compliance/Designee will review 5-8 residents sliding scale results for proper notification to MD if outside parameters weekly x 4 weeks. ADMIN/ADON/Regional Compliance/Designee will monitor all blood sugars outside parameters of sliding scale for notification to MD weekly x 4 weeks. Regional Compliance Nurse will review ADMIN/DON/Designee for monitoring compliance weekly x 4 weeks. The QA Committee will review findings and Physician Notification Policy and will make changes as needed monthly. On 03/26/23, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Record review of Resident #2 electronic medical record conducted and revealed there were no discrepancies for sliding scale insulin orders. Record review of Resident #3 electronic medical record conducted and revealed there were no discrepancies for sliding scale insulin orders. Record review of LVN H's Certificate of Completion , dated 02/24/23, reflected she had a satisfactory completion of Preparing and Administering insulin. Record review of LVN H Certificate of Completion , dated 02/24/23, reflected she had a satisfactory completion of Insulin Administration. Record review of the facility's signature sheet and in-service, High and Low Blood Sugars CNA Protocol, dated 02/26/23, reflected the in-service instructed CNAs were instructed to monitor the resident's baseline and notify nurses of any change in symptoms. Record review of the facility's signature sheet and in-service, Emergency vs. Non-Emergency Transportation, dated 02/26/23, reflected the in-service instructed facility staff that if any resident was being sent to the emergency room for any reason, then 911 emergency transport should be used. Record review of the facility's signature sheet and in-service on hyperglycemia, dated 02/25/23 reflected the several factors that could contribute to hyperglycemia in people with diabetes. It listed early symptoms and unrelated symptoms such as headache, blurred vision, frequent urination, and fatigue. It listed the negative outcomes if hyperglycemia was untreated. The outcomes included abdominal pain, shortness of breath, fruity-smelling breath, coma, nausea and vomiting, dry mouth, weakness, and confusion. An Interview was conducted on 02/26/23 at 3:39 PM, LVN F said she had received additional training before she was allowed to work. She reported if a resident's blood sugar were outside of the sliding scale parameters, she was trained to contact the physician and follow the physician's orders. She said she was trained to stay within the physician's orders. She said if she reports concerns regarding a resident, she has been trained to document the response of the MD. She stated if the resident's elevated blood sugar is not addressed, it can result in a coma. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/26/23 at 3:23 PM the MD said he was not notified about the elevated blood sugar until after the resident was already admitted to the hospital. He said he was told that he was not notified because transportation was already there to pick up the resident. He stated he could not remember who notified him and when they notified him but that he was notified after the resident was admitted into the hospital. He said if he had been notified he would have instructed the staff to follow the sliding scale . He said without giving insulin, there is increased confusion. In addition, he said it places the resident at risk for dehydration, infection, and renal failure. He said even if the resident has not eaten, he would have instructed the sliding scale insulin to be given because, with elevated blood sugar at 500, there is no concern that it will go too low. An Interview was conducted on 02/26/23 at 3:39 PM LVN F said she was not allowed to work until she was in-serviced. She said she was never trained to go outside the physician's orders. She said she was trained to report the information to the MD and wait for additional instructions if blood sugar levels were outside the sliding scale parameters. She said she was competent in the facility's expectations regarding blood sugars, MD notification, following physician's orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/26/23 at 3:58 PM, RN C said she had received additional training before being allowed to work. She said she would never deviate outside of physician's orders. She said emergency transportation should be used if a resident needed to go to the emergency room. She said elevated blood sugars outside of the sliding scale ranges should be reported to the physician for additional instructions. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/27/23 at 9:31 AM LVN D said she had been trained prior to work about blood sugar expectations. She said she were supposed to notify the MD if there are concerns with blood sugar levels. She said she was to never deviate outside the physician's orders for any reason. She said if physician's orders are not followed, the worst that could happen would be the resident could go into a coma and die. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/27/23 at 9:39 AM LVN C She said she was trained before working her shift. She said she was instructed but already knew to stay within the physician's orders. She said blood sugar levels outside the sliding scale parameters should be reported to the physician. She said if the physician did not respond appropriately with clear, concise instructions, she would clarify to ensure she was heard. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/27/23 at 9:50 AM, LVN B said she was trained before her shift about the importance of blood sugar levels. She said they were trained to notify the MD if the blood sugar level was too high or too low. She said if a resident has to go to the ER, non-emergency transport should not be used. She said she is required to document the response of the MD when they notify them of a change in the resident's condition. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An interview was conducted on 03/09/23 at 11:19 AM with LVN H. When asked why she did not document her conversation in detail with the MD representative specifically about notification of the blood sugar, she said: Things were happing so fast, and at the moment I was like, oh ok She said at that time she did not think to ask further information or clarification on what to do When asked had she been trained before the incident to document detailed notifications of MD instructions she said as a nurse she had been trained but not specifically by the facility. She said she was unaware of their process at that time for documentation. When asked about her experience as a nurse, what has she been taught about information that was not documented, and what does that mean? She said it would mean it was not done. A negative outcome could be not following the doctor's orders or knowing what was said. She said she was trained to contact the MD representative Monday-Friday 8-5, and then the MD Representative would contact the MD or the MD assistant. She said she was trained not to contact the MD directly. She said she was unaware that standing orders were available at the facility. She said at the previous facility, she was trained not to use the standing orders and to still notify the physician. An interview was conducted on 03/09/23 at 11:28 with the Administrator. When asked what her expectation of documentation of notifications was, she said they would document if there were any new orders and follow up with the orders. When asked about her experience as an administrator and what she was taught regarding information that is not documented and she said if it was not documented, it was not done. She said she did send the phone records of LVN H to HHSC but clarified that those records would not indicate the content of the calls. She said that based on the progress note entered in the electronic medical chart provided to the surveyor, she would not be able to tell if the MD was notified of the elevated blood sugar. She said that the MD was notified that day but not before leaving. She said that she expected the MD to be notified before the resident went to the ER. An interview was conducted on 03/09/23 at 11:47 AM with the MD representative. She said on 02/23/23, LVN H did not give her a detailed description of Resident #1 current issue with elevated blood sugar. She said the facility has standing orders is what the facility has on hand and what they have on anyone so that the MD does not have to call for everything. She said in the previous interview when she said she would have instructed LVN H to give the 10 units; she knew this exact amount because the facility has a standing order for sliding scale insulin, and that is what should have been followed on 02/23/23 when Resident #1 blood sugar was elevated to 501. When asked which order should be followed if the standing order differs from what is in the resident's electronic medical record, she said that the orders shouldn't have been different. She said the sliding scale order had been the same for a long time. She said she was not sure who entered the information on the facility. She said she does not review the orders once given to the facility. An interview was conducted on 03/09/23 at 6:08 PM with the MD, and when asked for clarification about the sliding scale order for Resident #1, he said that the sliding scale order should have been the same as the standing order. He said he did not know why the order on the computer would be different. He said the only reason the standing order would not match what was in the electronic medical record would be if the resident was under a different doctor and then came to the doctor. He said he was the attending doctor, and the orders should have matched. He said his standing order for sliding scale insulin was any blood sugar level over 451, 10 units would have been given, and after 30 minutes, if there were no changes, he should have been notified. On 02/25/23 at 5:06 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/26/23 at 4:14 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviews, and interviews, the facility failed to ensure that its residents are free of any significant medication errors for one (Resident #1) of five residents reviewed for medication review. 