**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the resident's physician and notify the resident representative of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 6 residents reviewed for notification of changes. The facility failed to ensure LVN A notified the physician/designee and the resident's representative after Resident #1 had a change of condition with agonal breathing (the medical term for gasping for air), fixed pupils, no urine output and lethargy. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 04/07/2025 and ended on 04/08/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for not receiving appropriate care and interventions and/or death. The findings included: Record review of Resident #1's face sheet dated 04/15/2025 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of chronic atrial fibrillation (a heart condition where the upper two chambers of the heartbeat irregularly and rapidly, lasting longer than 12 months), repeated falls and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 which indicated moderate cognitive impairment. Resident #1 was usually understood by others and usually understands. Resident #1 required setup assistance for eating and moderate assistance for personal hygiene. Resident #1 required maximal assistance with bathing, dressing and dependent with toileting hygiene. Record review of Resident #1's care plan dated 10/17/2023, reflected I have chosen do not resuscitate status. Ensure resident wishes are followed as desired. Follow my advanced directive/code status. Record review of Resident #1's orders undated revealed advanced directives code status DNR (do not resuscitate). Record review of Resident #1's nurse progress note dated 04/07/2025 at 5:00 a.m., wrote by LVN A said she was called by CNA this nurse to resident's room and upon assessment resident shows agonal breathing, skin is cold, eyes are fixed. Resident #1 vital signs were 54/53, 54, 93%, 128. Resident was a DNR and on hospice. Will continue to monitor. Record review of Resident #1's SW progress note date 04/05/2025 revealed, this social intern called the resident's family today. Family Member #1 asked not to be called at 3 A.M. unless it's an emergency, Resident #1 has passed or is in the emergency room. Record review of Resident #1's hospital records dated 04/07/2025 revealed death due to cardiopulmonary arrest. During an interview on 04/15/2025 at 8:50 A.M., the DON said CNA B reported the change of condition of Resident #1 to LVN A. LVN A only monitored Resident #1. LVN C the oncoming nurse assessed Resident #1, called the MD and sent her out to the emergency room. The DON said all LVN A did from 5-6:00 A.M. was monitor Resident #1. The DON said LVN A should have called the MD and probably sent her out to the hospital. She said LVN A should have called the family, and she did not call anyone. She said LVN A was a DNR/do not return after this. She said she believed the resident was neglected by LVN A. The DON said from 5-6:00 A.M. Resident #1 had agonal breathing and a fast heart rate. The DON said LVN C called her 04/07/2025 at 7:17 A.M. to tell her what was going on with Resident #1. During an interview on 04/15/2025 at 10:37 A.M., LVN C said she got to the facility the morning of 04/07/2025 about 6:30 A.M. and LVN A gave her report. LVN C said LVN A told her the aide notified her about 5am that Resident #1 was not acting right, so she went to assess the Resident #1. LVN C said LVN A told her Resident #1's blood pressure was low; the resident's pupils were fixed and she was not responding. LVN C said LVN A said Resident #1 was on hospice and she told her she was not on hospice. LVN C said she asked LVN A if she had notified anyone about the change in condition of Resident #1 and she said no. LVN C said after she and LVN A were finished with report, she went to assess Resident #1 and she was not responding so she called 911. Then LVN C said she notified the NP of Resident #1's change of condition and Resident #1 was not responding. Then LVN C said she notified the family and the DON. LVN C said LVN A said she did not understand how that was a change in condition. LVN C said once she received report from LVN A, LVN A left the facility. During an interview on 04/15/2025 at 12:07 P.M., LVN A said CNA B was making her last rounds when she came and her told Resident #1 did not look right. LVN A said she went to assess Resident #1 and her vital signs were low. She said Resident #1 looked like she was actively dying. She said Resident #1 was a DNR. She said she saw there was a progress note from the social worker that said the family requested not to call at 3:00 A.M. or in the middle of the night. She said the social worker progress note was put in on the 04/05/2025. She said she monitored Resident #1 the rest of her shift and she did 15 minutes checks on her. She said eventually the next nurse came in. She said she was confused about if the resident was actively passing, because in her training if they were actively passing the nurse should do nothing if the resident was a DNR. She said she did not notify the MD or NP and she said she did not notify the family, because the social worker progress note said the family did not want to be contacted in throughout the night and early morning hours. She said felt like she did her job because she monitored the resident. During an interview on 04/15/2025 at 12:31 P.M., the SW said she usually worked in the facility 3 days a week, but it depends on what the census was. She said yes, she had an intern to put a progress note in PCC (electronic health record) for Resident #1 on 04/05/2025. The SW verified that there was a note that stated Resident #1's family requested not to be contacted in the middle of the night or early in the morning regarding the resident's care. During an interview on 04/15/2025 at 12:41 P.M., CNA B said when she did her last rounds, she noticed Resident #1 had not wet during the shift. She said she was not a heavy wetter but had not voided the whole shift and she had not rested well. She said she had worked for hospice before, and she knew that was not a good sign. She said she notified the nurse immediately. She said the nurse checked Resident #1's vital signs and told her she might be right, that something was going on with Resident #1. CNA B said Resident #1's eyes were already fixed. She said LVN A was agency staff, and she was agency staff also, but she had worked with Resident #1 for a while. She said she thought LVN A did not know Resident #1 well enough to know that there was a change in her condition on how she usually acts, she guessed. She said she thought LVN A may have received report on Resident #1 not feeling well. She said after she completed her last rounds, she went home. She said she thought LVN A should have sent Resident #1 out to the hospital. She said LVN A told her Resident #1 was on hospice and she told her she did not know she was on hospice. She said she thought to herself if Resident #1 was on hospice, she should have notified the hospice company. She said later she found out Resident #1 was not on hospice. She said if she was in LVN A's shoes she would have sent Resident #1 out to the hospital, with her breathing the way she was breathing. During an interview on 04/15/2025 at 2:07 P.M., the MD said it does not ever hurt to notify the MD. He said any time there was an emergency with a resident the nurse should notify the NP or MD. He said with the incident with Resident #1 having low vital signs and agonal breathing, he would have wanted to be notified and he would have given orders for the nurse to send Resident #1 out to the hospital. He said the incident occurred and it sound like the nurse did not do her job and got fired and that was appropriate. During an interview on 04/15/2025 at 3:05 P.M., the DON said when the nurse was notified of a change of condition with Resident #1, the nurse should have done her assessment, then based off of her assessment she should have notified the NP or the MD. She said after she notified them of the change in condition they would have given her further orders. She said she felt like the nurse neglected Resident #1 by not notifying the MD and taking no further actions for the resident. She said they try to keep check off agency staff when we are performing any kind of check offs and they are working in our building. She said the facility did in-services and the book stayed at the nurses' station and they are supposed to sign and read the in-services before they start work. During an interview on 04/15/2025 at 3:47 P.M., the ADM said as soon as the nurse knew that there was a change in condition with Resident #1 she should have called the NP. She said the NP could have told her what to do, but by her not calling him she made a decision that she was not allowed to make, which was to do nothing. She said LVN A should have notified Resident #1's family as well. She said if she would have notified the NP, she would have been able to tell the family what the NP said about the resident's condition. She said she felt like LVN A made a stupid decision in her heart and the resident's needs were not met. She said there are in-services over Change of Condition, Abuse, Neglect and Exploitation, and DNR at the front nurse station since the 04/08/2025 every nurse has been in serviced on this. She said if she or the DON is not in the facility the off-going nurses were responsible for in servicing the incoming nurses who had not been in serviced on the topics. During an interview on 04/16/2025 at 10:19 A.M., the ADM said on the in-services you have to go to PCC to work Stopwatch tool, but there was not an actual way to show what we have been working on. She said Stopwatch is noted to a specific person when they were flagged in PCC. She said the stopwatch tool was to the signature page. We have in serviced everyone on the physical tool. Record review of the facility's Change in a Resident's Condition or Status revised date 02/2021 indicated .Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . .1.The nurse will notify the resident's attending physician or physician on call when there has been a(an)significant change of condition is a major decline or improvement in the resident's status . The facility corrected the noncompliance on 04/08/2025 by the following: -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN L, RN F, RN E,CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of In-services on COC (Change of Condition). All staff verbalized understanding CNAs are to alert nurses and nurses are to alert representative and physician of any changes in the resident's medical/mental condition or status. - Completed 04/08/2025. -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN L, RN F, RN E,CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of In-services on DNR (do not resuscitate). All staff verbalized education on DNR and meaning, but voiced it does not mean that the facility will not treat the resident in the event of a change of condition and does not mean do not send the resident to the hospital for emergency treatment. - Completed 04/08/2025. -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN L, RN F, RN E,CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of in-service on ANE (Abuse, Neglect and exploitation). Staff was able to identify the different types of abuse, neglect, exploitation and who to report it to. -Completed 04/08/2025. -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN E, RN L, RN F, CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of Stop and Watch, Early Warning Tool (Interact). Staff verbalizing if they identified a change while caring for or observing a resident/patient, please circle the change and notify a nurse. -Completed 04/15/2025. -All nurses interviewed (DON, ADON, MDS Nurse, RN L, RN E, and LVN C) on huddles an ongoing process was when the nurses got together during shift change to talk about any changes to the resident, anything new with the residents, anything to watch for. They said they talked about any new wounds would need to be reported. They said they always reported things as they happened but would go over it again in the huddle. They showed this surveyor in PCC how to find the flags for high-risk residents and anything the residents had flagged for. We looked at several residents with flags. There was only one resident with an SBar since 04/07/2025.Ongoing process. - QAPI meeting held to discuss appropriate care interventions were not provided in a timely manner following a resident's change in condition. This failure to act accordingly may have contributed to a delay in an assessment, treatment, or escalation of care on 04/07/2025: -The resident exhibited clear signs of a change in condition, including agonal breathing, cold skin, eyes fixed vital signs:54/53, 54, 93%, 128. -Documentation indicates that the change was either not communicated promptly or not acted upon in accordance with facility protocol (i.e, call NP/MD/DON). -Care team did not initiate appropriate clinical interventions or notify the appropriate providers within the expected time frame. - Completed 04/08/2025. During an interview on 04/16/2025 at 2:00 P.M., Family Member#1 of Resident #1 said the care she received from the facility was not great. Family Member #1 said she had laryngitis and she could not talk. During an interview on 04/17/2025 at 9:43 A.M., RN D said she had only worked at the facility a couple of times. She said she could not remember the resident by name. She said that was her first time working on that hall, but the last day she worked which was 04/06/2025 none on her residents were in critical condition and she had no reports of a change of condition on any of them. She said if a resident had a change in condition, she would have notified the MD and sent the resident to the hospital and notified the family. During an interview on 04/17/2025 at 10:49 A.M., the DON said she felt like once LVN A had been notified of the change of condition with Resident #1 had occurred she should have assessed her, notified the NP or MD of the findings and followed the orders. She said she was totally mind blown by LVN A's reaction to what she was taught. She said LVN A said she thought she did not do anything wrong. She said the facility put a DNR (do not return) on LVN A and the agency terminated her as well. During an interview on 04/17/2025 at 11:08 A.M., the ADM said she felt that everything LVN C did should have been done during the incident with Resident #1. She said LVN A had the tools she needs at the facility and there was another nurse on duty to assist her for guidance and to help her. She said LVN A chose to monitor Resident #1. She said LVN A should have called the NP, she should have called anyone. She said she believed LVN A's biggest downfall was she did not call anyone. The ADM said she believed that Resident #1 was in a-fib (an irregular and often rapid heart rhythm, but they do not know, because LVN A did not make a phone call. She said LVN A should have made a phone call to the family of Resident #1. The ADM said if Resident #1 was her family, yes I would want to be notified of her condition. She said LVN A's reaction was unacceptable, and she would be referring her to the Texas board of nursing. The noncompliance was identified as PNC. The noncompliance began on 04/07/2025 and ended on 04/08/2025. The facility corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice for 1 of 6 resident's reviewed for quality of care. The facility failed to notify the physician/designee and or seek a higher level of care on 4/07/2025 5:00 a.m. - 6:00 a.m. when Resident #1 had a change of condition with agonal breathing, fixed pupils, no urine output and lethargic. The facility failed to ensure LVN A documented any additional assessments/monitoring of Resident #1 after the initial assessment on 4/07/2025 at 5:00 a.m. The facility failed to ensure LVN A initiated any interventions to prevent a further decline in Resident #1. