**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 10 residents (Resident #101) reviewed for abuse. The facility failed to ensure Resident #101 was free from abuse. CNA H slapped Resident #101 on the face on 8/1/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 08/01/24 and ended on 08/01/24. The facility had corrected the noncompliance before the survey began. The facility was informed about the past non-compliance on 3/26/2025 at 12:32pm. This failure affected one resident and placed additional 9 residents who were on the memory unit at risk of abuse. Findings included: Record review of Resident#101's admission record dated 3/25/2025 reflected an [AGE] year-old female initially admitted on [DATE] with diagnoses of Alzheimer's Disease (a progressive neurodegenerative disorder that affects memory, thinking, and behavior), cognitive communication deficit (difficulties with communication arising from problems with cognitive process like, attention, memory, or reasoning, rather than speech or language difficulties themselves), dementia (a general term for a group of brain disorders that cause a progressive decline in cognitive abilities, memory and behavior). Record review of Resident #101's comprehensive care plan dated 5/9/2022 indicated she had a history of physical aggression and agitation/combative behavior towards staff and other residents. Resident #101 had severe cognitive impairment and needed moderate assistance with all ADLs. Record review of Resident #101's quarterly MDS dated [DATE] reflected a BIMS score of 00, indicating Resident #101 was severely cognitively impaired and had a wandering behavior that occurred daily. Record Review of Resident #101's incident report dated 8/1/24 reflected she had been slapped on the face by CNA H. The incident was witnessed by CNA I and RN J. The incident occurred while CNA H and CNA I tried to render care to Resident #101. Resident #101 became agitated and hit CNA H, and in response CNA H slapped Resident#101. The incident report revealed that the facility's investigation was confirmed for abuse. During an observation on 3/24/25 at 10:00 am, Resident #101 was in the dining room watching television and eating a snack. During an observation on 3/25/25 at 11:25 am, Resident #101 was in the dining room eating a snack. During an observation on 3/26/25 at 12:10 pm, Resident #101was in the dining room eating lunch. During an interview on 3/24/25 at 10:00 am Resident #101 was not able to recall the incident. In a telephone interview on 3/24/25 at 4:00 PM, CNA H denied that she had slapped Resident#101 on the face. CNA H said that she simply raised her hand to scare her. CNA H said RN J immediately intervened and instructed her to report to the Administrator's office. CNA H said the Administrator immediately suspended her and later terminated her. Record Review of CNA H's written statement (not dated) reflected in part that Resident #101 hit my face with force and I instantly hit her back not hard. I know it was wrong, but it was instinct. In an interview on 3/25/25 at 10:26 AM, CNA I said the incident occurred while she tried to convince Resident#101 to go back to her room to render perineal care. CNA I said Resident#101 refused and became agitated. CNA I said she went to ask CNA H for assistance. CNA I said Resident #101 followed her and at that time CNA H and CNA I tried to redirect Resident#101 back to her room. CNA I said Resident #101 became physically combative and suddenly slapped CNA H on the face. CNA I said CNA H reacted by slapping Resident #101 on the face. CNA I said the incident was witnessed by RN J who immediately protected Resident#101 and instructed CNA H to report to the Administrator's office. In an interview on 3/25/25 at 10:35 AM, RN J said she heard Resident#101 yelling at CNA H and CNA I while they tried to redirect her back to her room. RN J said that she immediately went to check on Resident #101. RN J said she observed CNA H slap Resident#101 on the face. RN J said that she immediately separated Resident #101, and CNA H. RN J said she instructed CNA H to exit the memory unit and report to the Administrator's office. RN J said she immediately a head to toe assessment was done for Resident#101 for any physical injuries and then reported the incident to the Administrator. RN J said that CNA H was removed from the facility after the incident. In an interview on 3/25/25 at 11:00 AM, the DON said that after the 8/1/24 incident CNA H was immediately suspended, and later terminated. The DON said all staff were in-serviced on 8/1/24 on of the topics of Dealing with challenging residents; Abuse Prohibition Policy. The DON said the following interventions were initiated: Resident #101 was closely monitored by staff and to monitor for any psychosocial behaviors. In an interview on 3/25/25 at 11:15 AM, the Administrator said that when CNA H reported to her office on 8/1/24 she was immediately suspended and instructed to leave the facility. The Administrator said she immediately reported the incident to the state. The Administrator said after the investigation the facility confirmed the allegation of abuse and CNA H was terminated. It was determined these failures placed Resident #101 in an Immediate Jeopardy situation on 08/01/24. The facility had corrected the noncompliance before the survey began. Record Review of the facility resident report dated 8/1/2024 of the following interventions were put in place: 1. Resident #101 was immediately protected by RN J. In an interview on 3/25/25 at 10:35 AM, RN J said she heard Resident#101 yelling at CNA H and CNA I while they tried to redirect her back to her room. RN J said that she immediately went to check on Resident #101. RN J said she observed CNA H slap Resident#101 on the face. RN J said that she immediately separated Resident #101, and CNA H. RN J said she instructed CNA H to exit the memory unit and report to the Administrator's office. RN J said she immediately a head to toe assessment was done for Resident#101 for any physical injuries and then reported the incident to the Administrator. RN J said that CNA H was removed from the facility after the incident. 2. CNA H was immediately removed from the facility. Record reveiw of incident report dated 8/1/24 revealed resident was suspended on 8/1/24. Record Review of incident report dated 8/1/24 CNA H was terminated on 8/6/24. 3. A head-to-toe assessment was conducted on Resident #101 on 8/1/24. Record review dated 8/1/24 of resident assessment revealed no physical harm, pain or mental anguish. 4. The facility's social worker assessed Resident #101 for signs of psychosocial harm on 8/1/24 and later referred Resident#101 to counseling. Interview with social worker revealed that she assessed the resident and there were not signs of psychosocial harm and was referred for counseling evaluation on 8/1/24. Record review dated 8/1/24 revealed social worker had done an assessment and referred resident for counseling. 5. Staff were in-serviced on 8/1/24 on the topics of Dealing with challenging residents and Abuse Prohibition Policy. Record review dated 8/1/24 revealed all staff were in-serviced on dealing with challenging residents and abuse prohibition policy. 6. All residents in the memory unit were interviewed and observed for abuse on 8/1/24 with no concerns mentioned. 7. Staff in the memory unit were interviewed on 3/24/25, 3/25/25 and 3/26/25 and all were familiar with the facility's protocol when dealing with residents with cognition impairment and aggressive behaviors and abuse prohibition policy. 4 CNAs were interviewed from different shifts, 3 License Vocational Nurses and 1 registered nurse. 3/24/25 at 1:39 PM, CNA EE 3/25/25 at 10:35 AM, RN J 3/25/25 at 10:26 AM, CNA I 3/25/25 at 1:34 PM, LVN F 3/25/25 at 1:49 PM, CNA DD 3/25/25 at 2:48 PM, ADON 3/25/25 at 2:25 PM, LVN CC 3/26/25 at 10:49 AM, CNA S Record Review of the facility's policy titled abuse, neglect and exploitation, date implemented 8/15/22, stated It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Physical Abuse includes, but is not limited to hitting, slapping, biting, and kicking. It also includes controlling behavior through corporal punishment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 6 residents (Resident #5) reviewed for abuse. 