1.LVN H failed to give Resident #1 sliding scale insulin when his blood sugar levels were noted at 501, greater than the 451 listed in the physician's orders. As a result, resident #1 blood sugar level continued to increase from 501 to 749, contributing to his emergency admission diagnosis of DKA. An IJ was identified on 02/25/23 at 5:02 PM. The IJ template was provided to the facility on [DATE] at 5:05 PM. While the IJ was removed on 02/26/23 at 1:24 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure placed the resident at risk of elevated blood sugars and potential risk for worsening conditions, including metabolic acidosis (production of too much acid in the body) and or death. Findings include: Review of Resident #1's face sheet revealed he was an [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of dementia and a secondary diagnosis of type 1 diabetes. Review of Resident #1's admission MDS, dated [DATE], revealed his BIMS was 09, suggesting that the resident's cognitive was moderately impaired. Review of Resident #1's 48-hour baseline care plan, dated 02/20/23, revealed that diabetes management had not been care planned. Review of Resident #1's physician's orders dated 02/27/23 revealed the following order was written on 02/17/23: HumaLOG Subcutaneous Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 59 Give OJ ; 60 - 150 = 0 units; 151 - 200 = 2 units; 201 -250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units; 451+ Call physician, subcutaneously four times a day for diabetes-related to Type 2 Diabetes Mellitus with unspecified diabetic retinopathy . Record Review of Resident #1's admission Medical Records, dated 02/15/22, listed diabetes mellitus and diabetic retinopathy as active problems and past medical problems. Record review of Resident #1's admission note, dated 02/18/23, revealed the resident had the a diagnosis of diabetes. Record Review of the Investigative worksheet for intake # 408693 revealed the following: On 2/23/23 [Resident #1] was eating feces and throwing up what appeared to be feces. [LVN H] got orders for a KUB, but the family requested he go out to be evaluated. [LVN H] canceled the KUB and called Non-Emergency transport resident to ER. After calling non-emergency transport,[ LVN H] got a blood sugar of 501 and did not administer insulin per sliding scale orders. [LVN H] reports she reported to EMS that he had a blood sugar of 501 and she had not administered insulin. It was reported that when he arrived to the ER his blood sugar was in the 700s but EMS reported 400s. Record review of Resident #1's progress notes dated 02/23/23, entered by LVN H, revealed the following: LVN H at 11:00 AM spoke with Resident #1's family about sending him out to the ER. LVN H checked Resident #1 blood sugar, and it was 501. The note reflected she reported to the transportation staff his blood sugar and that she had not given him insulin. The progress note reflected the MD Representative was notified that Resident #1 was going to the ER because the family wanted him to and that the KUB would be canceled. The progress note did not specifically indicate the MD Representative was notified of the blood sugar level of 501. Record review of Resident #1 Medication Administration Record, dated 02/25/23, revealed the Resident #1's blood sugar was documented as 149 on 02/23/23 at 07:00 AM which did not require any units of the sliding scale insulin to be given according to the physician's orders. Resident #1's blood sugar was documented as 501 on 02/23/23 at 11:00 AM. The record reflected no documented evidence Humalog subcutaneous solution 100 unit/ML was as administered. Record review of the MD standing order, dated 01/29/21, revealed the following documentation: 10. Sliding Scale insulin greater than 451 10 units , recheck in 30 minutes, if no significant improvement call the physician. On 02/25/23 at 2:31 PM an observation of 5 Humalog insulin injection 100/ml dated 02/21/23 for Resident #1 located in the medication storage room refrigerator. Attempted to obtain hospital records on the following dates and times: 03/01/23 at 4:15 PM and on 03/03/23 at 11:28 PM. An Interview was conducted on 02/25/23 at 10:39 AM LVN J said Resident #1 had not been at the facility for a long time. He said he came in the morning of the incident (02/23/23) to help with coverage. He said his blood sugar was 149 that morning when he checked it. He said Resident #1 did have behaviors where he was smearing feces between 6 AM and 7 AM that morning. He said he addressed the behavior by contacting the MD Representative and getting an order for a medication to calm him. LVN J said that his shift ended and that he left the facility at 8:45 AM. He said he completed