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 04/07/2025 and ended on 04/08/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for not receiving timely medical intervention. The findings included: Record review of Resident #1's face sheet dated 04/15/2025 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of chronic atrial fibrillation (a heart condition where the upper two chambers of the heartbeat irregularly and rapidly, lasting longer than 12 months), repeated falls and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 which indicated moderate cognitive impairment. Resident #1 was usually understood by others and usually understands. Resident #1 required setup assistance for eating and moderate assistance for personal hygiene. Resident #1 required maximal assistance with bathing, dressing and dependent with toileting hygiene. Record review of Resident #1's care plan dated 10/17/2023, reflected I have chosen do not resuscitate status. Ensure resident wishes are followed as desired. Follow my advanced directive/code status. Record review of Resident #1's orders undated revealed advanced directives code status DNR (do not resuscitate). Record review of Resident #1's SW progress note date 04/05/2025 revealed, this social intern called the resident's family today. Family Member #1 asked not to be called at 3 A.M. unless it's an emergency, Resident #1 has passed or is in the emergency room. Record review of Resident #1's nurse progress note dated 04/07/2025 at 5:00 a.m., noted by LVN A said she was called by CNA this nurse to resident's room and upon assessment resident shows agonal breathing, skin is cold, eyes are fixed. Resident #1 vital signs were 54/53, 54, 93%, 128. Resident was a DNR and on hospice. Will continue to monitor. Record review of Resident #1 nurse progress note dated 04/07/2025 at 6:45 a.m., noted by LVN C said after receiving report at 6:30 a.m. this nurse assessed resident, resident lying in bed, eyes open pupils fixed, unresponsive to verbal/tactile stimuli, respirations shallow, unable to obtain blood pressure, skin cold to the touch. She documented at 6:53 a.m. EMS called at this time. Record review of Resident #1 nurse progress note dated 04/07/2025 at 7:00 a.m. noted by LVN C said NP called notified about resident's change in condition and EMS being called, ok with sending resident to ER for evaluation. Record review of Resident #1 nurse progress noted date 04/07/2025 at 7:05 a.m. noted by LVN C said EMS here resident's daughter notified at this time. Record review of Resident #1 nurse progress noted date 04/07/2025 at 7:17 a.m. noted by LVN C said DON notified at this time. Record review of Resident #1 nurse progress noted date 04/07/2025 at 7:20 a.m. noted by LVN C said resident transported to UT Quitman at this time. Record review of Resident #1's hospital records dated 04/07/2025 revealed death due to cardiopulmonary arrest. During an interview on 04/15/2025 at 8:50 A.M., the DON said CNA B reported the change of condition of Resident #1 to LVN A. LVN A only monitored Resident #1. LVN C the oncoming nurse assessed Resident #1, called the MD and sent her out to the emergency room. The DON said all LVN A did from 5-6:00 A.M. was monitor Resident #1. The DON said LVN A should have called the MD and probably sent her out to the hospital. She said LVN A should have called the family, and she did not call anyone. She said LVN A was a DNR/do not return after this. She said she believed the resident was neglected by LVN A. The DON said from 5-6:00 A.M. Resident #1 had agonal breathing and a fast heart rate. The DON said LVN C called her 04/07/2025 at 7:17 A.M. to tell her what was going on with Resident #1. During an interview on 04/15/2025 at 10:37 A.M., LVN C said she got to the facility the morning of 04/07/2025 about 6:30 A.M. and LVN A gave her report. LVN C said LVN A told her the aide notified her about 5am that Resident #1 was not acting right, so she went to assess the Resident #1. LVN C said LVN A told her Resident #1's blood pressure was low; the resident's pupils were fixed and she was not responding. LVN C said LVN A said Resident #1 was on hospice and she told her she was not on hospice. LVN C said she asked LVN A if she had notified anyone about the change in condition of Resident #1 and she said no. LVN C said after she and LVN A were finished with report, she went to assess Resident #1 and she was not responding so she called 911. Then LVN C said she notified the NP of Resident #1's change of condition and Resident #1 was not responding. Then LVN C said she notified the family and the DON. LVN C said LVN A said she did not understand how that was a change in condition. LVN C said once she received report from LVN A, LVN A left the facility. During an interview on 04/15/2025 at 12:07 P.M., LVN A said CNA B was making her last rounds when she came and her told Resident #1 did not look right. LVN A said she went to assess Resident #1 and her vital signs were low. She said Resident #1 looked like she was actively dying. She said Resident #1 was a DNR. She said she saw there was a progress note from the social worker that said the family requested not to call at 3:00 A.M. or in the middle of the night. She said the social worker progress note was put in on the 04/05/2025. She said she monitored Resident #1 the rest of her shift and she did 15 minutes checks on her. She said eventually the next nurse came in. She said she was confused about if the resident was actively passing, because in her training if they were actively passing the nurse should do nothing if the resident was a DNR. She said she did not notify the MD or NP and she said she did not notify the family, because the social worker progress note said the family did not want to be contacted in throughout the night and early morning hours. She said felt like she did her job because she monitored the resident. During an interview on 04/15/2025 at 12:31 P.M., the SW said she usually worked in the facility 3 days a week, but it depends on what the census was. She said yes, she had an intern to put a progress note in PCC (electronic health record) for Resident #1 on 04/05/2025. The SW verified that there was a note that stated Resident #1's family requested not to be contacted in the middle of the night or early in the morning regarding the resident's care. During an interview on 04/15/2025 at 12:41 P.M., CNA B said when she did her last rounds, she noticed Resident #1 had not wet during the shift. She said she was not a heavy wetter but had not voided the whole shift and she had not rested well. She said she had worked for hospice before, and she knew that was not a good sign. She said she notified the nurse immediately. She said the nurse checked Resident #1's vital signs and told her she might be right, that something was going on with Resident #1. CNA B said Resident #1's eyes were already fixed. She said LVN A was agency staff, and she was agency staff also, but she had worked with Resident #1 for a while. She said she thought LVN A did not know Resident #1 well enough to know that there was a change in her condition on how she usually acts, she guessed. She said she thought LVN A may have received report on Resident #1 not feeling well. She said after she completed her last rounds, she went home. She said she thought LVN A should have sent Resident #1 out to the hospital. She said LVN A told her Resident #1 was on hospice and she told her she did not know she was on hospice. She said she thought to herself if Resident #1 was on hospice, she should have notified the hospice company. She said later she found out Resident #1 was not on hospice. She said if she was in LVN A's shoes she would have sent Resident #1 out to the hospital, with her breathing the way she was breathing. During an interview on 04/15/2025 at 2:07 P.M., the MD said it does not ever hurt to notify the MD. He said any time there was an emergency with a resident the nurse should notify the NP or MD. He said with the incident with Resident #1 having low vital signs and agonal breathing, he would have wanted to be notified and he would have given orders for the nurse to send Resident #1 out to the hospital. He said the incident occurred and it sound like the nurse did not do her job and got fired and that was appropriate. During an interview on 04/15/2025 at 3:05 P.M., the DON said when the nurse was notified of a change of condition with Resident #1, the nurse should have done her assessment, then based off of her assessment she should have notified the NP or the MD. She said after she notified them of the change in condition they would have given her further orders. She said she felt like the nurse neglected Resident #1 by not notifying the MD and taking no further actions for the resident. She said they try to keep check off agency staff when we are performing any kind of check offs and they are working in our building. She said the facility did in-services and the book stayed at the nurses' station and they are supposed to sign and read the in-services before they start work. During an interview on 04/15/2025 at 3:47 P.M., the ADM said as soon as the nurse knew that there was a change in condition with Resident #1 she should have called the NP. She said the NP could have told her what to do, but by her not calling him she made a decision that she was not allowed to make, which was to do nothing. She said LVN A should have notified Resident #1's family as well. She said if she would have notified the NP, she would have been able to tell the family what the NP said about the resident's condition. She said she felt like LVN A made a stupid decision in her heart and the resident's needs were not met. She said there are in-services over Change of Condition, Abuse, Neglect and Exploitation, and DNR at the front nurse station since the 04/08/2025 every nurse has been in serviced on this. She said if she or the DON is not in the facility the off-going nurses were responsible for in servicing the incoming nurses who had not been in serviced on the topics. During an interview on 04/16/2025 at 10:19 A.M., the ADM said on the in-services you have to go to PCC to work Stopwatch tool, but there was not an actual way to show what we have been working on. She said Stopwatch is noted to a specific person when they were flagged in PCC. She said the stopwatch tool was to the signature page. We have in serviced everyone on the physical tool. Record review of the facility's Change in a Resident's Condition or Status revised date 02/2021 indicated .Our community promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . .1.The nurse will notify the resident's attending physician or physician on call when there has been a(an)significant change of condition is a major decline or improvement in the resident's status . The facility corrected the noncompliance on 04/08/2025 by the following: -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN L, RN F, RN E,CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of In-services on COC (Change of Condition). All staff verbalized understanding CNAs are to alert nurses and nurses are to alert representative and physician of any changes in the resident's medical/mental condition or status. - Completed 04/08/2025. -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN L, RN F, RN E,CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of In-services on DNR (do not resuscitate). All staff verbalized education on DNR and meaning, but voiced it does not mean that the facility will not treat the resident in the event of a change of condition and does not mean do not send the resident to the hospital for emergency treatment. - Completed 04/08/2025. -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN L, RN F, RN E,CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of in-service on ANE (Abuse, Neglect and exploitation). Staff was able to identify the different types of abuse, neglect, exploitation and who to report it to. -Completed 04/08/2025. -All staff interviewed ( ADON, MDS Nurse, LVN C, CNA B, RN D, RN E, RN L, RN F, CNA G, CNA H, CWT I, CNA J, CNA K, SW, [NAME] M, CNA N, Maintenance O, DM P, Housekeeper Q, Housekeeper T, DA R, CNA S, CNA U and RN V ) on 04/16/2025 verbalized understanding of Stop and Watch, Early Warning Tool (Interact). Staff verbalizing if they identified a change while caring for or observing a resident/patient, please circle the change and notify a nurse. -Completed 04/15/2025. -All nurses interviewed (DON, ADON, MDS Nurse, RN L, RN E, and LVN C) on huddles an ongoing process was when the nurses got together during shift change to talk about any changes to the resident, anything new with the residents, anything to watch for. They said they talked about any new wounds would need to be reported. They said