1)The facility failed to ensure CNA F communicated Resident #5's allegation of abuse on 11/17/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 11/20/24 and ended on 11/20/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of emotional distress, fear, decreased quality of life and further abuse. The findings included: Record review of Resident #5's admission record dated 1/29/25 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of cerebral infarction (when blood flow to the brain is disrupted, which can lead to brain cell death), aphasia (a neurological disorder that impairs a person ' s ability to communicate), and mild intellectual disabilities. Resident #5 was discharged home with home health on 01/14/2025. Record review of Resident #5's quarterly MDS assessment dated [DATE] reflected she had short-term memory problem and cognitive skills for daily decision making were severely impaired. Record review of intake investigation worksheet, for Resident #5 revealed On 11/17/24 at about 8-9 am CNA F when into resident's room to pick up breakfast tray and saw that resident seemed sad. Asked her how it went when she went out on pass with her sister. Resident began to cry and stated that she was hit while out on pass by her nephews. Did not go into detail about incident. When asked if she wanted to speak with someone, she stated no. During the rest of the shift resident remained sad. During incontinent care and care CNA did not see any visible injuries. Facility made aware of allegation on 11/20/24 and resident is currently out on pass with sister. Family to be called to have resident return to facility. Upon arrival, police will be called, head to toe assessment will be conducted, interview to be done with resident. In an interview on 1/29/25 at 11:30 am with the police officer, he said no crime was discovered. He said they spoke to the resident, resident's family and staff and found that the resident may have referred to an incident that happened years ago, nothing recent. In an interview on 1/29/25 at 12:30 pm with the facility's Social Services, she said she recalls CNA F reported to a nurse when CNA F returned to work on 11/20/24 and the nurse told her to talk to me. CNA F said she did not tell anyone because she was doing work and while she was off, she thought about it, and she told the nurse when she returned. Social Services said she called the administrator, and she took over from there. She said Resident #5 was out on pass so could not interview her. Social Services said she called the family member to bring the resident back so they could assess her. Social Services said she asked the family member if any males were around the resident and the family member denied. The family member said Resident #5 was never alone, she was always with the family member. Social Services said they called the PD, and they took a statement from Resident #5. Social Services said the resident denied allegations of abuse to police and the family also denied. Social Services said Resident #5 also denied allegations to her. Social Services said the police talked to the family, RP, resident, and staff. Social Services said she completed the one-to-one with CNA F. In an interview on 1/29/25 at 5:54 pm with CNA F she said Resident #5 had gone on pass with a family member on 11/17/24. When Resident #5 returned, CNA F said she asked how it went, and Resident #5 began to cry. CNA F said Resident #5 said someone hit her while out on pass. She said it was the sobrinos (nephews). CNA F said after Resident #5 reported that to her, she never commented on it again. CNA F said Resident #5 went out on pass again on 11/20/24 with family and everything was normal. CNA F said she did not report to anyone at the time because it was a Sunday, and no one was there except a new nurse. CNA F said she got busy after she came out of the resident ' s room, so she forgot to report. She said after work that day she was off. CNA F said when she returned to work, she reported it to the nurse and then it was reported to the administrator. CNA F said she completed an Abuse, Neglect and Exploitation in-service after the incident, and they also completed a one-on-one. She said they ask them about the types of abuse and tell them who to report to. She said she should first report to the administrator. She said they tell them to report immediately. She said they tell them if the administrator is not there, they must report to Social Services or a nurse. She said allegations of abuse were not reported; she could lose her certification. She said residents could also continue to get abused. In an interview on 1/30/25 at 11:05 am with LVN H, said she worked with resident the night shift of 11/17/24 to 11/18/24. She said Resident #5 did not voice complaints or show distress. She said Resident #5 was in good spirits and while she was awake, there were no concerns, reports of abuse, or any emotional distress noted LVN H said when an incident happens on the day shift, they pass on report to her and she follows up or monitors the resident. LVN H said during in-services, they were informed they must report physical, verbal, or sexual abuse. She said they must report any abnormalites or suspiciouns they of staff or family. She said they must report these examples to the Administrator as soon as they suspect. She said they are informed of alternative people to report to if the Administrator is not available such as the ADON or DON. In an interview on 1/30/25 at 1:56 with the DON, she said that prior to the incident they drilled staff on abuse, neglect and exploitation and the importance of reporting timely, so for her to have voiced it was because she was off after or whatever reason she gave made no sense. The DON said staff know the phone numbers for who they need to report to. The DON said they use alert media to inform staff of the importance of reporting abuse, how to report abuse, who to report it to and the importance of reporting immediately. The DON said they sent the staff the Ombudsman ' s number, and they provided staff the 1-800 number in case they wanted to report anonymously. DON said they also have people from outside the facility to come and do random interviews and ask questions about who the abuse coordinator was and how do they make a report, and they get back to the administration if anyone needs any intervention. The DON said they come in twice a week. The DON said they even printed out and laminated cards to place behind the staff ' s ID with all the information, along with the Recognize, Remove and Report card as well. The DON said on those cards it even says to report immediately. The DON said right after the incident, they in-serviced on abuse, neglect, and exploitation. In an interview on 1/30/25 at 3:10 pm with the Administrator, she said all she remembered was that there was no excuse for that, especially since Resident #5 went out on pass again and they weren't aware. The Administrator could recall the exact date she went on pass again. The administrator said they did a one-to-one with CNA F. When this was brought to their attention, the family was interviewed and they insisted Resident #5 was not around any males at the home. The Administrator was notified on 02/10/2025 at 11:15 am, that a past noncompliance Immediate Jeopardy situation had been identified due to the above failures. It was determined these failures placed Resident #5 in an Immediate Jeopardy situation on 11/17/24. The facility had corrected the noncompliance before survey began. Record review of continuing education transcript for CNA F revealed completion of Abuse and Neglect training and Incident Reporting on 6/20/24 and 7/24/24 and training on Reporting Abuse Attestation on 6/20/24. Record review of Staff Individual Inservice Record One to One (1:1) Procedure dated 11/20/24 revealed, Subject: Abuse, Neglect and Ex;loitation How to Correct Employee re-educated on ANE and the importance of reporting any allegations of abuse immediately to facilites abuse coordinator. Record review of In-Service Training Report dated 11/22/24 - ongoing for General Staff revealed, Topic Abuse, Neglect and Exploitation (ANE) training Contents or summary of training session . Re-educated staff on Abuse, Neglect and Exploitation (ANE training acts that constitute abuse, neglect, and exploitation, signs and symptoms of abuse, neglect, and exploitation, methods to prevent abuse, neglect, and exploitation, and how to report. Abuse Coordinator Three Rs: Recognize, Remove, Report. It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Verbal Abuse: means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. IV. Identification of Abuse, Neglect and Exploitation B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff, or family report of abuse 5. Verbal abuse of a resident overheard VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting oa all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents were free from abuse for 1 of 32 residents (Resident #87) reviewed for abuse, in that: 1. The facility did not take measures to prevent verbal abuse of Resident #87 by LVN C. 2. The facility failed to implement measures, like identifying verbal abuse and handling residents with behaviors r/t PTSD, to protect residents from further abuse. 3. The facility failed to protect Resident #87 from having his mustache shaved against his will. 4. The facility failed to prevent LVN C from instructing staff to not give Resident #87 a blanket when Resident #87 complained of being cold. 5. The faciity failed to follow Resident #87's care plan in giving him fluids to prevent dehydration. 