all treatments for all of the resident's assigned to him. He said he gave report to the oncoming nurse. He said he specifically reported to LVN H about Reisdent #1's behaviors. He stated Resident #1 was calm and resting in bed when he left. He said Resident #1's blood sugar ran high 300 to 400 regularly. He said they normally had to give him his coverage (sliding scale insulin). He said it was important to always follow the sliding scale. He said there were times when they did not give insulin, but it was because they were following the sliding scales or an actual order from the physician. He said a potential negative outcome was a resident could go into a diabetic coma. He stated during that, the resident was at risk of organ failure and also at risk of becoming septic (the body's extreme response to infection). He said blood sugar was fragile because it could quickly transition either way. An Interview was conducted on 02/25/23 at 10:58 AM LVN I said she did not have any specific information regarding the incident with Resident #1 but that as a nurse the sliding scale is always followed. She said the MD is notified if a resident's blood sugar is above the parameters or below what is listed in the orders. She said when notifying the MD she should receive additional instructions to treat the information she reported. An Interview was conducted on 02/25/23 at 11:04 AM RN B said she did not have any specific information regarding Resident #1 but blood sugar levels are very serious, and nursing staff must make sure they are giving insulin orders as prescribed because it could affect the resident to the point of placing them in a coma. However, she said there is no reason not to give the insulin if it is prescribed. An Interview was conducted on 02/25/23 at 11:09 AM, the Administrator stated LVN H is new. She said she was told by LVN H on 02/24/23 that she did not give the insulin because Resident #1 had not eaten and was throwing up. When asked why she reported the incident as neglect, she said when the MD Representative called and reported that she had not been notified that Resident #1 blood sugar was 501 and the insulin should have been given, she took it that the MD representative was alleging that the resident had not been adequately taken care of. She said after interviewing LVN H, the nurse did well with notifying the family, the MD Representative, and the transport staff. She said she expected the nursing staff to follow all physician orders. An Interview was conducted on 02/25/23 at 11:35 AM, RN A said he did not have any information regarding Resident #1. She stated however, when asked if there is any instance where an elevated blood sugar would not be treated if the blood sugar is showing to be 500 or more, he said he would have given the prescribed sliding scale insulin because the blood sugar is at 500, and at that level, the resident could go into DKA. He said that is risky for the resident and could result in death. An Interview was conducted on 02/25/23 at 11:57 AM the MD Representative said she was the MD's nurse and was the equivalent of notifying the doctor. She said LVN J called first on 02/23/23 (time not disclosed) and wanted an order for Ativan to settle him down because he was exhibiting behaviors. She said she was told he was digging in his brief and painting the walls with his feces. She said LVN H called her later on 02/23/23 (time not disclosed) and told her she thought he was vomiting feces, which sounded like a bowel obstruction . The MD Representative said LVN H never mentioned that Resident #1 had an elevated blood sugar. The MD Representative said she was concerned that LVN H called an ambulance agency and not EMS or 911. The MD Representative said if notified, she would have told LVN H to go by the sliding scale and notified the doctor about the elevated blood sugar. She said the facility had standing orders that instructed the staff to notify the MD if the blood sugar was outside the sliding scale parameters. She said Resident #1 would have continued to be confused without insulin administration. She said if a blood sugar exceeded 451, they were to give 10 units of short-acting insulin but was not for sure because she did not have the orders in front of her at the time of the interview. She stated there is a standing order at the facility. She stated none of that was done that she was aware of. When asked what the potential negative outcome would be for not administering the insulin to a resident with an elevated blood sugar, she said it was hard to answer because it can be different individually. She said some people lose consciousness or can experience metabolic acidosis due to diabetes. She said acidosis could affect several body parts, such as the kidneys and mental status. She said it could build up toxins in the body. She said the elevated blood sugar could have caused the vomiting. She said LVN H should have known to treat the blood sugar. She said the lack of insulin contributes to the