they always reported things as they happened but would go over it again in the huddle. They showed this surveyor in PCC how to find the flags for high-risk residents and anything the residents had flagged for. We looked at several residents with flags. There was only one resident with an SBar since 04/07/2025.Ongoing process. - QAPI meeting held to discuss appropriate care interventions were not provided in a timely manner following a resident's change in condition. This failure to act accordingly may have contributed to a delay in an assessment, treatment, or escalation of care on 04/07/2025: -The resident exhibited clear signs of a change in condition, including agonal breathing, cold skin, eyes fixed vital signs:54/53, 54, 93%, 128. -Documentation indicates that the change was either not communicated promptly or not acted upon in accordance with facility protocol (i.e, call NP/MD/DON). -Care team did not initiate appropriate clinical interventions or notify the appropriate providers within the expected time frame. - Completed 04/08/2025. During an interview on 04/16/2025 at 2:00 P.M., Family Member#1 of Resident #1 said the care she received from the facility was not great. Family Member #1 said she had laryngitis and she could not talk. During an interview on 04/17/2025 at 9:43 A.M., RN D said she had only worked at the facility a couple of times. She said she could not remember the resident by name. She said that was her first time working on that hall, but the last day she worked which was 04/06/2025 none on her residents were in critical condition and she had no reports of a change of condition on any of them. She said if a resident had a change in condition, she would have notified the MD and sent the resident to the hospital and notified the family. During an interview on 04/17/2025 at 10:49 A.M., the DON said she felt like once LVN A had been notified of the change of condition with Resident #1 had occurred she should have assessed her, notified the NP or MD of the findings and followed the orders. She said she was totally mind blown by LVN A's reaction to what she was taught. She said LVN A said she thought she did not do anything wrong. She said the facility put a DNR (do not return) on LVN A and the agency terminated her as well. During an interview on 04/17/2025 at 11:08 A.M., the ADM said she felt that everything LVN C did should have been done during the incident with Resident #1. She said LVN A had the tools she needs at the facility and there was another nurse on duty to assist her for guidance and to help her. She said LVN A chose to monitor Resident #1. She said LVN A should have called the NP, she should have called anyone. She said she believed LVN A's biggest downfall was she did not call anyone. The ADM said she believed that Resident #1 was in a-fib (an irregular and often rapid heart rhythm, but they do not know, because LVN A did not make a phone call. She said LVN A should have made a phone call to the family of Resident #1. The ADM said if Resident #1 was her family, yes I would want to be notified of her condition. She said LVN A's reaction was unacceptable, and she would be referring her to the Texas board of nursing. The noncompliance was identified as PNC. The noncompliance began on 04/07/2025 and ended on 04/08/2025. The facility corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 9 residents (Residents #1 and #2) reviewed for abuse. The facility failed to ensure CNA A did not sexually abuse Resident #1 during his shower earlier in the week of January 5, 2025 - January 9, 2025, when he allegedly placed his finger in his rectum. The facility failed to ensure CNA A did not sexually abuse Resident #2 during a shower provided during the period of December 28, 2024, and December 29, 2024, when he allegedly attempted to place his finger in his rectum. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) noncompliance began on 1/11/2025 and ended on 1/11/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for emotional distress, fear, decreased quality of life, and further abuse. Findings included: 1)Record review of a face sheet dated 1/21/2025 indicated Resident #1 was a [AGE] year-old male, who admitted on [DATE] with the diagnosis of blindness (loss of vision), major depressive disorder (clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest in normally enjoyable activities), and intellectual disabilities (condition that limits intelligence and disrupts abilities necessary for living independently). Record review of Resident #1's Annual MDS assessment dated [DATE] indicated Resident #1 in Section A1510 Level ll Preadmission Screening and Resident Review (PASRR) conditions was marked as having an intellectual disability. The MDS indicated Resident #1 usually was understood, and usually understood others. The MDS indicated Resident #1 had a severely impaired vision (no vision or sees only light, colors or shapes; eyes do not appear to follow objects). The MDS indicated Resident #1's BIMS score was 5 indicating severe cognitive impairment. The MDS indicated Resident #1 had no physical, verbal, or other behaviors directed at others. The MDS indicated Resident #1 had rejected care 1-3 days during the assessment period. The MDS in the section F Preferences for Customary Routine and Activities Resident #1 indicated it was very important to him to him choose between a tub bath, shower, bed bath, or sponge bath. The MDS in Section GG-Functional Abilities and Goals indicated Resident #1 required substantial/maximal assistance with bathing, and partial/moderate assistance with dressing and personal hygiene. Record review of Resident #1's comprehensive care plan dated 9/24/2021 and revised on 5/06/2024 indicated Resident #1 had an ADL self-care performance deficit related to his blindness. The care plan goal was Resident #1 would maintain his current level of function. The interventions of the care plan included Resident #1 would be allowed to perform tasks as much as possible, bathing/showering, and personal hygiene he required assistance of one staff. The care plan indicated Resident #1 used antidepressant medication related to depression. The goal of this care plan was Resident #1 would be free from discomfort related to the use of antidepressant therapy. The interventions for Resident #1 included to administer the antidepressant medication, and to monitor, document, and report any adverse reactions to the antidepressant, a change in behavior/mood/cognition, social isolation, and social isolation. Record review of a hospital emergency room discharge form dated 1/11/2025 indicated Resident #1 was seen at the local emergency room and discharged on 1/11/2025 with the primary diagnosis of sexual assault of adult. The triage notes section of the discharge form indicated Resident #1 arrived by EMS from the nursing facility. The note indicated Resident #1 arrived with complaints of sexual assault for unknown amount of time. The note indicated Resident #1 stated his caregiver had penetrated his rectum with a finger during showers. The note indicated Resident #1 indicated the last event was last week, and he had been refusing showers since then. The note indicated the family requested the transfer to the emergency room for a SANE (Sexual Assault Nurse Examination) exam. The history and physical portion of the discharge note indicated Resident #1 had intellectual disability, chronic kidney disease, and legal blindness. The history and physical noted Resident #1 had a complaint of sexual assault for an unknown period of time with a caregiver in the nursing facility that penetrated the patient's rectum on multiple occasions with his finger while the patient (Resident #1) was showering. The note indicated the patient (Resident #1) had been refusing to shower the past week and his family requested a SANE exam. The note indicated the patient (Resident #1) endorsed rectum pain, denied abdominal or leg pain, dysuria, or blood in his stool. The note indicated the family indicated even if Resident #1 had blood stool he was unable to see the stool due to his blindness. The note in the Review of Systems portion indicated in the gastrointestinal section indicated Resident #1 was positive for rectal pain. Record review of the Provider Investigation Report dated 1/14/2025 indicated the state agency was notified on 1/11/2025 at 11:15 a.m., of the allegation of abuse occurring on 1/07/2025 with no time of day indicted occurring in the shower. The Provider Investigation Report indicated Resident #1 was independently ambulatory, able to be interviewed, but was unable to make decisions. The Provider Investigation Report indicated Resident #1 had a history of false allegations of embellishing tales of attention, refusing showers, and refusing medications. The Provider Investigation Report indicated the alleged perpetrator was identified by name, and was identified as CNA A. The Provider Investigation Report indicated CNA A denied the allegation. The Provider Investigation Report indicated Resident #1 was sent to the local hospital emergency room and the local police was notified with a case # 2500025. The Provider Investigation Report indicated Resident #1's physician, family member, and the ombudsman were notified. Record review of an Employee Timecard dated 1/11/2025 indicated CNA A worked on 1/01/2025 from 6:13 a.m. - 6:30 p.m., 1/02/2025 from 6:10 a.m. - 7:15 a.m., 1/06/2025 from 6:12 a.m. - 7:00 p.m., 1/07/2025 from 6:13 a.m. - 6:45 p.m., 1/10/2025 from 6:02 a.m. - 7:15 p.m., and on 1/11/2025 from 6:05 a.m. - 9:22 a.m. Record review of an undated ADL sheet indicated Resident #1 received a shower from CNA A 1/02/2025, and then again on 1/07/2025. The ADL sheet documentation had no further baths provided from 1/08/2025 - 1/21/2025. Record review of a daily staff schedule dated 1/06/2025 indicated CNA A was scheduled to work on halls 200, 300, and 400. Record review of a daily staff schedule dated 1/07/2025 indicated CNA A was scheduled to work on halls 200, 300, and 400. Record review of a daily staff schedule dated 1/10/2025 indicated CNA A was scheduled to work on halls 200, 300, and 400. Record review of a daily staff schedule dated 1/11/2025 indicated CNA A was scheduled to work with no specified halls. Record review of the Police Report dated 1/11/2025 at 9:43 a.m., indicated a crime/incident of aggravated sexual assault of another person was reported. The suspect was named as CNA A, and the victim was Resident #1, the reporter was LVN B. The report indicted he received the report from LVN B upon arrival that Resident #1 had identified CNA A as the individual who had inserted his finger into his rectum while taking a shower. The officer documented upon arrival at the facility, LVN B indicated she had to send CNA A home, then he was escorted to Resident #1's room. The officer wrote Resident #1 was accompanied with his family member. The officer wrote Resident #1 said yes, he wanted to make a report on a staff member. The officer wrote Resident #1 said he had a finger in my butt. The report indicated Resident #1 made a fist with his right hand and pointing his index finger straight out. The report indicated Resident #1 made a motion suggesting CNA A was inserting his finger in and out of his anus. The report indicated Resident #1 said when I take a shower, he put a finger in my butt. The officer documented when he asked Resident #1 how long this had occurred, he indicated a long time. The report indicated the family member said a couple of months ago when out of the facility Resident #1 complained his butt was sore. The report indicated Resident #1 indicated CNA A plays the music too loud in the shower too. The report indicated Resident #1 said, In the shower, he keeps the thing too loud, and when he is doing that thing in my butt with it. The report indicated the family member stated they could identify CNA A. The report indicated Resident #1 said he wanted to go to the hospital. The report indicated the officer spoke to the Administrator and gained information on CNA A. The Administrator was noted informing the officer Resident #1 had behaviors of telling falsehoods but never this severe. The report indicated LVN B indicated CNA A had played music on his phone. The officer ended the report with Resident #1 was transferred to the local hospital, but the hospital was not equipped with the specialized SANE nurse and therefore was transferred to a larger hospital. Lastly the report indicated the case was referred to the criminal investigation division for further investigation. During an observation and interview on 1/21/2025 at 10:54 a.m., Resident #1 was making his bed when the surveyor entered his dark room. Resident #1 said CNA A had given him a shower last week. Resident #1 said CNA A penetrated his rectum with CNA A's penis. Resident #1 was asked to clarify was it CNA A's penis or finger. Resident #1 again indicated he was penetrated in his rectum by CNA A's penis while he received his shower. Resident #1 also indicated the rock and roll music was too loud in the shower playing on CNA A's personal phone. Resident #1 was unable to cognitively express how the alleged actions of CNA A made him feel but said that was why he refused his next shower. During an interview on 1/21/2025 at 11:21 a.m., LVN B said Resident #1's family member came to her on Saturday 1/11/2025 and indicated Resident #1 refused his shower because he indicated CNA A's finger goes in and out of his butt when he was last showered. LVN B said she notified the Administrator immediately of the allegation, and was advised to send CNA A home immediately, to call 911 to send Resident #1 to the hospital, and then notify the local police. LVN B said she had not performed an assessment of Resident #1 prior to leaving with emergency personnel. During an interview on 1/21/2025 at 11:48 a.m., Resident #1's family member said she arrived for a visit with Resident #1 on 1/11/2025. The family said Resident #1 told her CNA A had touched his butthole making a moving motion and this was why he refused his shower. The family member said she went to the nurse and reported what Resident #1 had said. The family member said Resident #1 retold the same information to the local police officer, hospital staff, and the police officer who arrived at the hospital. The family member said the nurse performing the examination said Resident #1 had tearing around his