6. The facility failed to allow Resident #87 to have his meal tray in front of him for the entirety of his meal because he was eating quickly, instead of assisting Resident #87 per his care plan. 7. The facility failed to ensure that LVN C's abusive behavior was reported and corrected. An IJ was identified on 12/20/2023. While the IJ was removed on 12/22/2023, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. This failure could affect the residents at the facility and place residents at risk for physical, verbal, and/or psychosocial harm. The findings were: Record review of Resident #87's face sheet, dated 12/18/23 revealed a [AGE] year old male admitted to the facility on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder (reaction to stress an intense, excessive, and persistent worry and fear about everyday situations), hemiplegia and hemiparesis (weakness or loss of strength on one side of the body), schizophrenia (A mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior), major depressive disorder, and need for assistance with personal care. Record review of Resident #87's most recent MDS assessment, dated 11/29/2023, revealed a BIMS score of 9/15, signifying moderate cognitive impairment. The MDS assessment further revealed that it was known that Resident #87 had verbal behavioral symptoms directed towards others, such as threatening others, screaming at others, cursing at others. It was revealed that Ressident #87 needed supervision while eating. No pertinent information was revealed in Section K-Swalloing/Nutritional Status of the MDS assessment. Record review of Resident #87's comprehensive care plan revealed: Resident #87 is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t cognitive deficits, physical limitations, revised on 12/7/2023, with an intervention of all staff to converse with [Resident #87] while providing care. Resident #87 has an ADL self-care performance deficit r/t left sided hemiplegia and hemiparesis d/t CVA, revised 12/7/2023, with an intervention of EATING: The resident requires assistance b (1) staff to eat. Resident #87 is verbally aggressive with staff r/t poor impulse control and schizophrenia, revised 12/7/2023, with interventions of analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. And Provide positive feedback for good behavior. Emphasize positive aspects of compliance. And Psychiatric/Psychogeriatric consult as indicated. Resident #87 has impaired cognitive function or impaired thought processes r/t dementia, paranoid schizophrenia, anxiety, bipolar disorder, revised 12/7/2023, with an intervention of COMMUNICATION: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Resident #87 has a communication problem r/t impaired ability to understand and make self understood, revised 12/11/2023, with an intervention of Speak on an adult level, speaking clearly and slower than normal. Resident #87 needs assistance from staff for dehydration, at risk for dehydration, revised 12/7/2023, with an intervention of Encourage the resident to drink fluids of choice. Record Review on 12/19/23 of Resident #87's comprehensive care plan revealed that the facility revised Resident #87's care plan on 12/18/23. The updated comprehensive care plan revealed: Resident #87 has hx of torture, PTSD and active dx of paranoid schizophrenia., revised 12/19/2023, with interventions of Provide explanation when resident is denied an item he cannot have i.e. food not according to order., when redirecting resident maintain calm voice tone, look directly at resident, do not touch resident unless there is imminent danger to resident or others, maintain relaxed body posture. Resident #87 has Schizophrenia and Bipolar at risk for behavioral problems with an intervention of resident to see [counseling] per resident needs/prn Record Review of a nurse's progress note on 12/18/23 at 2:09 PM, author unknown, [Resident #87] was in dining room during lunch, claims charge nurse yelled at him. Feels that its abuse. Charge nurse was removed from schedule. Resident assessed for any signs of emotional distress. None noted at this time. Resident up to wheelchair at nurse's station. [NP] made aware. [Resident #87's RP] called but no response. During an observation on 12/18/2023 at 12:35 PM in the 600-hall dining room for lunch service, Resident #87 was coughing while eating his lunch meal. There were no drinks present on his lunch meal tray. Resident #87 was sitting by himself while LVN C was sitting at another table about 8 feet away, helping other residents eat. LVN C addressed Resident #87 in an elevated, derogatory voice, telling the resident to slow down while eating, multiple times. LVN C appeared to have her brow furrowed and with an upset expression on her face. After Resident #87 kept coughing while eating, LVN C told CNA E to take food away from the resident. CNA E took Resident #87's lunch meal tray away from him as he continued to cough, without telling the resident what she was going to do. Observation and interview 12/18/2023 at 12:40 PM, Resident #87 stated that LVN C was mean. During an observation and interview on 12/18/2023 at 12:41 PM, the RD had a surprised expression on her face and confirmed that LVN C was yelling at Resident #87 across the dining room. The RD was present during 12/18/23 lunch service and confirmed that there was no beverage present on Resident #87's lunch meal tray. The RD revealed that there should be a beverage on Resident #87's meal trays, and Resident #87 drank, ate quickly, and required cueing. During an interview on 12/18/2023 at 12:45 PM, the RD stated it was inappropriate for LVN C to be yelling across the room to Resident #87. The RD further stated that if LVN C was speaking to her like LVN C was speaking to Resident #87 she would not like it. The RD further stated LVN C should have spoken to Resident #87 in a more passive tone. During the interview with the RD, Resident #87 stated he did not get respect and wanted another staff member instead of LVN C to provide care for him. Resident #87 further stated LVN C was mean to him in the mornings as well. During an interview on 12/18/2023 at 1:12 PM, Resident #87 stated he had not reported that LVN C was mean to him to anyone else. Resident #87 was unable to quantify how long this was going on but that LVN C was always mean to him. During an interview on 12/18/23 at 1:38 PM, the RD stated she was going to report to the DON what happened to Resident #87 during lunch. During an interview on 12/18/2023 at 1:53 PM, CNA E revealed that she worked in the 600 hall for 3 months. CNA E was present during 12/18/2023 600-hall lunch service. CNA E stated that yelling at Resident #87 was the way LVN C talked to Resident #87 when he coughed at mealtimes. Resident #87 got his tray removed from him so he could calm down and stop coughing. CNA E stated they removed drinks from Resident #87's meals because he rushed to eat and drink. CNA E further stated she knew to care for Resident #87 from LVN C and not from a care plan. CNA E further stated when Resident #87 got cold LVN C would tell CNA E to not cover the resident because he would get a rash. CNA E further stated LVN C was rude and raised her voice at times but, that was the way she spoke. CNA E stated LVN C only treated Resident #87 like that. CNA E stated she would feel bad if she was treated how LVN C treated Resident #87. CNA E stated she did not recognize LVN C's behaviors as abuse. During an interview on 12/18/2023 at 2:11 PM, CNA CC stated LVN C would talk to Resident #87 with authority. CNA CC stated LVN C told nursing staff to give Resident #87 liquids after he ate so that he did not choke, even though Resident #87 would ask for his drinks during his meal. CNA CC was present during 12/18/2023 600-hall lunch service. CNA CC stated LVN C spoke loudly and raised her voice at Resident #87, however CNA CC would not say that LVN C yelled at Resident #87 during 12/18/2023 lunch service. CNA CC stated she would not feel welcome if LVN C spoke to her how LVN C spoke to Resident #87. During an interview on 12/18/2023 at 2:30 PM, Restorative Aide DD stated LVN C was strict, but it was best for the residents. Restorative Aide DD stated LVN C provided more focus on Resident #87, and further stated LVN C would speak in a loud tone but, can't tell if it's a yell or not. Restorative Aide DD stated no staff should be speaking loudly to residents and staff should be speaking calmly to residents. Restorative Aide DD stated he did not recognize LVN C's behaviors as abuse. During an interview on 12/18/23 at 5:33 PM, The PT/Rehab Director revealed that the last time Speech Therapy assessed Resident #87, they determined that Resident #87 was to eat 2-3 bites of food then drink some fluids throughout his meal. It was also revealed that Resident #87 should be fed by staff, however, staff reported that he did not want to be fed. During an interview on 12/19/23 at 11:49 AM, Resident #87's RP stated Resident #87 had complained about a nurse being in a bad mood when the resident would ask for something. Resident #87's RP stated they were concerned because the staff was paid for taking care of the residents at the facility. Resident #87's RP stated he had not reported it because he did not want to have problems with the facility because Resident #87 was by himself in the facility. Resident #87's RP stated he felt sad and hurt about Resident #87's experience. During an interview on 12/19/23 at 12:18 PM, the DON stated there were no concerns with LVN C, and further stated LVN C was previously educated on customer service because LVN C's tone had come off as aggressive versus stern in the past. The DON confirmed there were no other complaints about LVN C. During an interview and record review on 12/19/2023 at 12:26 PM, the DON revealed Resident #87 had a history of aggressive behavior towards staff, so that was expected from Resident #87. The DON further stated the facility was Resident #87's home and staff should treat the resident with dignity. The DON stated LVN C tried to make Resident #87 slow down while eating. The DON stated there was a way to redirect Resident #87 and to speak to Resident #87 in a calm tone. The DON stated LVN C had been educated on not having an aggressive tone of voice in the past. The DON further statedthat because Resident #87 had PTSD then LVN C's voice should not have been elevated. The DON read through various nurse's notes for Resident #87. Record review of a nursing note, authored by LVN C, on 9/19/2023 at 1:00PM revealed, [Resident #87] became combative when [CNA D] shaving mustache, punched him in the stomach, when nurse approached and explained keeping mustache not good hygiene due getting food stuck on it and stained with juice given to him, called nurse [expletive], reminded not to disrespect staff and [CNA D] only attempting to render care, reminders futile, will continue to monitor. The DON stated Resident #87 had the right to keep his mustache, if he wanted, because it was his right. The DON further stated Resident #87 should not be told what to do and the nursing staff should have adjusted the resident's care to his behaviors. During an interview on 12/19/23 at 1:16 PM, CNA F stated they had not worked at the facility since November 2023. CNA F worked since June 2023 with LVN C. CNA F stated most staff were kind of scared or concerned about working with LVN C because she could be very stern. CNA F stated Resident #87 would argue with LVN C. CNA F further stated LVN C would, not necessarily yell at him, but would speak in a, loud assertive voice,,then Resident #87 would yell back. CNA F stated that if Resident #87 was cold, he would not be given a blanket because LVN C stated it was a safety issue. CNA F stated at mealtimes they would let Resident #87 eat his food first and then let him drink fluids because he would rush to eat and choked. CNA F staed LVN C told staff to not give liquids to Resident #87 while he was eating, and further stated that was odd and would understand why Resident #87 would feel frustrated. CNA F did not think any of that behavior should be reported as abuse and that emotional abuse should be reported to the Administrator. During an interview on 12/19/23 at 1:51 PM, CNA D stated the plan of care for Resident #87 would be based off what LVN C told the other nursing staff to do. CNA D stated if Resident #87 asked for another drink when he already had one in front of him, they would not give him another one because he needed to drink one drink at a time. CNA D spoke about a time that Resident #87 refused to get his mustache shaved but LVN C told Resident #87 that he would have to have his mustache shaved because he got food in his mustache. CNA D stated it was easier to wash Resident #87's mustache than to shave his mustache. CNA D explained that abuse could be if Resident #87 was not able to do what he wanted to do. CNA stated that if he was treated like that, it, wouldn't go well if it happened to him, but did not identify that behavior as abuse. During an interview on 12/19/2023 at 5:00 PM, Resident #87 stated LVN C yelled at him all of the time and, you can see it in her eyes that she is angry with me. Resident #87 stated, she is bad, and there was, anger in face and eyes. Resident #87 stated one-time LVN C ordered for his mustache to be shave, and repeated that, she's [LVN C] mean. Resident #87 stated he had a mustache when he got to the facility and they wanted to shave it because food would get stuck in his mustache, but he did not want to have his mustache shaved. Resident #87 stated, I don't want them to do it, about not wanting his mustache shaved. Resident #87 stated CNA D was the CNA who had shaved his mustache and further stated, I got mad. Resident #87 stated the nursing staff would not give him beverages when he asked for them during mealtime. Resident #87 stated he did not want go into more detail about not having his beverages given to him. Resident #87 was unable to quantify how long this had been going on. During an interview on 12/20/2023 at 1:20 PM, LVN C stated Resident #87 was always choking while he had meals and LVN C was the one who had to redirect the resident because none of the other staff redirected him. LVN C stated she had asked CNA E to move Resident #87's tray during 12/18/2023 lunch because the resident was coughing. LVN C stated speech therapy had not advised nursing staff to move the tray from Resident #87 if he was coughing while he was eating, but that this was how they cared for Resident #87 during mealtimes. LVN C stated Resident #87 could have food then was given liquids after he was done with the food portion of his meal. LVN C stated she did not tell speech therapy about the interventions the nursing staff was doing for the resident. LVN C stated these interventions were not documented anywhere, and LVN C stated she did not read the resident's care plans. LVN C stated Resident #87 got mad at her because LVN C was the only one telling Resident #87 to slow down. LVN C further stated Resident #87 thought she was picking on him because she told him to slow down while eating, and further stated Resident #87 did not like to be told to slow down. LVN C stated when Resident #87 did not seem to want his mustache shaved but was okay after LVN C explained he needed to have his mustache shaved because a lot of food would remain in his hair. About the incident that occurred on 12/18/2023, LVN C stated she did not feel like she was yelling at Resident #87 because that was how she talked. LVN C revealed that she had been working with Resident #87 for several years, but the exact timeframe was unknown. During an interview on 12/22/23 at 5:48 PM. PT/Rehab Director revealed that Resident #87 could sip fluids fine throughout meals, but someone needed to sit with him and cue him while he ate. He revealed that you cannot cue a resident from across the room. Resident #87 was educated on how he had to eat to prevent coughing/choking and Resident #87 was able to learn quickly. The PT/Rehab Director further revealed that Resident #87 struggled with feeding himself at mealtime because he had a stroke. The PT/Rehab Director further revealed that mealtime should be enjoyable, and Resident #87 responded well to positive reinforcement. The PT/Rehab Director stated Resident #87 would have ongoing speech therapy and ensure that Resident #87's care plans would be updated so that other staff was aware of how to care for Residnet #87. During an interview on 12/22/2023 at 6:10 PM, the DON stated she had trained the facility staff to think about how they would treat their family members at the facility. The DON stated she wanted to make sure residents were safe. The DON stated Resident #87's care plan was updated to indicate his diagnosis of PTSD due to torture. The DON stated it was inappropriate to speak in a, raised, voice when speaking to a resident with PTSD. Record review of the facility's policy titled, Promoting/Maintaining Resident Dignity During Mealtimes, implemented 1/13/23, revealed, It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. Record review of facility policy Abuse, Neglect, and Exploitation, implemented 8/15/2022, revealed: III. Prevention of Abuse, Neglect, and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, register, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. IV. Identification of Abuse, Neglect, and Exploitation A. The facility will have written procedures to assist staff in identifying different types of abuse . B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 5. Verbal abuse of a resident overheard 7. Psychological abuse of a resident observed 8. Failure to provide care needs such as comfort safety, feeding, bathing, dressing, turning & positioning 10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. This was determined to be an Immediate Jeopardy (IJ) on 12/20/2023 at 10:30 AM. The Administrator was notified and provided with the IJ template on 12/20/2023. The following Plan of Removal was accepted on 12/21/2023 at 7:01 PM. Immediate Jeopardy PLAN OF REMOVAL LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Issue: F-Tag 600: Abuse The facility failed to ensure the resident's right to be free from abuse and neglect. Done for those affected: - Resident #87 was assessed by facility social worker for psychosocial wellbeing on 12/20/23. - Resident #87 was assessed on 12/20/23 by ADON and there were no signs and symptoms of dehydration. On 12/18/23, the dietician evaluated for hydration needs and no additional recommendations were provided. - There was not a note from the RD, just the interview - Resident #87 Plan of Care was reviewed and updated on 12/20/23 to ensure appropriate interventions to assist the resident in attaining and maintaining the highest level of function are in place. - The alleged staff member was suspended on 12/18/23 and terminated on 12/20/23. Identify residents who could be affected: - On 12/20/23, the Facility Social Worker(s) completed 100% of interviews of residents to assess for potential abuse. No additional concerns were identified. - On 12/20/23, DON reviewed grievances in the last 30 days to ensure that concerns were addressed, and abuse allegations were reported per HHSC requirement. Systemic Process: - Effective immediately on 12/20/2023, the Administrator/ DON and/ or designee began reeducation to 100% of facility staff on the following: - Abuse, Neglect & Exploitation - Assistance of Residents Activities of Daily Living Staff will be reeducated prior to the start of their next scheduled shift. Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated prior to the start of their next scheduled shift. - The facility will utilize the following processes if the resident or family is unable to or fearful of voicing concerns: - The Interdisciplinary Team (IDT) will review the Grievance Reporting process during the quarterly and annual IDT care plan meeting and will provide the resident and resident's representative with the Compliance Hotline number and the Ombudsman Information. - The Compliance Hotline and Ombudsman information will be provided to the resident's representative in the IDT mailed care plan meeting invitation. - On 12/21/23 the facility sent a Media Alert to facility staff and resident's representative with the Compliance Reporting Hotline: - If you have concerns about the care we provide or any compliance or legal concerns, please contact us at any time without fear of retaliation by calling our 3rd Party Compliance Hotline at [PHONE NUMBER]. - [Facility] is committed to honest and ethical behavior and conducting our business with integrity. - If you witness questionable activity or areas where we can improve our commitment to patient care, please tell us. - On 12/21/23 the facility sent a Media Alert to facility staff and resident's representatives with the Ombudsman Information: - If you have a concern or question, the Long-Term Care Ombudsman Program can help, confidentially and free of charge. Our local Ombudsman is [name redacted] and can be reached at: (956)682-3481 ext. 117 or [PHONE NUMBER] ext 117. - An Ombudsman helps, residents, family members, friends or facility staff members on behalf of a resident. - An Ombudsman will: - listen - protect your rights - offer ideas and options - help resolve concerns - support resident and family counsels - respect your choices - The facility maintains an onsite Weekend Manger and Nursing Supervisor that conduct rounds and may initiate and address resident grievances and may escalate to the appropriate administrative staff when required. The Administrator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation. - To monitor, the Director of Nursing/ designee will review Grievances and resident incidents in facility Stand-up Morning Meeting, attended Monday - Friday. Grievances and resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. - The Compliance Hotline and Ombudsman information will be reviewed at the Resident Council Meeting - The Administrator/designee will review new grievances and resident incidents daily Monday-Friday to insure concerns are addressed timely and if necessary reported per HHSC guidelines. - Administrator/designee will conduct quarterly and as needed on Abuse, Neglect, & Exploitation education to ensure facility staff remains knowledgeable on the identification and reporting of abuse/neglect/exploitation. - The facility has the Essential Rounds Program in place where administrative staff is assigned to residents. Staff will round and visit to ensure resident wellness and safety. Findings will be reported during Morning Stand-up meetings to address and follow up on concerns/grievances. - The facility will place written information in each resident's room informing them how to file grievance and/or an allegation of abuse and neglect. The poster will contain the following: - Ombudsman name and contact information - Compliance Hotline number - Abuse Coordinator name and contact information Monitoring: - DON/designee will audit Grievances and residents' incidents for possible abuse/neglect/exploitation issues 3 times per week for 3 months. - Administrator/designee will present findings to the QAPI committee monthly for 3 months. The QAPI Committee will make recommendations accordingly. - An AdHoc QAPI was conducted on 12/20/23 attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F tag 600 - Free from Abuse and Neglect and develop the above Action Plan Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 12/20/2023. POR Verification During an interview with SW AA, SW RR, and the DON on 12/22/2023 at 10:02 a.m., SW AA, SW RR, and the DON confirmed that Resident #87 was assessed for psychosocial wellbeing. Record Review of Resident #87's clinical record as of 12/22/2023, revealed a progress note: New psychosocial intervention added - consult with psychologist for talk therapy in addition to services already in place from psychiatric NP. During an interview with ADON H on 12/22/2023 at 10:02 a.m., ADON H confirmed she assessed Resident #87 on 12/20/2023 and there were no signs of dehydration. During interview with the Consultant RD on 12/22/2023 at 10:15 a.m., the Consultant RD confirmed she evaluated Resident #87 for hydration needs and no additional recommendations were provided. Record Review of Resident #87's clinical record as of 12/22/2023 revealed a progress notes written by ADON H and dated 12/20/2023 which stated an assessment for dehydration had been completed. During an interview with the DON on 12/22/2023 at 10:02 a.m., the DON confirmed Resident #87 Plan of Care was reviewed and updated on 12/20/23 to ensure appropriate interventions to assist the resident in attaining and maintaining the highest level of function are in place. Record review of Resident #87's plan of care as of 12/22/2023 revealed it was updated on 12/20/2023. During an interview with the DON on 12/22/2023 at 10:02 a.m., the DON confirmed the alleged staff member was suspended on 12/18/23 and terminated on 12/20/23. Record review the alleged staff member's personnel file revealed Personnel Action Form dated 12/20/2023 which stated the staff member was terminated. During an interview with SW AA, SW RR, and the DON on 12/22/2023 at 10:02 a.m., SW AA, SW RR, and the DON confirmed that SW AA and SW RR interviewed 148 facility residents to assess for potential abuse with no additional concerns identified. During an interview with the DON on 12/22/2023 at 10:02 a.m., the DON confirmed she reviewed grievances in the last 30 days to ensure that concerns were addressed, and abuse allegations were reported per HHSC requirement. Record review of the grievance log book as of 12/22/2023 revealed no unresolved grievances. Record review of the HHSC intake system as of 12/22/2023 revealed no new incidents or complaints regarding abuse had been filed. A record review of the facility's nursing roster revealed a nursing staff of 100, to include RN's, LVN's, and CNA's. 26 staff were interviewed and a sample of the 26 from all 3 shifts were documented as follows: 08:00 AM to 05:00 PM shift: During an interview on 12/22/2023 at 9:57 AM, Van Driver YY stated she had received recent training on abuse, neglect, and exploitation. She was able to give examples of abuse and the abuse coordinator was the Administrator. During an interview on 12/22/2023 at 10:01 AM, Central Supply stated he had received recent training to include abuse, neglect, and exploitation. He was able to identify multiple examples. During an interview on 12/22/2023 at 10:02 AM, SW AA stated she received training to include abuse, neglect, exploitation. She was able to present several examples. During an interview on 12/22/2023 at 10:05 AM, the Maintenance Director and Maintenance assistant ZZ received recent training to include abuse, neglect, and exploitation and reported that the Administrator is the abuse coordinator. During an interview on 12/22/2023 at 10:07 AM, the DM and the food service department were interviewed, including dietary aides BBB/FFF/V and Cooks CCC/DDD/EEE/AAA/W. They received recent training that included abuse, neglect, and exploitation. During an interview on 12/22/2023 at 10:13 AM, the therapy department, including Speech Therapist GGG, Occupational Therapist HHH, PTA III, PTA JJJ, OT/Assistant Rehab Director, PT/Rehab Director. They received recent training that included abuse, neglect, and exploitation. 06:00 AM to 02:00 PM shift: During an interview on 12/22/2023 at 4:09 PM CNA TTT stated she had received recent training to include abuse, neglect, and exploitation. She was able to identify some examples and who to report to. During an interview on 12/22/2023 at 4:16 PM CNA UUU stated she had received recent training to include abuse, neglect, and exploitation. She was able to identify some examples and who to report to. 02:00 PM to 10:00 PM nursing shift: During an interview on 12/22/2023 at 2:28 PM, RN PPP, RN QQQ, CNA LLL, LVN RRR, and LVN SSS stated that they had received recent training to include abuse, neglect, and exploitation. They were able to give examples of these and knew who to report to. 10:00 PM to 06:00 AM nursing shift: During an interview on 12/22/2023 at 3:45 PM, CNA MMM stated that she had received recent training to include abuse, neglect, and exploitation. She was able to give examples of these and knew who to report to.