admitting diagnosis. She said if they had given his insulin, that would have started the blood sugar coming down but doing nothing did not help the resident. The MD representative said that she was not notified about Resodent #1 blood sugar level until after his admission in the hospital. She said that she had limited access to the hospital medical recor and this is how she was aware that the resident's blood sugar was at 749 when he arrived at the hospital. An Interview was conducted on 02/25/23 at 12:36 PM, the Hospital RN said Resident #1's admitting diagnosis was DKA. He said the lack of insulin could contribute to the diagnosis. He said the failure to give the resident insulin would allow his blood sugar to rise, which can become very dangerous for the resident. He said he was not clear on the surrounding events that led Resident #1 to be admitted , but it was his understanding that there was no insulin available at the facility that he resided at. He said the resident blood sugar level was noted as 749 when he was admitted . He said the sliding scale insulin is vital to prescribed residents because it means the long-lasting insulin is not enough, and they need the sliding scale insulin to maintain. He said with a blood sugar as high as 500 there should have been no concerns with his blood sugar going too low. He stated when a resident reaches the level of DKA it becomes complex to treat. He said DKA is treated with an IV drip and requires constant insulin and hourly monitoring because during the process the resident is at high risk of going either way regarding blood sugar levels. He said in his experience, even if a resident has not eaten when blood sugars reach that level, then the sliding scale insulin should be given, and the physician notified. He said to have high blood sugar it is odd that the resident's blood sugar was elevated. He said failure to give the sliding scale insulin at such elevated blood sugar levels could cause at the very worst DKA, coma, or death, but that it can also cause vomiting. An Interview was conducted on 02/25/23 at 12:46 PM, the Hospital MD said she was not the admitting MD but had treated Resident #1 since he had been at the hospital. She said it is her understanding that Resident #1 was given long-acting insulin but not his sliding-scale insulin and when he arrived his blood sugar level was 749. She said his admitting diagnosis (DKA) was the only issue they found since he was hospitalized . She said there were no signs of infection. However, she said with his diagnosis of dementia and the medications he is on could cause constipation and that may have explained the vomiting. She stated in her experience she would have encouraged giving the sliding scale insulin even if he had not eaten because the high blood sugar needed to be addressed. When asked about the potential negative outcome of not giving insulin, she said, He could end up in a condition the way he is now and how he came to us. She said he came in with elevated blood sugar which required him to be admittted to medical ICU and on an insulin drip that focused on lowering his blood sugar to safer levels. An Interview was conducted on 02/25/23 at 12:53 PM Family Member A said she was aware that Resident #1 did not have insulin given to him and that his blood sugar tested high. She said she was told by Family Member B the reason the insulin was not given was that the nurse ( LVN H) did not want to interfere with the treatment that the ER would give. An Interview was conducted on 02/25/23 at 12:56 PM, Resident #1 said he did not know why he was at the hospital. He was unable to answer any questions that were asked accurately. He was not oriented to time and place. An Interview was conducted on 02/25/23 at 1:33 PM Family Member B said she was aware Resident #1 was admitted to the hospital with the diagnosis of DKA, and she knew Resident #1 was not given his sliding scale insulin. She said she was told by LVN H that she did not administer any insulin because she did not want to interfere with the treatment the EMS workers would give. She said the facility knew Resident #1 was a brittle diabetic . She said during admission she explained he needed his blood sugar checked at least 4 times a day. She said he never became acclimated to the nursing facility, which was traumatic for him. She said Resident #1, waited 45 minutes for transportation to the ER from the time his blood sugar was tested until he was picked up from the facility. An Interview was conducted on 02/25/23 at 1:57 PM, LVN H stated she had been a nurse since 1990 and had been trained in dealing with residents with diabetes. She said she took over Resident #1 from LVN J around 10:15 AM or 10:30 AM on 02/23/23 She stated she was told by LVN J that Resident #1 had been throwing up and had not had breakfast. She said LVN J reported Resident #1's blood sugar was 147 at 7:00 AM that day. LVN H said it was reported to her that Resident #1 vomit appeared like poop. She stated she observed