anus. The family member said Resident #1 had never made any allegations in the past regarding sexual abuse, and this behavior of making this type of allegation was not his normal behavior. The family member said Resident #1's emotional behavior seemed scared to bathe. The family member indicated Resident #1 was usually very happy and cooperative. During an interview on 1/21/2025 at 11:58 a.m., CNA A said on Tuesday 1/07/2025 in the morning hours he took Resident #1 to the shower. CNA A said he provided Resident #1 with a shower and a shave that time and numerous other times. CNA A said Resident #1 could perform portions of his showers but required the physical assistance of making sweeping motions to Resident #1's buttocks and then said Resident #1 was able to perform cleansing of his genitals. CNA A said Resident #1 thanked him for the shower and shave afterwards. Therefore, he believed there were no issues. CNA A said on Saturday 1/11/2025 in the morning hours, he was providing care to another resident when he was approached by the nurse and advised he had to leave immediately there was an allegation of abuse. CNA A said after exiting the resident's room he was informed of the allegation that Resident #1 indicated in which he placed a finger in Resident #1's anus during a shower. CNA A then denied the allegations made by Resident #1. When asked about any other allegations of this nature CNA A indicated he had been named in an allegation in 2023 with the exact same allegation of putting a finger in the rectum. When asked about the findings of the previous allegations, he replied the resident was no longer residing in the facility, and the results were not confirmed because the resident did not like me. CNA A said he could not explain how two residents not knowing each other could have the exact same allegation against him. CNA A said an allegation of this type was considered sexual abuse, should be reported immediately to the abuse coordinator being the administrator immediately. CNA A said he had resigned his position as CNA on Wednesday 1/15/2025 and was not currently employed but was seeking employment elsewhere. CNA A said he had not been interviewed by the local police. 2)Record review of a face sheet dated 1/21/2025 indicated Resident #2 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, and Parkinson's disease (a movement disorder of the nervous system that worsens over time). Record review of a Significant Change MDS dated [DATE] indicated Resident #2 was understood and understands others. The MDS indicated Resident #2's BIMS score was a 13 indicating he had no cognitive issues. The MDS in Section E-Behaviors there was no indications Resident #2 had any physical, verbal, or other behaviors affecting others. The MDS also indicated Resident #2 had not refused care. The MDS in Section F-Preferences for Customary Routine indicated Resident #2 said it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. The MDS indicated in Section GG-Functional Abilities and Goals indicated Resident #2 required partial to moderate assistance with shower/bathe Record review of a Comprehensive Care Plan dated 7/04/2023 and a revision date of 1/12/2024 indicated Resident #2 had an ADL self-care performance deficit related to his Parkinson's disease. The goal of the care plan was Resident #2 would maintain his current level of function. The interventions included the provision of one staff for assistance with bathing, dressing, toileting, and transfers. Record review of a shower schedule dated 12/28/2024 indicated CNA C marked Resident #2 as showered. Record review of a Daily Staffing Schedule dated 12/28/2024 indicated CNA A was scheduled to work. The Daily Staffing Schedule had CNA A handwritten in for halls 200, 300, and 400. Record review of a Safe Survey dated 1/11/2025 at 11:08 a.m., the HR/BOM asked Resident #2: *Has someone (resident or staff) touched you in a way that made you feel uncomfortable example sexually? Resident #2's answer was marked no. *Has someone (resident or staff) made sexual comments or statements to you? Resident #2's answer was marked no. *Has someone (resident or staff) shown you pictures, videos, or other materials of sexual nature? Resident #2's answer was marked no. *Does staff treat you with respect? Sometimes, depends on the person or agency was Resident #2's answer. During an interview on 1/21/2025 at 1:35 p.m., Resident #2 was asked if he had ever been abused by anyone who worked at the facility. Resident #2 said, yes I have. Resident #2 seemed hesitant to explain when asked by pausing. Although we were in his room, and privately talking he would look past me watching the door. Resident #2 said approximately 3 weeks ago, CNA A provided him with a shower, and during the shower he attempted to put his finger in his rectum. Resident #2 said when CNA A was attempting to place his finger in his rectum, he quickly moved in the shower chair, so his anus was not exposed, and Resident #2 said CNA A stopped. When asked to further explain why he failed to tell staff when the staff asked about any abuse, Resident #2 said I did not tell them the truth and I should have told them the truth, but I felt as though they would have thought I was a troublemaker. Resident #2 went on to say he felt embarrassed to talk about it and said, I felt cheap. Resident #2 agreed to tell the staff when I returned with a team member. During an interview on 1/21/2025 at 1:40 p.m., the DON entered Resident #2's room with the surveyor. Resident #2 was asked to inform the DON what he had just reported. Resident #2 then said to the DON, I should have told you when I was asked about being abused but I thought I would be making trouble for CNA A. Resident #2 informed the DON that CNA A attempted to put his finger inside his rectum during a shower approximately 3 weeks ago. Resident #2 said he could not remember the exact day it occurred. Resident #2 said on that day he had made up his mind CNA A would never provide his shower again. During a telephone interview on 1/21/2025 at 2:22 p.m., CNA A said on occasion he had cared for Resident #2. CNA A said he could not remember providing Resident #2 a shower when he was assisting CNA C on the 100-hall. CNA A again denied any forms of abuse. CNA A again had no explanation as to why 3 male residents have made the same allegation. During an interview on 1/21/2025 at 2:28 p.m., CNA C said she had worked with CNA A in the recent past month. CNA C said she worked on the weekend shifts. CNA C said when CNA A worked the hall with her, she would take the female residents and CNA A took the male residents. CNA C said she would complete the documentation for all the residents. CNA C said she would only document a bath if she saw CNA A taking a resident to the shower room. CNA C said she had not witnessed CNA A abusing any resident. Record review of an undated ADL sheet indicated Resident #2 showers were offered but refused on 12/23/2024, 12/25/2024, 12/27/2024, 12/30/2024, 1/1/2025, and 1/06/2025. The ADL sheet indicated Resident #2 accepted a shower on 1/03/2024. During an interview on 1/21/2025 at 3:30 p.m., the ADON said when she informed the surveyor, she completed all the staffing assignments and there was no time since October 2024 that CNA A was assigned to work with Resident #2. The ADON said she had made a mistake and CNA A had been assigned to work with Resident #2 on 12/28/2024 and 12/29/2024. During an interview on 1/21/2025 at 5:15 p.m., the Administrator said although she could not confirm the allegations of sexual abuse, she said lightening can't strike twice. The Administrator said the same allegation with three residents seemed suspicious. The Administrator said abuse was monitored daily during rounds asking questions about abuse and monitor for abuse. The Administrator said she was the abuse coordinator. The Administrator said when she became aware of the allegation, we responded appropriately to protect the residents. The Administrator said safe surveys were conducted, and there were no other residents who voiced any abuse concerns. The Administrator said although CNA A resigned his position, the termination process for CNA A was already approved. The Administrator said the risk of affecting a resident's emotional wellbeing was at risk when abuse occurred and could be harmful over time. During an interview on 1/21/2025 at 5:19 p.m., the DON said she had called CNA A and spoke to him about the allegation regarding Resident #1. The DON said she discussed with CNA A the current allegation with Resident #2 and the previous allegation with the discharged resident in 2023 whether confirmed or not was cause for alert. The DON said she randomly makes walking rounds and asked staff members the abuse questions and monitors for residents for abuse. The DON said she as well believed once the facility learned of the allegation, they acted appropriately to protect all the residents. Record review of CNA A's personnel record revealed he was hired on 5/06/2022. There were no issues noted with the criminal history checks. The personnel record included a formal termination form indicating CNA A was terminated for violating the code of conduct regarding safety health, and security, and regarding preventing abuse and neglect. Record review of an Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated 2001 and revised in April 2021 indicated, the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of facility-wide commitment and resource allocation to support the follow objectives: 1. Protect residents from abuse, neglect, and exploitation or misappropriation of property by anyone including but not necessarily limited to: a. facility staff . Record review of the Abuse and Neglect-Clinical Protocol policy dated 2005 and revised in March 2018 indicated, .3. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. 4. Willful, as defined as used in the definition of abuse, means the individual must have acted deliberately, no that the individual must be intended to inflect injury or harm. The Administrator was notified of the IJ PNC on 1/21/2025 at 5:01 p.m., due to the above failures. The Administrator was provided the IJ template on 1/21/2025 at 5:01 p.m. via email. The surveyor confirmed the following actions had been implemented sufficiently to remove the immediacy by: *During a Record review on 1/21/2025 at 11:00 a.m., the Provider Investigation Report dated 1/11/2025 indicated the facility notified the family, physician, local police, and the ombudsman on 1/11/2025. *During a record review on 1/21/2025 at 11:00-12:00 Resident #1's clinical record indicated he was sent to the local hospital and a SANE exam was provided. *During an interview on 1/16/2025 at 1:18 p.m., the Victim's Advocate said Resident #1 was referred to the advocacy group for sexual crimes. *Record review of an Abuse and Neglect in-service was provided on 1/11/2025. The policy reviewed the definition of abuse and neglect as well as timeframes associated with reporting abuse and neglect to the state agency. The signature page had 32 signatures ranging from all shifts and all disciplines. *Record review of a Termination form dated 1/16/2025 for CNA A with the last day worked noted as 1/11/2025. *Record review of a Resignation letter dated 1/15/2025 for CNA A formal resignation of his role as a CNA. *Record review of a Facility counseling form indicating on 1/15/2025 CNA A was formally terminated with the criteria of not meeting job performance and or behavior expectation related abuse and neglect and violation of the code of conduct. *Review of the daily monitoring tool used for monitoring staff's knowledge of abuse and monitoring for abuse with the start date of 1/11/2025 and was current as of 1/21/2025. The monitoring tool had a staff members last name on each day. *Review of the resident safe surveys with no areas of concerns dated for 1/11/2025. *Review of Residents #1 and #2's allegations reported within the two-hour timeframe to the state agency. *Review of the police reports for Resident #1 (case# 25000025) and Resident #2 (case# 25000045). *Interviews with residents regarding abuse and neglect with a focus presented on sexual abuse revealed they all denied abuse with the exceptions of the above mentioned. *Interviews with staff indicated they had been in-serviced on abuse since 1/11/2025 and were able to define abuse, when to report, whom to report. The noncompliance was identified as PNC. The IJ noncompliance began on 1/11/2025 and ended on 1/11/2025. The facility had corrected the non-compliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent the abuse of residents for 1 of 7 residents (Resident #149) reviewed for abuse. 1. The facility failed to ensure the Administrator was notified immediately when Resident #149 accused CNA L of sexual abuse. 2. The facility failed to ensure Resident #149 and other vulnerable residents were protected from CNA L. CNA L was not immediately suspended and remained in the facility until the end of his shift. 3. The facility failed to ensure allegations of abuse were thoroughly investigated. The facility did not include evidence of Resident #149's interview, resident safe surveys, and LVN D's one-on-one education of the abuse policy in their provider investigation report. 