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 9 residents (Resident #61) reviewed for treatment and care for diabetic assessments and supports, in that: The facility failed to identify care or support for Resident #61 needs for an insulin [a hormone that lowers the level of glucose (a type of sugar) in the blood] delivery pump, blood glucose [sugar] monitor, remote controller and lab assessments for HbA1C [ an average blood glucose (sugar) levels for the last two to three months]. Resident #61 was admitted on [DATE] with an insulin pump. The pump was designed only to be used with 100-units per milliliter insulin and was used with 200-units per milliliter insulin. The manufacturer of the pump warned not to use any other strength of insulin and warned the practice could include adverse reactions including death. The practice if using 200-units per milliliter continued from 05/01/2023 to 12/23/2023. The facility was unaware of the practice, was untrained on supporting Resident #61 with the insulin pump, and did not monitor Resident #61 blood sugar levels. An IJ was identified on 12/20/2023. While the IJ was removed on 12/22/2023, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions. This failure placed Residents at risk for harm to include death by a failure to assess, train, and support residents needs for insulin delivery adaptive equipment. The findings included: A record review of Resident #61's Face Sheet, dated 12/18/2023, revealed an admission date of 05/01/2023 with diagnoses which included type 2 diabetes [the most common type of diabetes, is a disease that occurs when your blood glucose, also called blood sugar, is too high]. A record review of Resident #61's quarterly MDS assessment, dated 10/31/2023, revealed Resident #61 was a [AGE] year-old male, diagnosed with diabetes, admitted for long term care and assessed with a BIMS score of 15 out of a possible score of 15 which indicated no mental cognitive impairment. A record review of Resident #61's care plan, dated 12/18/2023, revealed, Resident #61 has Diabetes Mellitus and has an insulin pump, at risk for hyperglycemia and other complications. Further review of Resident #61's care plan did not reveal interventions for care and or support of the insulin pump. A record review of Resident #61's physicians orders, dated 12/18/2023, revealed DR. T prescribed Resident #61 insulin lispro [a fast-acting insulin used to control high blood sugar in adults and children with diabetes] to be injected subcutaneously [the injection is given in the fatty tissue, just under the skin] with an injection pen, [insulin lispro] Subcutaneous Solution Pen injector 200 units [u] per milliliter [ml]; Inject 40 unit subcutaneously before meals related to type 2 diabetes mellitus, unsupervised self-administration use with [brand name] insulin pump. May obtained B/S results from B/S; call MD if less than 70 milligrams [mg] / deciliter [dl] or greater than 250 mg/dl, Start Date-11/17/2023 1100. A record review of the insulin pumps' manufacturer's website, https://www.omnipod.com/sites/default/files/Omnipod-5_User-guide.pdf , User Guide, accessed 12/20/2023, revealed, 1.4. Compatible Insulins The [brand name insulin pump] Pump (Pod) is compatible with the following U-100 insulins: [brand names of insulin lispro 100-units per milliliter] . 1.5. General Warnings . Warning: ONLY use rapid-acting U-100 [brand name insulin lispro] insulin in the [brand name insulin pump] System as they have been tested and found to be safe for use with this system . Warning: ALWAYS be prepared to inject insulin with an alternative method if insulin delivery from the Pod is interrupted. You are at increased risk for developing hyperglycemia if insulin delivery is interrupted because the Pod only uses rapid-acting U-100 insulin . A record review of the insulin lispro 200u/ml injection pen manufactures' website; https://medical.lilly.com/us/products/answers/can-humalog-insulin-lispro-200-units-ml-be-administered-using-an-insulin-pump-36312?redirect-referrer=https%3A%2F%2Fwww.google.com%2F#reference-2918962f-8b1a-45c0-9054-805e5c1e3af0-3 accessed 12/18/2023 revealed, Can [brand Name] (insulin lispro) 200 units/mL be administered using an insulin pump? Do not administer Humalog (insulin lispro) 200 units/mL by continuous subcutaneous infusion using an insulin pump. Administration Using an Insulin Pump Do NOT administer [brand Name] (insulin lispro injection) 200 units/mL by continuous subcutaneous infusion using an insulin pump. [Brand Name insulin lispro] 200 units/mL is only available in a [pen injector brand name] presentation. Do not transfer Humalog 200 units/mL from Humalog 200 units/mL[pen injector brand name] to syringe. The markings on the insulin syringe will not measure the dose correctly. An overdose may occur, causing severe hypoglycemia (low blood sugar), putting the patient's life in danger .Date of Last Review: May 10, 2022. During an observation and interview on 12/17/2023 at 10:33 AM Resident #61 presented in his room in bed. Resident #61 was awake active with arts and crafts activity. Resident #61 stated he was frustrated by the staff and or pharmacy. Resident #61 explained he had a need for insulin injection pens to refill his insulin pump and was frustrated he would run out and the injection pens would not be available. Further interview revealed Resident #61 had a battery powered insulin pump adhered to his abdomen adjacent to a battery powered wireless blood glucose monitor also adhered to his abdomen. Resident #61 lifted his shirt to demonstrate the equipment. Resident #61 stated his endocrinologist T and NP U had supported him to use the pump by refilling the pump with insulin lispro 200u/ml via an injection pen. Resident #61 stated the nursing staff would give him an injection pen and syringes and he would draw the insulin out of the injector pen with a syringe and inject the medication into his pump every 3-4 days. resident #61 stated the equipment was controlled by a wireless application downloaded to his cell phone and communicated with Dr. T and NP U. Resident #61 stated the facility did not have information regarding the insulin pump and only provided the insulin injection pens from the pharmacy. Resident #61 stated the facility did not monitor his blood sugar levels. Resident #61 stated the facility had not given him any training for the insulin pump. Resident #61 stated he did not have lab blood work done at the facility. Resident stated he attended quarterly appointments with Dr. T and NP U at their clinic. During an observation and interview on 12/17/2023 at 2:00 PM, Resident #61 stated he had a need for 200 unit/mL Humalog insulin injection pens supplied by the facility supplied because he removed the insulin from the pens and injected it into his insulin pump. Resident #61 showed the surveyor his blood sugar monitor and insulin pump and said that they wirelessly communicated with an application on his cell phone. During an interview on 12/17/2023 at 6:21 PM, RN A stated she was Resident #61's evening charge nurse and she had supplied Resident #61 with the 200 unit/mL Humalog insulin pen and assisted Resident #61 refill the insulin pump. RN A stated she was not trained on how to refill the insulin pump and had no detailed knowledge about the insulin pump stating, he was admitted with the pump and he knows how to do it. RN A stated the physicians order for the insulin pen was for nursing to administer 40 units of the 200 unit/mL insulin three times a day prior to meals and to monitor blood glucose levels and to report to the physician any measurements outside of the physicians' parameters. RN A stated nobody, including herself, had documented the administrations or glucose readings on Resident #61's MARs. RN A stated, he was admitted with the pump and he takes care of it himself .at times he asks us to manually check his blood glucose levels so he can calibrate his wireless glucometer monitor .but he has refused to allow us [nursing staff] to check his sugars [blood glucose levels] and has refused to show his glucose levels on his phone. During interview on 12/17/2023 at 6:28 PM, ADON B stated she was RN A's supervisor and stated Resident #61 had a need for 200 unit/mL Humalog insulin pens which he self-administered. ADON B stated the facility's pharmacy would supply the resident with 200 unit/mL Humalog insulin pens and, he refills his pump .he has no need for self-administration training .he was admitted with the pump and knows how to use it, .he will not allow anyone to touch it. During an interview on 12/19/2023 at 9:28 AM Nurse Practitioner Q stated she was the NP for Resident #61, and she was responsible for Resident #61 since November 1, 2023. NP Q stated she was not aware Resident #61 was not being monitored for blood sugar levels, HbA1C laboratory results, and supervision for the insulin pump. NP Q stated at a minimum the expectations would be for Resident #61 to be monitored once a shift for blood sugar levels, once every 3 months for HbA1C blood sugar levels, and for daily supervision for care and support of the insulin pump. NP Q stated nursing staff needed to be trained to care and support Resident #61 with the insulin pump per the manufacture's recommendations. NP Q stated the risk for Resident #61 was fluctuations in blood sugar levels to include low blood sugar levels and high blood sugar levels. During an interview on 12/19/2023 at 4:19 PM Pharmacy Doctor R stated the practice of removing insulin from an insulin injection pen could not be supported by the pharmacy and were contrary to the insulin pen manufactures recommendations. A record review of the facility's Insulin Administration policy dated September 2014, revealed, the nursing staff will have access to specific instructions [from the manufacturer if appropriate] on all forms of insulin