Resident #1's vomit. She stated it was dark and resembled coffee grounds. She stated she notified Resident #1's family. She said the family wanted Resident #1 to go the ER. She said she checked Resident #1 insulin between 11:15 AM and 11:20 AM. She stated his blood sugar was 501. She stated she notified the MD Representative shortly after she checked the blood sugar. She stated she was still determining the exact time but believed it was 7 to 8 minutes after she took the resident blood sugar is when she called and notified the MD representative of Resident #1 blood sugar level. When asked what the representative said when she told her about the elevated blood sugar, she said the representative said, Oh, okay. She said she had already called the non-emergency transportation before she checked Resident #1 blood sugar. She said she is unsure why she called the non-emergency transportation vs. the emergency transportation. She said at that time she did not think it was an emergency. She said Resident #1 family was okay with her not giving the insulin. She said it seemed like the non-emergency transportation was taking a long time, so she called them twice. She said the resident waited 40- 45 minutes. She said she checked his blood sugar because the family had requested it, but because it would have been the scheduled time to check it. She said it was her decision not to administer the insulin. She said she was afraid that he would bottom out. She said Resident #1 had not had any food that day and that it concerned her. When asked to explain bottom out, she said that happens when a resident's blood sugar exceeds 60. She said the physician must be the one to determine whether insulin should be held if the resident's blood sugar is outside of the parameters of the sliding scale. She said she further told the MD Representative she was holding the insulin and canceling the KUB . She said she told the MD Representative she was sending Resident #1 out because of his vomiting and she had concerns about bowel obstruction. She stated when Resident #1 was picked up by the non-emergency transportation she told them he had a blood sugar level of 500 and that she had not given him the sliding scale insulin. She stated in hindsight that she should have given the insulin and at blood sugar levels of 501 and that was a dangerous level and should have been an emergent situation but that she did not call 911 because the non emergency transport said they were near the facility. Record review of the facility's policy, Glucometer, revised 02/13/2007, revealed the following documentation: Abnormal Results 1. Notify the physician if the blood glucose is outside of any physician-specific parameters and implement any new orders prescribed. Record review of the facility's policy, Guidelines for notifying Physicians of Clinical Problems , dated 02/2014, revealed the following: Overview These guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record. When contacting the practitioner, especially at night and on weekends the nurse should have the following information available: 1. Detailed description of current issues or problems, including a chronological story story of symptoms and treatment to date, Record Review of the facility's policy, Nursing Care of the Resident with Diabetes Mellitus, dated 05/07/23 revealed: Glucose Monitoring (1) The management of individuals with diabetes mellitus should follow physician's orders. .(5) Approximate reference ranges for hypoglycemia (high blood sugar) are: 1. Mild hypoglycemia 55-70 mg/dl 2. Moderate hypoglycemia 40-55 mg/dl 3. Severe hypoglycemia <40 mg/dl. On 02/25/23 at 5:02 PM, the Administrator was notified that the facility would be placed in immediate jeopardy status due to failure to administer Resident #`1 sliding scale insulin when the resident blood sugar was outside the parameters . Record Review of the POR submitted by the Administrator revealed the following: 02/25/2023 Plan of Removal- Quality of Care Interventions: 100% blood sugar audit in progress Physician will be notified of all blood sugars outside the parameters The following in-services were initiated 02/24/2023 by Admin: Any nurse not present or in-serviced on 2/25/23 will not be allowed to assume their duties until in-serviced: o Following facility policy for hypoglycemia located in the Glucometer policy: o Following facility policy for hyperglycemia located in the Glucometer policy: o Staff in-service on utilization of SBARs and E-transfers (SBAR includes change of condition, notification to physician/family, and new orders if applicable) o Staff in-service on following physician orders and not deviating from orders unless directed by physician. · Notify the physician if the blood glucose is outside of any physician specific parameters and implement any new orders as prescribed. o In-Service nursing staff that any transport going to the emergency room will be 911. There will be no non emergent transports when going to the emergency room. · Abnormal