4. The facility failed to ensure allegations of sexual abuse was reported to local law enforcement. An IJ was identified on 06/21/24. The IJ template was provided to the facility on [DATE] at 5:30 p.m While the IJ was removed on 06/23/24, the facility remained out of compliance at scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could place residents at risk of abuse, neglect, physical harm, pain, mental anguish, emotional distress, and serious harm. Findings included: Record review of Resident #149's face sheet, dated 06/20/24, indicated he was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), depressive disorder (mood disorder causing persistent sadness and a loss of interest), mild cognitive impairment, anxiety disorder, Type 2 diabetes (chronic condition that affects how the body regulates and uses sugar), left below the knee amputation cerebrovascular disease (condition that affects blood flow to the brain) and left sided hemiplegia and hemiparesis following cerebral infarction (left sided mild weakness and severe paralysis due to a stroke). Resident #149 was discharged from the facility on 08/11/23. Record review of Resident #149's MDS assessment dated [DATE] indicated he had had moderately impaired cognition and required extensive one person assistance with toileting. Resident #150 had diagnoses of hypertension (high blood pressure), depression (mood disorder causing persistent sadness and a loss of interest), mild cognitive impairment, anxiety disorder, Type 2 diabetes (chronic condition that affects how the body regulates and uses sugar), left below the knee amputation cerebrovascular disease (condition that affects blood flow to the brain) and hemiplegia or hemiparesis (mild weakness or severe paralysis), and depression (mood disorder causing persistent sadness and a loss of interest). Record review of Resident #149's Care Plan dated 05/27/23 indicated he was abusive to staff, made false accusations. Interventions stated to allow resident to express his feelings about what he believed the situation might have been, give reassurance no one was trying to hurt him, interview other residents to verify if staff member was being abusive to them, investigate remarks resident made against staff, obtain statement from any witnesses that might have been present when such problem occurred (initiated 07/19/22). Resident #150 had an ADL self-care performance deficit related to cerebrovascular accident (bleeding in the brain) and interventions included he required one staff member to assist with toileting. Record review of Resident #149's progress notes dated 08/09/23 at 1:00 a.m. by LVN D indicated she spoke with CNA L about the complaint. CNA L asked LVN D to go into his room because the resident accused him of putting his finger up his butt. LVN D agreed and supervised all care that was done for the resident. There was no documentation in Resident #149's progress notes by LVN D to indicate she supervised the resident's care. Record review of Resident #149's progress notes by LVN D, after her entry on 08/09/23 at 1:00 a.m. to the end of her shift on 08/09/23 6:00 a.m., indicated there was no documentation she supervised the resident's care. A provider investigation report dated 08/11/23 signed by the DON indicated the incident with the allegation of abuse occurred in Resident #149's room on 08/08/23 at 11:00 p.m Resident #149 was interviewable with the capacity to make informed decisions and had no history of similar allegations. Resident #149 identified the alleged perpetrator CNA L by name. The Administrator was informed on 08/09/23 by CNA K that Resident #149 told him that CNA L stuck his finger up his butt and turned him in a rough manner on 08/08/23 during care. CNA K reported the incident to the Administrator. Resident #149 was assessed with no injuries then sent to the hospital. The facility notified the physician, responsible party, and Adult Protective Services. There was no documentation to indicate the facility notified the local police department. CNA L, the alleged perpetrator, was notified on 08/09/23; he was suspended pending the outcome of the investigation. CNA L denied the allegations. Provider action taken post-investigation indicated all nurses were in-serviced one on one regarding who the abuse coordinator was and when to call. LVN D received written counselling regarding reporting any reports of abuse or neglect and completed compliance education with test. The nurses were instructed to call if any verbal accusations are made no matter if they knew them to be unfounded. There was no witness statement for Resident #149 documented in the provider investigation report. Record review of LVN D's timecard for August 2023 indicated she clocked in at the facility on 08/08/23 at 5:44 p.m. and clock out on 08/09/23 at 6:11 a.m Record review of CNA L's timecard for August 2023 indicated he clocked in at the facility on 08/08/23 at 10:05 p.m. and clock out on 08/09/23 at 6:11 a.m Record review of LVN D's employee file indicated there was no documentation in her file she had received written counselling regarding reporting any reports of abuse or neglect related to Resident #149. During an interview on 06/21/24 at 2:08 p.m., Resident #149 said CNA L was cleaning him up after he had a bowel movement and stuck his finger in his asshole. Resident #149 said it felt uncomfortable like he was being raped. Resident #149 said he told CNA L what he had done, and his response was that he did not. Resident #149 said he did not recall seeing his nurse come in with CNA L when he checked on him a few times after that. Resident #149 said he transferred to another nursing facility a few days after the incident happened. Resident #149 said he felt safer in the facility that he was at now than in the other facility where the incident occurred. During a phone interview on 06/20/24 at 3:16 p.m., LVN D said she was the charge nurse and worked the 6:00 p.m. - 6:00 a.m. shift. LVN D said she worked on 08/08/23 and provided care to Resident #149. LVN D said sometime after midnight on 08/09/23, CNA L asked her if she would go with him into Resident #149's room when he needed to provide him care because the resident had accused him of sticking his finger up his butt. LVN D said she assessed Resident #149 after he made the allegation. LVN D said she never asked Resident #149 about the incident during her assessment, and he never mentioned it to her. LVN D said Resident #149 had no emotional distress and the only complaint he had was pain to the stump of his left below the knee amputation. LVN D said Resident #149 never mentioned the incident to her or showed emotional distress during her assessment. LVN D said she did not notify the Administrator because she felt that Resident #149 was not in any danger after she assessed him and decided to supervise CNA L's care with Resident #149. LVN D said she went into Resident #149's room with CNA L 2-3 more times before the end of her shift. LVN D said the facility contacted her about the incident and she was in-serviced one on one by the DON about the types of abuse and who to report it to. During an interview on 06/20/24 at 3:24 p.m., CNA L said he worked the 10:00 p.m. to 6:00 a.m. shift on 08/08/23 and provided care to Resident #149. CNA L said he provided incontinent care to Resident #149 after he had a bowel movement. CNA L said he was cleaning Resident #149's anal area when Resident #149 told him he had stuck his finger up his butt. CNA L said he told Resident #149 he did not and was having a difficult time getting the area cleaned because his bowel movement was like a thick paste. CNA L said he left Resident #149's room after he finished cleaning him up and told LVN D, Resident #149 had accused him of sticking his finger up his butt during incontinent care. CNA L said LVN D went into Resident #149's room with him 2-3 times during his shift. CNA L thought he would be sent home immediately after he told LVN D about Resident #149's allegations he made against him and thought it was odd he was allowed to complete his shift. CNA L said the facility notified him on 08/09/23 that he was suspended during the investigation. CNA L said he did not stick his finger up Resident #149's butt. During an interview on 06/20/24 at 3:34 p.m., the DON said she assisted the previous administrator with the investigation involving Resident #149 and CNA L. The DON said the facility first learned of the allegation on 08/09/23 during the 2:00 p.m.-10:00 p.m. when Resident #149 told CNA K that on 08/08/24 CNA L stuck his finger up his butt. The DON said CNA K notified the previous Administrator immediately and CNA L was notified he was suspended. The DON said LVN D did not call the administrator on 08/08/24 when she first learned of the allegation. The DON said CNA L remained in the facility until his shift ended and was not suspended until the following day. The DON said all staff were in-serviced on types of abuse and who to report it to. The DON said she did a one-on-one in-service on types of abuse and who to report it to with LVN D. The DON said when an allegation of abuse was made, the person identified as alleged perpetrator should be removed from the facility immediately and suspended during the facility's investigation to ensure residents are protected. The DON said Resident #149 and the other residents were at risk for abuse when CNA L was not suspended immediately on 08/08/24. During an interview on 06/20/24 at 3:46 p.m., the Administrator said she started working at the facility in February 2024. The Administrator said she was the abuse coordinator and expected staff to report an allegation of abuse to her immediately. The Administrator said when an allegation of abuse is made, the person who is identified as alleged perpetrator should be removed from the facility immediately and suspended at that time during the facility's investigation to ensure residents are protected. The Administrator said the police should be notified when there is an allegation of physical abuse or sexual abuse. The Administrator said the incident between Resident #149 and CNA L was investigated by the previous administrator. The Administrator said the previous administrator did not notify the police and she should have because it involved sexual abuse. During an observation and interview on 06/21/24 at 3:01 p.m. with the local police department's assistant at the front desk revealed (he/she) checked their database system and said they had no records on file that showed the facility called them on 08/09/23 to report an incident involving Resident #149. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated 04/2021 indicated, Residents have the right to be free from abuse .1. Protect residents from abuse .by anyone including, but no necessarily limited to: a. facility staff . Record review of the facility's Abuse Investigation and Reporting policy dated 04/2017 indicated, All reports of resident abuse .shall be promptly reported to local, state and federal agency (as defined by current regulations) and thoroughly investigated by facility management .Role of the Administrator: .4. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation Role if the Investigator: .d. Interview any witnesses to the incident. e. Interview the resident (as medically appropriate) .2. The following guidelines will be used when conducting interviews: .c. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it . The Administrator was notified on 06/21/24 at 5:25 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 06/21/24 at 5:30 p.m The facility's Plan of Removal was accepted on 06/22/24 at 6:08 p.m. and included: Identify responsible staff/ what action taken to prevent further abuse: o ADON, MDS coordinator and Administrator will conduct 100% resident rounds to determine if further allegations of abuse are alleged. This will be completed by 6/22/24. o Safe surveys will be conducted by Social Worker, Human Resources and Activity Director for all cognitive residents. This will be completed by 6/22/24. In-Service conducted o In-servicing was initiated by Regional Nurse Consultant, Administrator and ADON on 06/21/24 and will continue until it is complete. o In-service will be provided to all staff on Immediate Notification of Allegations to Facility Abuse Coordinator, Investigating Allegations of Abuse and Neglect, Reporting of Abuse Neglect and Misappropriation, and notification of proper local and state entities, education included that any individual accused of abuse would be escorted immediately out of the building and resident would be protected. o The Abuse Coordinator was educated on 6-21-24 by the Regional Director of Clinical Services on how to investigate allegations of abuse and the importance of a thorough investigation and written documentation of statements and in-services. o This will be completed by 6/22/24. o Agency staff that work in the facility or staff on PTO or LOA will have in-servicing completed prior to working the floor. o Abuse and Neglect training will be a part of the new hire orientation effective immediately. o Any staff member who is an alleged perpetrator for any allegation will be suspended immediately pending investigation and will be escorted out of the facility immediately by the senior staff member on duty or law enforcement and will not be allowed to return to the building until the investigation is complete. Implementation Date of Changes o 06/21/24 Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 06/21/24. Involvement of QA QAPI will review and approve Plan of Removal On 06/23/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verifying the Medical Director had been informed of the Immediate Jeopardy on 06/21/24 from documentation by the Administrator. Record review of in-services indicated all staff were educated on Immediate Notification of Allegations to Facility Abuse Coordinator, Investigating Allegations of Abuse and Neglect, Reporting of Abuse Neglect and Misappropriation, and notification of proper local and state entities, education included that any individual accused of abuse would be escorted immediately out of the building and resident would be protected. Record review of resident rounds for all cognitive residents indicated rounds were conducted and completed on 06/22/24. Documentation indicated there were no identified complaints or allegations of abuse. Record review of LVN D's Counseling Form dated 06/22/24 indicated she received a verbal and written warning for violating the abuse and reporting policy on 08/08/23 by not reporting an allegation of sexual abuse immediately. Interviews with 5 Licensed Nurses (6 a.m.-6 p.m., 6 p.m.-6 a.m. and Weekend Doubles including agency), 7 CNAs (6 a.m.- 2 p.m., 2 p.m.-10 p.m., 10 p.m.