delivery system[s] prior to their use. residents who are capable of managing their glucose monitoring and or insulin administration must be assessed periodically for their ongoing willingness and ability to do so safely and effectively. any resident who is actively involved in glucose monitoring and insulin administration will be provided with diabetes self-care education [as appropriate], and supported by the staff person designated for diabetes teaching and management. This was determined to be an Immediate Jeopardy (IJ) on 12/20/2023 at 10:30 AM. The Administrator was notified. The Administrator was provided with the IJ template on 12/20/2023. The following Plan of Removal was accepted on 12/21/2023 at 7:01 PM. LETTER OF CREDIBLE ALLEGATION FOR REMOVAL OF IMMEDIATE JEOPARDY Issue: F-Tag 684: Quality of Care. The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. Done for those affected: - Resident #61 was assessed by the ADON for signs and symptoms of hypo/hyper glycemia on 12/20/23 and found to be in stable condition. On 12/20/23, Resident #61 was asked by ADON if experiencing any signs of hypo/hyperglycemia and verbalized no concerns. A physicians order was obtained on 12/20/23 for assessing resident for signs and symptoms of hypo/hyperglycemia to ask resident for personal reading of blood glucose; ask resident if experiencing signs and symptoms of hypo/hyperglycemia as listed below: - Signs and Symptoms of Hypoglycemia: Shakiness, Excess sweating, Dizziness, headache, irritability, anxiety and/or fatigue - Signs and Symptoms of Hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, and pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma - Resident #61 completed endocrinologist tele-medicine appointment on 12/20/23. No change in orders given by the endocrinologist. The current order and plan of care include: - [Brand Name] Sensor to be changed out every 10 days to start on 12-21-23; Licensed Nurse will check for placement every shift. Resident will change the [Brand Name] Sensor. The licensed nurse will supervise resident to ensure the [Brand Name] sensor is applied correctly. - Tegaderm applied to abdomen site prior to new [Insulin pump] change every 2-3 days to prevent irritation by the resident and supervised by the licensed nurse. Nurse to assess every shift. - [Insulin pump] to be changed and refilled every 2-3 days by resident, supervised by staff. - [Insulin pump] Packaging provided Needle for Pod refill, resident will extract 200 units of [Insulin Lispro] from [Insulin pen] insulin and refill [Insulin pump] as instructed by [Insulin pump] Monitor follow the [Insulin pump] prompts (2 beeps) Discard Needle in sharps container. Await refill prompt from [Insulin pump] Monitor once prompted then proceed to apply as directed, Resident will then proceed to apply refilled [Insulin pump] to Tegaderm prepped area with abdomen area of choice. Wait for insertion of needle, resident will sense it and we hear a clicking noise then [Insulin pump] will turn pink to ensure proper placement of needle as per [Insulin pump] Monitor. - [Insulin Lispro injection pen] Subcutaneous Solution Pen-injector 200 UNIT/ML (Insulin Lispro) **DAW** Inject 40 unit subcutaneously before meals related to TYPE 2 DIABETES MELLITUS WITH MILD NONPROLIFERATIVE DIABETIC RETINOPATHY WITHOUT MACULAR EDEMA, BILATERAL (E11.3293) (Insulin to be administered as per [Insulin pump] Insulin Management Device) request blood sugar read from resident to be obtained from [Insulin pump] Management Device to be released as per Settings of [Insulin pump]set by [Manufacturing company]) - Self-Administration of Medication Assessment was completed on 12/19/23 by DON and resident was completely capable of self-administration as evidenced by return demonstration by resident. The Self Administration of Medication Assessment will be completed quarterly and with changes in condition. - On 12/19/23, an order was issued by the Facility Family Nurse Practitioner for blood sugar monitoring as needed if noted with signs and symptoms of hypo/hyperglycemia. - Resident #61 Plan of Care was reviewed and updated on 12/19/23 to reflect the resident's use of the [Insulin pump] insulin administration device and nursing interventions to include but not limited to monitoring of glucose readings from the device or resident before meals as ordered and as needed for any signs of hypo/hyperglycemia, notify MD notifications for any concerns and/or blood glucose outside of the physician's parameters, monitoring for signs and symptoms of hypo/hyperglycemia, Completing self -administration assessment/re-assessment to ensure resident's abilities with utilization of the [Insulin pump]; assisting resident with the [Insulin pump] insulin administration unit as needed. Identify residents who could be affected: - On 12/20/23, the ADON, audited all residents receiving automated insulin and BS management system device and no other residents were identified. - The Care Management Nurses completed a 100% review on 12/20/23 of residents with Insulin administration orders to ensure ongoing blood glucose monitoring as ordered to include documentation and notification to providers when resident glucose levels exceed parameters. Systematic Process: - Endocrinologist instructed DON on [Insulin pump] management on 12/20/23. - On 12/20/23 licensed staff who provides direct care for Resident #61 were instructed on management of the [Insulin pump] insulin management system using the manufacturer's Quick Guide and the manufacturer's online training video. - Effective immediately on 12/20/2023, DON/designee began reeducation to 100% of licensed nursing staff on the following: - Use of the [Insulin pump] Insulin Management System utilizing the [Insulin pump] Quick Guide - Assessment, documentation and monitoring of signs and symptoms of hypo/hyperglycemia Signs and Symptoms of Hypoglycemia: Shakiness, Excess sweating, Dizziness, headache, irritability, anxiety and/or fatigue - Signs and Symptoms of Hyperglycemia: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, and pain, Kussmaul breathing, acetone breath (smells fruity), stupor, coma - Staff will be reeducated prior to the start of their next scheduled shift. Any facility staff on FMLA, Leave of Absence or PTO will be reeducated prior to the start of their next scheduled shift. The Director of Nursing/ Designee will review new orders received for insulin administration to ensure that orders are complete to include monitoring and plan of care completed during the Morning Clinical Meeting attended Monday-Friday. Additional resident and staff training will be conducted as indicated with regards to plan of care. Monitoring: - DON/designee will audit residents with automatic insulin delivery devices 2 times/week to assess for ongoing assessment of blood sugars, signs of symptoms of hypo/hyperglycemia and notification of providers when deviation from as per ordered parameters, completion of Self Administration of Medications quarterly and with change in condition and proper functioning of automatic insulin delivery device. - The results of the reviews will be presented by the Administrator/designee to the QAPI committee monthly for 3 months. The QAPI committee will make recommendations as needed. - DON/designee will visually assess the [Insulin pump] insulin administration system weekly for: - [Insulin pump] controller is charged and operational. - [Insulin pump] for proper placement - [Brand Name] sensor of the [Insulin pump] for proper placement - [Brand Name] transmitter of the [Insulin pump] for proper placement The DON/designee will monitor compliance with the process weekly. Results of the findings will be discussed in the QAPI meeting monthly for 3 months. The plan will be continued as needed. - An AdHoc QAPI was conducted on 12/20/23 attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F tag 684 - Treatment and Care in Accordance with Professional Standards of Care and development of the above Action Plan. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy issued on 12/20/2023. POR Verification During an interview with ADON H on 12/22/2023 at 10:36 a.m., ADON H confirmed she has assessed Resident #61 and found him to be in stable condition. Record review of Resident #61's clinical record revealed a progress note, dated 12/20/2023 which stated ADON had assessed Resident #61 and found him to be in stable condition. During an interview with the DON on 12/22/2023 at 10:36 a.m., the DON confirmed she completed a Self-Administration of Medication Assessment with Resident on 12/20/2023. The DON stated Resident #61 was completely capable of self-administration as evidenced by return demonstration by the resident, and stated the Self Administration of Medication Assessment will be completed quarterly and with changes in condition. Record review of Resident #61's clinical record revealed a progress note, dated 12/20/2023 which stated the DON had completed a Self-Administration of Medication Assessment with Resident #61. Record review of Resident #61's clinical record revealed an order, dated 12/19/2023 for Resident #61's blood sugar to be monitored as needed if noted with signs and symptoms of hypo/hyperglycemia Record review of Resident #61's clinical record revealed his care plan was updated on 12/19/2023 to reflect the resident's use of the [insulin pump] insulin administration device and nursing interventions to include but not limited to monitoring of glucose readings from the device or resident before meals as ordered and as needed for any signs of hypo/hyperglycemia, notify MD notifications for any concerns and/or blood glucose outside of the physician's parameters, monitoring for signs and symptoms of hypo/hyperglycemia, Completing self -administration assessment/re-assessment to ensure resident's abilities with utilization of the [insulin pump]; assisting resident with the [insulin pump] insulin administration unit as needed. Record review of the clinical records as of 12/22/2023 of all residents who received insulin revealed only Resident #61 received insulin via BS management system. During an interview with the DON, ADON B, ADON H, ADON I, and Regional RN Y on 12/22/2023 at 10:36 a.m., the DON, ADON B, ADON H, ADON I, and Regional RN Y confirmed that the ADONs completed a 100% review on 12/20/23 of residents with Insulin administration orders to ensure ongoing blood glucose monitoring as ordered to include documentation and notification to providers when resident glucose levels exceed parameters. Record review of all facility residents' clinical records as of 12/22/2023, revealed 32 residents received insulin. Record review of the clinical records as of 12/22/2023 of 10 residents who received insulin, revealed all 10 records were accurate. During an interview with the DON on 12/22/2023 at 10:36 a.m., the DON confirmed she had received instruction regarding insulin pump management from Endocrinologist [Dr. T]. During an interview with the DON, ADON B, ADON H, ADON I, and Regional RN Y on 12/22/2023 at 10:36 a.m., the DON, ADON B, ADON H, ADON I, and Regional RN Y confirmed that all licensed staff who provide direct care for Resident #61 were instructed on management of the [insulin pump] insulin management system using the manufacturer's Quick Guide and the manufacturer's online training video. During an interview with the DON, ADON B, ADON H, ADON I, and Regional RN Y on 12/22/2023 at 10:36 a.m., the DON, ADON B, ADON H, ADON I, and Regional RN Y confirmed that all licensed staff who provide direct care for Resident #61 were educated as described above. A record review of the facility's nursing roster revealed a nursing staff of 100, to include RN's, LVN's, and CNA's. 53 staff were interviewed and a sample of the 53 from all 3 shifts were documented as follows: 06:00 AM to 02:00 PM nursing shift: During an interview on 12/22/2023 at 10:18 AM CNA FF stated she had received recent training to include residents' signs and symptoms of too much blood sugar [being thirsty and hungry, frequent urination, muscle cramps, fruity breath]. During an interview on 12/22/2023 at 10:19 AM CNA GG stated she had received recent training to include residents' signs and symptoms of too little blood sugar [having shakiness, sweating, dizziness, headaches, irritability, anxiety and/or fatigue]. During an interview on 12/22/2023 at 10:20 AM CNA HH stated he received training for residents who used an insulin pump. CNA HH stated he would report to the nurse any signs of the pump making warning sounds, becoming displaced, or redness, swelling, and or discomfort to the pump site. During an interview on 12/22/2023 at 10:17 AM CNA II stated she had received recent training to include residents' signs and symptoms of too much blood sugar [being thirsty and hungry, frequent urination, muscle cramps, fruity breath]. During an interview on 12/22/2023 at 10:21 AM CNA JJ stated he had received recent training to include residents' signs and symptoms of too little blood sugar [having shakiness, sweating, dizziness, headaches, irritability, anxiety and/or fatigue]. During an interview on 12/22/2023 at 10:19 AM LVN KK stated she received training for residents who used an insulin pump from the DON. LVN KK stated she had reviewed the manufactures instructions for care and maintenance of the pump as well as the physicians' orders for the use of the insulin pump. During an interview on 12/22/2023 at 10:38 AM LVN MM stated she received training for residents who used an insulin pump from the DON. LVN KK stated she had reviewed the manufactures instructions for care and maintenance of the pump as well as the physicians' orders for the use of the insulin pump. 02:00 PM to 10:00 PM nursing shift: During an interview on 12/22/2023 at 10:18 AM CNA NN stated he had received recent training to include residents' signs and symptoms of too much blood sugar [being thirsty and hungry, frequent urination, muscle cramps, fruity breath]. During an interview on 12/22/2023 at 2:04 PM CNA D stated he had received recent training to include residents' signs and symptoms of too little blood sugar [having shakiness, sweating, dizziness, headaches, irritability, anxiety and/or fatigue]. During an interview on 12/22/2023 at 2:05 PM CNA OO stated she received training for residents who used an insulin pump. CNA OO stated she would report to the nurse any signs of the pump making warning sounds, becoming displaced, or redness, swelling, and or discomfort to the pump site. During an interview on 12/22/2023 at 10:18 AM CNA PP stated she had received recent training to include residents' signs and symptoms of too much blood sugar [being thirsty and hungry, frequent urination, muscle cramps, fruity breath]. During an interview on 12/22/2023 at 2:28 PM CNA QQ stated he had received recent training to include residents' signs and symptoms of too little blood sugar [having shakiness, sweating, dizziness, headaches, irritability, anxiety and/or fatigue]. During an interview on 12/22/2023 at 2:03 PM LVN RR stated she received training for residents who used an insulin pump from the DON. LVN RR stated she had reviewed the manufactures instructions for care and maintenance of the pump as well as the physicians' orders for the use of the insulin pump. During an interview on 12/22/2023 at 2:04 PM LVN SS stated she received training for residents who used an insulin pump from the DON. LVN SS stated she had reviewed the manufactures instructions for care and maintenance of the pump as well as the physicians' orders for the use of the insulin pump. 10:00 PM to 06:00 AM nursing shift: During an interview on 12/22/2023 at 3:47 PM CNA TT stated she had received recent training to include residents' signs and symptoms of too much blood sugar [being thirsty and hungry, frequent urination, muscle cramps, fruity breath]. During an interview on 12/22/2023 at 3:54 PM LVN UU stated she received training for residents who used an insulin pump from the DON. LVN UU stated she had reviewed the manufactures instructions for care and maintenance of the pump as well as the physicians' orders for the use of the insulin pump. During an interview on 12/22/2023 at 3:50 PM LVN VV stated she received training for residents who used an insulin pump from the DON. LVN VV stated she had reviewed the manufactures instructions for care and maintenance of the pump as well as the physicians' orders for the use of the insulin pump. During an interview on 12/22/2023 at 3:42 PM LVN XX stated she received training for residents who used an insulin pump from the DON. LVN XX stated she had reviewed the manufactures instructions for care and maintenance of the pump as well as the physicians' orders for the use of the insulin pump. During an interview with the Administrator, DON, and Regional RN Y on 12/22/2023 at 10:36 a.m., the Administrator, DON, and Regional RN Y confirmed the DON/designee will audit residents with automatic insulin delivery devices 2 times/week to assess for ongoing assessment of blood sugars, signs of symptoms of hypo/hyperglycemia and notification of providers when deviation from as per ordered parameters, completion of Self Administration of Medications quarterly and with change in condition and proper functioning of automatic insulin delivery device Record Review of the DON's initial audit was completed, Interview was completed to ensure that she plans to continue to do so 2 times per week as per POR. During an interview with the Administrator, DON, and Regional RN Y on 12/22/2023 at 10:36 a.m., the Administrator, DON, and Regional RN Y confirmed that results of the reviews will be presented by the Administrator/designee to the QAPI committee monthly for 3 months. The QAPI committee will make recommendations as needed. During an interview with the DON on 12/22/2023 at 10:36 a.m., the DON confirmed she or designee will visually assess the [Insulin pump] insulin administration system weekly for: Record Review of the DON's initial assessment was completed, Interview was completed to ensure that she plans to continue to do so 1 time per week as per POR. During an interview with the Administrator and DON on 12/22/2023 at 10:36 a.m., the Administrator and DON confirmed the DON/designee will monitor compliance with the process weekly. Results of the findings will be discussed in the QAPI meeting monthly for 3 months. The plan will be continued as needed. Record review of AdHoc QAPI meeting attendance sheet, dated 12/20/2023 revealed the committe met. The Administrator was informed the Immediate Jeopardy was lifted on 12/22/2023 at 6:08 PM. While the IJ was removed on 12/22/2023, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor their corrective actions.