Results-see glucometer policy · If the resident is unresponsive, notify emergency medical services. Notified Medical Director of IJ situation on 2/25/23 at 6:06 PM. Monitoring: ADMIN/ADON/Regional Compliance/Designee will review 5-8 residents sliding scale results for proper notification to MD if outside parameters weekly x 4 weeks. ADMIN/ADON/Regional Compliance/Designee will monitor all blood sugars outside parameters of sliding scale for notification to MD weekly x 4 weeks. Regional Compliance Nurse will review ADMIN/DON/Designee for monitoring compliance weekly x 4 weeks. The QA Committee will review findings and Physician Notification Policy and will make changes as needed monthly. On 03/26/23, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Record review of Resident #2 electronic medical record conducted and revealed there were no discrepancies for sliding scale insulin orders. Record review of Resident #3 electronic medical record conducted and revealed there were no discrepancies for sliding scale insulin orders. Record review of LVN H's Certificate of Completion , dated 02/24/23, reflected she had a satisfactory completion of Preparing and Administering insulin. Record review of LVN H Certificate of Completion , dated 02/24/23, reflected she had a satisfactory completion of Insulin Administration. Record review of the facility's signature sheet and in-service, High and Low Blood Sugars CNA Protocol, dated 02/26/23, reflected the in-service instructed CNAs were instructed to monitor the resident's baseline and notify nurses of any change in symptoms. Record review of the facility's signature sheet and in-service, Emergency vs. Non-Emergency Transportation, dated 02/26/23, reflected the in-service instructed facility staff that if any resident was being sent to the emergency room for any reason, then 911 emergency transport should be used. Record review of the facility's signature sheet and in-service on hyperglycemia, dated 02/25/23 reflected the several factors that could contribute to hyperglycemia in people with diabetes. It listed early symptoms and unrelated symptoms such as headache, blurred vision, frequent urination, and fatigue. It listed the negative outcomes if hyperglycemia was untreated. The outcomes included abdominal pain, shortness of breath, fruity-smelling breath, coma, nausea and vomiting, dry mouth, weakness, and confusion. An Interview was conducted on 02/26/23 at 3:39 PM, LVN F said she had received additional training before she was allowed to work. She reported if a resident's blood sugar were outside of the sliding scale parameters, she was trained to contact the physician and follow the physician's orders. She said she was trained to stay within the physician's orders. She said if she reports concerns regarding a resident, she has been trained to document the response of the MD. She stated if the resident's elevated blood sugar is not addressed, it can result in a coma. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/26/23 at 3:23 PM the MD said he was not notified about the elevated blood sugar until after the resident was already admitted to the hospital. He said he was told that he was not notified because transportation was already there to pick up the resident. He stated he could not remember who notified him and when they notified him but that he was notified after the resident was admitted into the hospital. He said if he had been notified he would have instructed the staff to follow the sliding scale . He said without giving insulin, there is increased confusion. In addition, he said it places the resident at risk for dehydration, infection, and renal failure. He said even if the resident has not eaten, he would have instructed the sliding scale insulin to be given because, with elevated blood sugar at 500, there is no concern that it will go too low. An Interview was conducted on 02/26/23 at 3:39 PM LVN F said she was not allowed to work until she was in-serviced. She said she was never trained to go outside the physician's orders. She said she was trained to report the information to the MD and wait for additional instructions if blood sugar levels were outside the sliding scale parameters. She said she was competent in the facility's expectations regarding blood sugars, MD notification, following physician's orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/26/23 at 3:58 PM, RN C said she had received additional training before being allowed to work. She said she would never deviate outside of physician's orders. She said emergency transportation should be used if a resident needed to go to the emergency room. She said elevated blood sugars outside of the sliding scale ranges should be reported to the physician for additional instructions. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/27/23 at 9:31 AM LVN D said she had been trained prior to work about blood sugar expectations. She said she were supposed to notify the MD if there are concerns with blood sugar levels. She said she was to never deviate outside the physician's orders for any reason. She said if physician's orders are not followed, the worst that could happen would be the resident could go into a coma and die. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/27/23 at 9:39 AM LVN C She said she was trained before working her shift. She said she was instructed but already knew to stay within the physician's orders. She said blood sugar levels outside the sliding scale parameters should be reported to the physician. She said if the physician did not respond appropriately with clear, concise instructions, she would clarify to ensure she was heard. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An Interview was conducted on 02/27/23 at 9:50 AM, LVN B said she was trained before her shift about the importance of blood sugar levels. She said they were trained to notify the MD if the blood sugar level was too high or too low. She said if a resident has to go to the ER, non-emergency transport should not be used. She said she is required to document the response of the MD when they notify them of a change in the resident's condition. She said she feels competent in the facility's expectations regarding blood sugars, MD notification, following physician orders, and deciphering between emergency vs. non-emergency situations. An interview was conducted on 03/09/23 at 11:19 AM with LVN H. When asked why she did not document her conversation in detail with the MD representative specifically about notification of the blood sugar, she said: Things were happing so fast, and at the moment I was like, oh ok She said at that time she did not think to ask further information or clarification on what to do When asked had she been trained before the incident to document detailed notifications of MD instructions she said as a nurse she had been trained but not specifically by the facility. She said she was unaware of their process at that time for documentation. When asked about her experience as a nurse, what has she been taught about information that was not documented, and what does that mean? She said it would mean it was not done. A negative outcome could be not following the doctor's orders or knowing what was said. She said she was trained to contact the MD representative Monday-Friday 8-5, and then the MD Representative would contact the MD or the MD assistant. She said she was trained not to contact the MD directly. She said she was unaware that standing orders were available at the facility. She said at the previous facility, she was trained not to use the standing orders and to still notify the physician. An interview was conducted on 03/09/23 at 11:28 with the Administrator. When asked what her expectation of documentation of notifications was, she said they would document if there were any new orders and follow up with the orders. When asked about her experience as an administrator and what she was taught regarding information that is not documented and she said if it was not documented, it was not done. She said she did send the phone records of LVN H to HHSC but clarified that those records would not indicate the content of the calls. She said that based on the progress note entered in the electronic medical chart provided to the surveyor, she would not be able to tell if the MD was notified of the elevated blood sugar. She said that the MD was notified that day but not before leaving. She said that she expected the MD to be notified before the resident went to the ER. An interview was conducted on 03/09/23 at 11:47 AM with the MD representative. She said on 02/23/23, LVN H did not give her a detailed description of Resident #1 current issue with elevated blood sugar. She said the facility has standing orders is what the facility has on hand and what they have on anyone so that the MD does not have to call for everything. She said in the previous interview when she said she would have instructed LVN H to give the 10 units; she knew this exact amount because the facility has a standing order for sliding scale insulin, and that is what should have been followed on 02/23/23 when Resident #1 blood sugar was elevated to 501. When asked which order should be followed if the standing order differs from what is in the resident's electronic medical record, she said that the orders shouldn't have been different. She said the sliding scale order had been the same for a long time. She said she was not sure who entered the information on the facility. She said she does not review the orders once given to the facility. An interview was conducted on 03/09/23 at 6:08 PM with the MD, and when asked for clarification about the sliding scale order for Resident #1, he said that the sliding scale order should have been the same as the standing order. He said he did not know why the order on the computer would be different. He said the only reason the standing order would not match what was in the electronic medical record would be if the resident was