- 6 a.m. including agency), 1 Laundry Staff, 1 Housekeeping Staff, 1 Dietary Staff, and 1 Social Worker were performed on 06/22/24 and 06/23/24. All staff were able to correctly identify Immediate Notification of Allegations to Facility Abuse Coordinator, Investigating Allegations of Abuse and Neglect, Reporting of Abuse Neglect and Misappropriation, and notification of proper local and state entities, education including that any individual accused of abuse would be escorted immediately out of the building and resident would be protected. During an interview on 06/23/24 at 9:46 a.m., the Administrator said she was educated on how to investigate allegations of abuse, the importance of a thorough investigation, written documentation of statements and in-services. On 06/23/24, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately consult with the physician regarding a significant change in resident's condition for 1 of 3 residents sampled for change in condition. (Reident#1) The facility failed to immediately consult the resident's physician when Resident #1 experienced a change in condition in which he began to have involuntary jerking movements. The facility failed contact Resdient #1' the physician when NP orders on 01/06/23 for a UA were not followed, and on 01/10/23 the resident was sent to the hospital septic from a UTI. An Immediate Jeopardy (IJ) situation was identified on 02/03/23 at 1:30 p.m. While the IJ was removed on 02/04/23 at 5:22 p.m., the facility remained out of compliance at a scope of isolated with actual harm, due to the facility's need to evaluate the effectiveness of the corrective systems This failure could place residents at risk for not receiving adequate care and treatment, hospitalization and possible death. Findings included: Record review of Resident #1's face sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His admitting diagnoses were depression, diabetes, obesity, anxiety, high blood pressure, and kidney disease. Resident #1 also had a diagnosis of benign prostatic hyperplasia (an age associated prostate gland enlargement tach can cause urination difficulty.) Record review of Resident #1's quarterly MDS dated [DATE] indicated he had intact cognition. The MDS indicated he was extensive assist with bed mobility, and transfer with the assistance of two people. The MDS indicated for toilet use the resident was totally dependent and required two-person physical assistance. Record review of Resident #1's care plan dated 12/28/22 indicated the resident had a problem of being incontinent of bladder. One of the interventions was monitor and document for signs and symptoms of UTI, pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in eating patterns. Record review of nursing progress note dated 1/6/23 indicated Resident #1 was alert, lying in bed with involuntary jerking movements of the BUE, unable to hold cell phone in his hand. He denied any pain or discomfort. His vital signs were within normal limits. The NP was notified an indicated a new order for a UA with culture and sensitivity if indicated. If the resident condition got worse to notify the NP. Resident #1 and his family were notified. Written by LVN A. Record review of a physician telephone order dated 01/06/23 at 7:06 p.m. indicated Resident #1 was to receive a UA with culture and sensitivity if indicated one time only until 1/8/2023. Record review of nursing progress note dated 01/10/23 at 7:05 a.m., indicated Resident #1 was lying in bed, hard to arose resident would open eyes briefly, but not answer questions that were asked, involuntary jerking movements noted to BUE. His blood pressure was 128/54, his pulse was 75, his temp was 97.3, pulse oximetry was 88 on CPAP, blood sugar was 389. He was sent to the emergency room. Written by LVN A. Record review of Resident #1's hospital physician progress notes dated 01/11/2023 indicated Resident #1 was a [AGE] year-old male who presented to the hospital on 01/10 23 with Sepsis (a life-threatening complication of an infection). He presented to the hospital with altered mental status and hypoxia (absence of enough oxygen in the tissues to sustain body functions). Resident #1's oxygen saturation in the 80s on a CPAP (Continuous Positive Airway Pressure) and revealed his creatinine was 1.5 (normal level 0.74-1.35 high level indicated kidney failure.) the potassium was 6.8. (Normal lever 3.6 to 5.2- potassium levels higher than 6.0 can be dangerous and required immediate treatment). He was encephalopathic (altered brain function) but arousable and able to maintain airway. The notes indicated the resident had acute respiratory failure with hypoxia secondary to volume overload status. Chronic kidney disease stage 3 now with worsening renal function with a plan for dialysis. Resident #1 had acute metabolic encephalopathy and sepsis with evidence of Leukocytosis (high white blood cell count), tachypnea (fast breathing) secondary to UTI. During an interview on 01/12/23 a 10:20 a.m. LVN A said she worked at the facility since 2004. She said on 01/06/23 Resident #1 had some jerking motions. She said CNA C called her to his room who said he was shaking and had a large BM. She said she assessed Resident #1 and his vital signs were normal around 3 p.m. and he appeared fine. In a later interview she said she had gone back into his room around 7:00 p.m. and he was shaking quite a bit and unable to hold his cell phone. LVN A said she called the NP and received an ordered for a UA with culture and sensitivity. She did not contact the physician. She said she did not attempt to collect the UA because she did not have time. She was off work over the weekend. She said she came back on to work on 01/09/23 and Resident #1 was fine. She did not attempt the UA on Monday, 01/09/23 because she did not have time. The LVN said on 1/9/23 Resident #1 did not eat his lunch. She said Resident #1 said it was the same thing and it was not what he wanted for lunch. On the morning of 01/10/23 she sent Resident #1 to the hospital because he was basically unresponsive and his O2 stat was low. She called the NP and family. In a later interview LVN A said the NP did not write any order for a Stat UA but all they had to do was call the lab for a weekend pickup. LVNA said she did not notify the NP the lab was not collected. During an interview on 01/12/23 at 10:55 a.m. Resident #1's family member said they received a call on 01/06/23 saying his Resident #1 had shaking movements and a UA was ordered. He said on 01/10/23 they received a call saying Resident #1 was sent to the Hospital. When they arrived at the hospital, they were told Resident #1 was septic from a UTI and need to be placed on dialysis. He said Resident #1 was in ICU, and he was still shaking. During an interview o 01/12/23 at 2:20 p.m. the DON said on 01/06/23 someone told her Resident #1 was having some issues. She saw LVN A coming out of his room and the nurse said Resident #1 was fine. The DON said she found out later during her investigation the LVN had contacted the NP and received an order on 01/06/23. The DON said the protocol was for the nurse to let the DON know of any changes. The DON said she had specifically asked LVN A to let her know of any changes with Resident #1, but she did not. The DON said the first time she was aware of the NP order for a UA was on 1/9/23. She said LVN A said the resident was still in need of a UA because it had not been completed. The DON said LVN A had not completed the UA and had not tried. The DON said after the VA Representative contacted the facility on 01/10/23 they began their investigation. The DON said she started in services on that day on 01/10/23 and was developing a plan of action for QA as part of their QA measures for correction. During a telephone interview on 01/12/23 at 3:50 p.m. the NP said she was not informed the Resident #1's UA was not completed. She said she should have been notified and was not. During a telephone interview on 01/24/22 at 8:09 a.m. Resident #1 said he was sick all weekend prior to going to the hospital. He did not remember anyone trying to collect urine from him during the weekend. He said sometimes he felt better than others, but he felt sick the whole weekend. Resident #1 said he did not remember what happen on the morning of 01/10/23, he was mostly out of it. During an interview on 02/02/23 at 2:26 p.m. the MD said he was not made aware Resident #1 had a change in condition and did not receive his UA until after he went to the hospital. He said the UA was requested because when an elderly person had any change in condition it was most frequently due to a UTI. The MD said he was not aware of any issues related to Resident #1 having prostate problems, there was no indication he had a blockage. The MD said Resident #1 had a multitude of complex problems. He said the nurse could have suggested to the NP the UA be Stat. The MD said apparently, the nurse did not convey any emergency to have the UA done quickly. He said either way they wanted it done sooner rather than later. The MD said if Resident #1 had a UTI and it seemed apparent that he did. His condition would only decompensate the longer they waited to provide treatment. The MD said he had some concerns that it was not done within a day or so. The MD said that was what they expect of an order for a UA. He said usually the UA results would come back in a few hours or the next day. The MD said he and DON talked and would do better communication in the future. He said they would make sure UAs are done timely. During an interview on 02/03/23 12:10 p.m. the DON said she just did a verbal counseling with LVN A and a one on one in service with her. The DON said with this company they do not have anything written in regard to an empoyee's disciplinary actions. She said she had done some in servicing on 01/10/23 regarding labs and change in condition. However, she did not have a current system in place to train all agency staff. Record review of the facility's Change in a Resident's Condition or Status Policy revised February 2021 indicated our community promptly notified the resident, their attending physician, and the resident representative of changes in the resident's medical condition and status. The nurse would notify the residents attending physician or physician on call when there was a significant change in the resident's physical, emotional, or mental condition. If there was the need to alter the resident treatment significantly. A refusal of treatment or medications two or more consecutive times. The nurse would record in the resident's medical record information related to changes in the resident's medical or mental condition or status. The Administrator, MDS nurse, DON, and ADON were notified on 02/03/23 at 1:30 p.m. an Immediate Jeopardy (IJ) situation was identified due to the above failures and an IJ template was provided. The facility plan of removal was accepted on 02/04/23 at 3:22 p.m. was as follows: [The facility failed to notify the Physician of failure to obtain ordered labs. The Physician was not notified that lab was not drawn, resulting in a COC that resulted in his hospitalization on 1/10/23. Identify residents who could be affected All Residents have the potential to be affected. The Facility census on 1/6/23 was 43. An audit was initiated on 2/3/23 and will be completed on 2/4/23 to ensure there are no further labs that have not been drawn. DON/Designee initiated and completed a round on all current residents on 2/3/23 to determine if there are any changes in residents condition. All findings were reported to Physician and orders obtained and carried out as required. . In-Service conducted All nurses will receive education on carrying out Physicians orders, education on procedures for notifying Physicians when an order is not able to be carried out and education on Identification and reporting to Physicians any change in resident's condition using the INTERACT tools. It is not acceptable to notify NP of an acute. change of condition Nurse aides will be educated on the Stop and Watch tool to help identify early signs of condition change. Implementation Date of Changes In-servicing was initiated on 2/3/23 by the DON and will continue until it is completed by the DON/Designee on 2/4/23. Agency staff and staff on leave that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. . Involvement of Medical Director The Medical Director, [name] was notified about the immediate Jeopardy on 2/3/23. Involvement of QA QAPI will review and approve Plan of Removal on 2/4/23 Who is responsible for implementation of process? Administrator and DON (Director of Nursing).] On 02/04/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of the facility employee roster indicated they have 5 full time LVNs, one part time LVN and two weekend RNs and the ADON who was an LVN. They have 9 nurse's total. They had 7 CNAs. During an observation and interview on 02/04/23 at 3:39 p.m. the DON said she had a binder with a list of Agency staff, their discipline, and when they received the training. She said she would monitor what agency staff had been trained and prior to each agency staff beginning work they would receive training if they were not in the book. Observation of the book showed the training, each staff, a list of training they received. There was a list of 5 agency LVNs and two agency CNAs indicating they had been trained on labs, physician notification, identification of change in condition and physician notification. During interviews on 02/04/23 between 3:30p.m. and 5:15 p.m. three CNAs said they were educated on the Stop and Watch tool (a form used by aides to identify changes in a resident such as different symptoms, change in need for assistance, eating less, agitated, more confused or change in skin color.) to help identify early signs of condition change to the charge nurse. They said they are to fill out the form and give it to the nurse, so they have verification they told the nurse of the change in condition. They were told they could make a copy of the form and place it under department heads doors if they felt their concerns were not addressed. During interviews on 02/04/23 between 3:3 0p.m. and 5:15 p.m. were conducted with 3 facility LVNs and 1 RN and 2 agency LVNs that indicated they were knowledgeable on following physician orders, identification of resident change in condition. The nurses said they would follow guidelines for monitoring. They would monitor residents with possible UTIs for any symptoms. If a resident refused treatment, they would educate the resident on possible consequences and let the physician know of the resident status. The nurses were able to demonstrate through interviews their understanding of those policies, procedures, and in services. Record Review of a Resident record identified as needing a UA was reviewed and the facility put measures in place, such as notifying the physician, getting a timely UA. Detailed documentation of the resident condition was noted in the record to include the INTERACT assessment tool(an assessment form that is used to help nursing staff evaluate the resident for change in condition). The physician was notified of the lab results and the resident place on an antibiotic. With additional physician orders. On 02/04/23 at 5:42 p.m. the Administrator, DON, and ADON were informed the IJ was removed; however, the facility remained out of compliance at level of actual harm with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 3 residents reviewed for care and services. (Resident #1) *The facility did not complete a provider ordered UA on 1/6/23 until 1/10/23. The resident was admitted to the hospital on the morning of 1/10/23 with a diagnosis of sepsis due to UTI. *The facility failed to increase monitoring and provide accurate documentation of attempted UA collection. *The facility failed to identify signs and symptoms of a UTI. *The facility failed to notify the physician timely when they did not compete the UA. An Immediate Jeopardy (IJ) situation was identified on 02/03/23 at 1:30 p.m. While the IJ was removed on 02/04/23 at 5:22 p.m., the facility remained out of compliance at actual harm with a scope identified isolated, due to the facility's need to evaluate the effectiveness of the corrective systems This failure could place residents at risk for not receiving adequate care and treatment to prevent hospitalization and possible death. Findings included: Record review of Resident #1's face sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His admitting diagnoses were depression, diabetes, obesity, anxiety, high blood pressure, and kidney disease. Resident #1 also had a diagnosis of benign prostatic hyperplasia(an age associated prostate gland enlargement tach can cause urination difficulty.) Record review of Resident #1's quarterly MDS dated [DATE] indicated he had intact cognition. The MDS indicated he was extensive assist with bed mobility, and transfer with the assistance of two people. The MDS indicated for toilet use the resident was totally dependent and required two-person physical assistance. Record review of Resident #1's care plan dated 12/28/22 indicated the resident had a problem of being incontinent of bladder. One of the interventions was monitor and document for signs and symptoms of UTI, pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in eating patterns. Record review of nursing progress note dated 1/6/23 Resident #1 was alert, lying in bed with involuntary jerking movements of the BUE, unable to hold cell phone in his hand. He denied any pain or discomfort. His vital signs were within normal limits. The NP was notified an indicated a new order for a UA with culture and sensitivity if indicated. If the resident condition got worse to notify the NP. Resident #1 and his family were notified. Written by LVN A. Record review of a physician telephone order dated 01/06/23 at 7:06 p.m. indicated Resident #1 was to receive a UA with culture and sensitivity if indicated one time only until 1/8/2023. Record review of the facility 24-hour report dated 01/06/23 indicated the following: *Evening shift: Resident #1 had involuntary jerking of the bilateral upper extremities his vital signs were within normal limits; the NP was notified a new order for a UA and notify the NP if the condition worsened. *Night shift: there was no mention of the UA or the resident's involuntary movement. Record review of nursing progress note dated 01/07/23 at 12:21 p.m. indicated Resident #1 was in bed with family at bedside. His respirations were even and unlabored. He denied pain and voiced no concerns. There was no involuntary jerking noted at this time. Vital signs were within normal limits and no mental status change or behaviors noted. Signed by ADON Record review of the 24-hour report dated 01/07/23 indicated the following: *Resident #1 needed a UA, call the lab for pick up( at the top of the page). *Day shift: was blank for Resident #1. *Evening shift: continue jerking monitor for jerking bilateral upper extremities. *Night shift: no involuntary jerking this shift, would continue to monitor BUE for jerking. There was no documentaion on the 24-hr report that indicated a UA was attempted. Record review of the facilities 24- hour report dated 01/08/23 indicated the following: on the *Day shift: Resident #1 needed a UA. No involuntary jerking noted this shift. *Evening shift: UA needed, no involuntary jerking this shift. *night shift: stable. Record review of the 24-hour report dated 01/09/23 indicated the following: *Day shift: Resident #1 had no change. *Night shift: gave bath and clean clothes; he left; was to leave the facility at 4:30 a.m.; UA needed. Record review of a nursing progress note dated 01/10/23 at 6:22 a.m. indicated the UA was collected. Written by an agency LVN B. Record review of nursing progress note dated 01/10/23 at 7:05 a.m., said Resident #1 was lying in bed, hard to arose resident would open eyes briefly, but not answer questions that were asked, involuntary jerking movements noted to BUE. His blood pressure was 128/54, his pulse was 75, his temp was 97.3, pulse oximetry was 88 on CPAP, blood sugar was 389. He was sent to the emergency room. Written by LVN A. Record review of nursing progress note created 1/10/23 at 8:23 a.m. titled late entry indicated on 01/9/23 at 11:39 a.m. Resident #1 was resting quietly in bed, he refused his lunch, with no involuntary movements to his BUE. His vital were within normal limits, no pain or distress noted at this time. Written by LVN A. Record review of nursing progress note created 01/10/23 at 11:24 a.m. titled late entry indicated on 1/6/23 at 9:00 p.m. Resident #1 had new order noted for collection of UA. An attempt was made was made but no results. Will continue to monitor and retry. Signed by the ADON. Record Review of nursing progress note created 01/10/23 at 3:52 p.m. titled late entry dated 1/7/23 at 12:20 p.m. indicated attempted to collect a UA from Resident #1 but was unsuccessful. The resident attempted to give a sample without being catharized at his request. Would continue to monitor. Written by ADON. Record review of nursing progress note created 01/10/23 at 3:49 p.m. titled late entry indicated on 01/08/23 at 11:42 a.m. Resident #1 was in bed with family at the bed side. He denied any problems at that time. He voiced no concerns. An attempt was made to collect the UA earlier in the shift but failed. The resident was requesting not to be catharized at this time, he said he would try to urinate on his own. Will continue to monitor. Signed by the ADON. Record review of Resident #1's hospital physician progress notes dated 01/11/2023 indicated Resident #1 was a [AGE] year-old male who presented to the hospital on 01/10 23 with Sepsis (a life-threatening complication of an infection). He presented to the hospital with altered mental status and hypoxia (absence of enough oxygen in the tissues to sustain body functions). Resident #1's oxygen saturation in the 80s on a CPAP (Continuous Positive Airway Pressure) and revealed his creatinine was 1.5 (normal level 0.74-1.35 high level indicated kidney failure.)the potassium was 6.8. (Normal lever 3.6 to 5.2- potassium levels higher than 6.0 can be dangerous and required immediate treatment). He was encephalopathic (altered brain function) but arousable and able to maintain airway. The notes indicated the resident had acute respiratory failure with hypoxia secondary to volume overload status. Chronic kidney disease stage 3 now with worsening renal function with a plan for dialysis. Resident #1 had acute metabolic encephalopathy and sepsis with evidence of Leukocytosis (high white blood cell count), tachypnea (fast breathing) secondary to UTI. Record review of the facility Provider Investigation Report dated 01/10/22 indicated the following: Investigation: On 01/06/23 the administrator informed the DON Resident #1 needed to have a COVID test because he had diarrhea like symptoms. At 6:00 p.m. the DON asked [ LVN A] about the resident and she said Resident #1 was fine. [ LVN A] was informed to make sure to contact the DON if there was any change in Resident #1's condition. A chart review indicated [ LVN A] contacted the NP on 01/06/23 at 7:00 p.m. and received a telephone order for a UA due to involuntary jerking movements. The LVN did not call the DON but waited until 01/09/23 to inform the DON of the change of condition and the new order for the UA. From1/6/23-1/8/23 the ADON checked on Resident #1 and attempted to obtain a urine sample per her report, but the resident was unable to give the sample and unwilling to have a straight catheter per her report. On 01/08/23 the DON went to the facility to provide wound care to Resident #1. He was in good spirits made no complaints and was in no distress. He asked for a sandwich after the treatment was competed. There were no jerking movements or abnormalities visible. On 01/09/23 during clinical meeting [ LVN A] reported there was a UA that needed to be collected on Resident #1. LVN A told the DON she received the order on 01/06/23 but Resident #1 was acting normal today. The DON was told [ LVN A] to contact the NP and tell her Resident #1 was doing okay. LVN A was told to ask the NP if Resident #1 still needed the UA or did it need to be discontinued. There was no documentation that the LVN contacted the NP as she was told to obtain the UA. On 01/10/23 at 6:22 a.m. the UA was finally collected by an agency nurse. On 01/10/23 at 7:45 a.m. Resident #1 was sent to the emergency room with altered mental status. On 01/10/23 at 2:00 PM the NP said her rationale for ordering the UA was Resident #1 had previously experienced jerking movements and the jerking movements were related a UTI. However, the UA had not been ordered as stat. The report indicated education was provided on UTI's and UA's which indicated when a nurse received the order for the UA. They must immediately contact the DON and attempt the same shift to obtain the urine sample. the nurse must not pass the order or the next shift hoping it will get done. Delaying care for possible infection can lead to complications such as sepsis. The plan of correction for the investigation was the DON would write LVN A up for failure to obtain the UA order. By her own admission she did not attempt to get the sample on 01/06/23 or 01/09/23[ LVN A] failure to communicate the change of condition and new order for UA immediately to the DON also delayed patient care. In the future the nurse who received the order would be responsible for obtaining the urine sample. Nurses must no longer pass the order to the next shift. The nurses should also utilize urine dipsticks per physician standard order while waiting for UA to return for quick results and contact the physician with the results. Record review of an in service dated 01/10/23 at 4:30 p.m. indicated nurses were trained on Education on UTI's and UA's, Change in Condition and Documentation, and Labs. The in service on Labs indicated, When we obtained an order for a UA or any other type of labs. You need to notify the DON by phone right away and family members. When trying to get a UA sample and not able to obtain it. Make sure you put a progress note about how many times you tried and the reason of why you were not able to obtain the sample. (signed by 7 nurses to include LVN A.) During an interview on 01/12/23 a 10:20 a.m. LVN A said she worked at the facility since 2004. She said on 01/06/23 Resident #1 had some jerking motions. She said CNA C called her to his room who said he was shaking and had a large BM. She said she assessed Resident #1 and his vital signs were normal around 3 p.m. and he appeared fine. She said she had gone back into his room around 7:00 p.m. and he was shaking quite a bit and unable to hold his cell phone. LVN A said she called the NP and received an ordered for a UA with culture and sensitivity. She did not attempt to collect the UA because she did not have time. She was off work over the weekend. She said she came back on to work on 01/09/23 and Resident #1 was fine. She did not attempt the UA on that 01/09/23 because she did not have time. The LVN said on 1/9/23 Resident #1 had not eaten his lunch. She said her said it was the same thing and it was not what he wanted. On the morning of 01/10/23 she sent Resident #1 to the hospital because he was basically unresponsive and his O2 stat was low. During an interview on 01/12/23 at 10:55 a.m. Resident #1's family member said they received a call on 01/06/23 saying his Resident #1 had shaking movements and a UA was ordered. He said on 01/10/23they received a call saying Resident #1 was sent to the Hospital. When they arrived at the hospital, they were told Resident #1 was septic from a UTI and need to be placed on dialysis. He said he was in ICU, and he was still shaking. During an interview on 01/12/23 at 11:30 a.m. CNA C said she went into Resident #1's room around 3 or 4 p.m. on Friday 01/06/23 to give him a bath. She said his eyes were rolled back and he was shaking. She got the assistance of CNA D to help her. Resident #1 had an extra-large BM. She told LVN A, and she came and assessed Resident #1. Resident #1 said he did not feel well. She said they finished cleaning him up and she left for the day. CNA C said she was off the weekend. During an interview on 01/12/23 at 2:00 p.m. the administrator said she had called an intake into the state agency regarding Resident #1. She said on 01/10/23 a VA Representative had informed her the facility had failed to notify the physician regarding Resident #1's change in condition. She said she felt an allegation of neglect had been made. She called it into the state and started an investigation into the incident. The Administrator said they did a review of Resident #1's record and started in servicing staff. The DON had completed in services on 01/10/23. During an interview o 01/12/23 at 2:20 p.m. the DON said on 01/06/23 someone told her Resident #1 was having some issues. She saw LVN A coming out of his room and the nurse said Resident #1 was fine. The DON said she found out later during her investigation the LVN had contacted the NP and received an order on 01/06/23. The DON said the protocol was for the nurse to let the DON know of any changes. The DON said she had specifically asked LVN A to let her know of any changes with Resident #1, but she did not. The DON said the first time she was aware of the NP order for a UA was on 1/9/23. She said LVN A said the resident was still in need of a UA because it had not been completed. The DON said LVN A had not completed the UA and had not tried. The DON said after the VA Representative contacted the facility on 01/10/23 they began their investigation. The DON said she started in services on that day and was developing a plan of action for QA as part of their QA measures for correction. During an interview on 01/12/23 at 2:55 p.m. the ADON said she worked Saturday, 01/07 23 and Sunday, 01/08/23 as the floor nurse. The ADON said she wrote late entry progress notes on Resident #1 because she did not have enough time to write during her shift. She could not say why the notes were written two days later; on the day the resident went to the hospital. She said during the weekend Resident #1 was fine and had no issues that she noted. The ADON said on 01/07/23 she tried to get the urine sample that morning and Resident #1 was not able to produce any urine. She asked if he wanted to do the straight catheter and he said no, he wanted to try and go in his own. She said later he had family and did not want to be bothered. She said he was happy because a friend had come to visit that he had not seen in a while. The ADON said she did not know how Resident #1 ate that day, but the family brought in food. The ADON on 01/08/23 Resident #1 had no complaints or issues. The ADON said she was in serviced on labs and physician notification. During a telephone interview on 01/12/23 at 3: 30 p.m. CNA E said on 01/07/23 Resident #1 said he was not feeling his normal self. She said she knew he did not eat breakfast very well. She had to help CNA F cleanup the bed. He spilled his cereal all over the bed due to his shaking. She said as the day went on, he appeared to feel better. CNA E said she heard CNA F tell the LVN H Resident #1 was not feeling well. She he was not her resident and she only helped out when needed because he was two person. During a telephone interview on 01/12/23 at 3:35 p.m. CNA F said she recalled Resident #1 was shaking and sick all day on 01/07/23. She said he did not really eat breakfast and was shaking badly. He spilled his cereal all over the bed due to his shaking. CNA F said they had to clean up the bed. Resident #1 requested a waited spoon to eat his lunch but even with that he did not eat well. She said she had reported to the nurse LVN H he was shaking and not feeling well. LVN H said okay and acted like she already knew the resident was not feeling well. CNA F said she had changed him through the day, and he did appear to be a little better as the day progressed. His family was with him most of the day and he did okay. She said she did not work on 01/08/23. During a telephone interview on 01/12/23 at 3:40 p.m. CNA G said on the morning of 01/07/23 Resident #1 was hard to arose. She said he did not have on his CPAP so that may have been the reason. However, she said after they got him awake, he did not have any other issues that she noted. She was the medication aide and did not really provide him any care. During a telephone interview on 01/12/23 at 3:50 p.m. the NP said she was not informed the Resident #1's UA was not completed. She said she should have been notified and was not. During an interview on 01/12/23 at 4:00 p.m. CNA D said on the evening of 01/06/23 he assisted CNA C with providing care to Resident #1. He said Resident #1 was shaking and CNA C went and got the nurse. He said by the time LVN A got there Resident #1 appeared better. He said the resident did shake some during the night. Resident #1 did not know when he had urinated but knew when he was wet. CNA D said he had gone back into his room at least two times during his shift. He said Resident #1 did not complain of anything and he changed him at least once maybe twice during his shift. CNA D said Resident #1 drank a lot of water and Dr. Peppers and voided frequently. He said Resident #1 did not have another BM, but he was incontinent of urine. During an interview on 01/17/23 at 10:30 a.m. the ADON said the UA was not collected on the weekend. It was ordered on Friday and the lab does not pick up on weekends. The ADON said she had worked that weekend and had not called the doctor because Resident #1 was doing fine. During an interview on 01/07/23 at 11:26 a.m. CNA C said she was out on Monday, 01/09/23. She had come in early on 01/10/23 to ride to another city for an appointment with Resident #1. She said on that morning he was mostly unresponsive. She helped to clean him up and they sent him to the hospital. During a telephone interview on 01/24/22 at 8:09 a.m. Resident #1 said he was sick all weekend prior to going to the hospital. He did not remember anyone trying to collect urine from him during the weekend. He said sometimes he felt better than others, but he felt sick the whole weekend. Resident #1 said he did not remember what happen on the morning of 01/10/23, he was mostly out of it. During an interview on 02/02/23 at 12:35 p.m. the DON said she was not aware Resident #1 had an order for a UA until Monday, 01/09/23. So, she was not aware of Resident #1 needed a UA. The DON said because she was unaware there was an order for the UA, she did not put any interventions in place. She was also not aware the UA was not completed for the same reason. The DON said she started to work in October 2022. She was not aware Resident #1 had issues with shaking related to a UA in the past. During interview on 02/02/23 at 12:50 p.m. the ADON said she did not get an order to monitor Resident #1 more closely. She worked as an aide one day over the weekend. She said Resident #1 would pull the light to be changed and did not appear to have a change in his urination patterns. She said the problem was by the time they got to the room he had already gone. The ADON said he was on blood pressure monitoring three times a day. They did not do anything else in regard to monitoring his behaviors. He seemed fine. She did not note any shaking and he did not complain. She said he was not a complainer. The ADON said she worked as an aide on 01/08/23, and when she went to his room, he was already wet. The ADON she tried to try and get the UA sample. She said Resident #1 refused an in and out cath. The ADON said she started working at the facility in October 2022. She was not aware Resident #1 had issues with shaking related to a UA in the past. The ADON said she was aware of the signs of a UTI in the elderly. During an interview on 02/02/23 at 1:30 p.m. agency LVN I said this was her third time working at the facility. When she first came she was given a brief overview of the nurses station. However she had not received any recent in service about labs or UAs. During aa interview on 02/02/23 at 1:47 p.m. LVN A said the NP did not write any order for a Stat UA but all they had to do was call the lab for a weekend pickup. LVNA said she did not notify the NP the lab was not collected. During an interview on 02/02/23 at 2:26 p.m. the MD said he was not made aware Resident #1 did not receive his UA until after he went to the hospital. He said the UA was requested because when an elderly person had any change in condition it is most frequently due to a UTI. The MD said he was not aware of any issues related to Resident #1 having prostate problems, there was no indication he had a blockage. The MD said Resident #1 had a multitude of complex problems . He said the nurse could have suggested to the NP the UA be Stat. The MD said apparently, the nurse did not convey any emergency to have the UA done quickly. He said either way they wanted it done sooner rather than later. The MD said if Resident #1 had a UTI and it seemed apparent, he did his condition would only decompensate the longer they waited to provide treatment. He said he had some concerns that it was not done within a day or so. The MD said that is what they expect of an order for a UA. He said usually a UA results will come back in a few hours or the next day. The MD said he and DON had talked and would do better communication in the future and make sure UAs are done timely. During a telephone interview on 2/2/23 at 2:37 p.m. the lab technician at the Laboratory company the facility utilized, said the UA's do not have to be Stat on the weekend. All the facility needed to do was call and they would pick them up. Record Review of the ADON's time sheet from 01/5/23 through 1/9/23 indicated that she was not at work on 01/06/23 at 9 p.m. ( ADON wrote a late entry note for that time.) During an interview on 2/2/23 at 2:50 p.m. with the HR Director and the ADON. The HR Director said the ADON clocked out on Friday, 01/06/23 at 6:28a.m. The HR Director said she did not return to work again until Saturday, 01/07/23 at 8:06 a.m. She said the ADON worked until 9:50 p.m. that day. The HR Director said on Sunday, 01/08/23 the ADON clocked in at 8:00 a.m., left for lunch from 2:30 p.m. to 3:30 p.m., clocked out at 9:06 p.m., and clocked back in at 10 23 p.m. to 11:44 p.m. The ADON said the time sheet could not be right, she worked during the time the nurses note was written. The HR Director said the pay period ended on 01/15/23 and missed punched needed to have been submitted by 01/16/23. The pay checks went out on 01/25/23 and she had no complaints about the ADON's check not being correct. The ADON continued to insist she had worked on Friday night 01/06/23. During an interview on 02/03/23 at 10:26 a.m. the ADON said she was not at the facility on Friday 01/06/23 on that night at 9:00 p.m. She said she was mistaken. The ADON said when she wrote the note, she was trying to put it in for Saturday 01/07/23. The ADON said at that time they had 3 shifts but recently switched to 12-hour shifts. She said she worked Saturday 6-2 charge nurse- from 3 to 10 as a medication aide. She said on Sunday she was CNA for first shift. The ADON said she was a CNA for first three hours on the second shift. She said she did not know why she was the only nurse that charted on Resident #1 failed attempts to get the UA. The ADON said Resident #1 did not like to be moved but he did not complain. During an interview on 2/3/23 at 11:45 a.m. LVN/treatment nurse said she was in-service on change in condition, when to call the DON and physician. She said they were to make sure to get labs timely. If unable to get a lab let the physician know and document attempts. During an interview on 02/03/23 12: 10 p.m. DON said she just did a verbal counseling with LVN A and a one on one in service with her. The DON said with this company do not have anything written. She said she had done some in servicing on 01/10/23 regarding labs and change in condition. However, she did not have a current system in place to train all agency staff. During a telephone interview on 2/3/23 at 12:22 p.m. LVN H said she remembered LVN A told her during report on 1/6/23 that Resident #1 was doing some jerking and needed a UA. She said she said not noticed any kind of jerking when she observed Resident #1. LVN H said she did not get the UA during her shift. She said when she got to Resident #1's room his brief was wet. LVN H said there was a note on the 24-hour report about getting the UA. LVN H said she could not remember if she had written a note regarding Resident #1 condition or failed attempt to obtain the UA or not. She said she really did not remember that incident well. LVN H said she received an in services regarding change in condition, and labs. LVN H said she would not have done anything any different with Resident #1. She said she let the next shift know she was unable to get the UA. This was determined to be an Immediate Jeopardy (IJ) in the area of Quality of Care on 02/03/23 at 1:30 p.m. The facility Administrator, MDS nurse, DON, and ADON were notified. The Administrator was provided with the IJ template on 02/03/23 at 1:30 p.m. The facility plan of removal was accepted on 02/04/23 at 3:22 p.m. was as follows. [The facility failed to provide timely laboratory services as ordered by the Physician on 1 Resident on 1/6/23. The Physician was not notified that lab was not drawn, resulting in a COC that resulted in his hospitalization on 1/10/23. Identify residents who could be affected All Residents have the potential to be affected. The Facility census on 1/6/23 was 43. An audit was initiated on 2/3/23 and will be completed on 2/4/23 to ensure there are no further labs that have not been drawn. DON/Designee initiated and completed a round on all current residents on 2/3/23 to determine if there are any changes in residents' condition. All findings were reported to Physician and orders obtained and carried out as required. In-Service conducted All nurses will receive education on Following Physicians orders, education on procedures for notifying Physicians when an order is not able to be carried out and education on Identification and reporting to Physician any change in resident's condition using the INTERACT tools. Following Physician notification and the severity of the condition nurses will follow Physicians guidance for monitoring with a minimum of daily documentation as it relates to the change of condition and vital signs. In-servicing will be completed by DON/Designee. For residents with a suspected UTI monitoring each shift will consist of urinary output, change in mentation, flank pain and odor and color. In-servicing will be completed by DON/Designee. If a resident refuses treatment or catheterization for a UA they will be educated on the risks of not following Physician orders by the charge nurse and the physician will be notified. Nurse aides will be educated on the Stop and Watch tool to help identify early signs of condition change by the DON/Designee. Implementation Date of Changes In-servicing was initiated on 2/3/23 and will be completed by 2/4/23 Agency staff and on leave or PRN nurses that work in the facility will have in-servicing completed prior to working the floor by the DON/Designee. . Involvement of Medical Director The Medical Director, [name] was notified about the immediate Jeopardy on 2/3/23. Involvement of QA QAPI will review and approve Plan of Removal on 2/4/23 Who is responsible for implementation of process? Administrator and DON (Director of Nursing).] On 02/04/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of the facility employee roster indicated they have 5 full time LVNs, one part time LVN and two weekend RNs and the ADON who is an LVN. They have 9 nurses total. They had 7 CNAs. During an observation and interview on 02/04/23 at 3: 39 p.m. DON said she had a binder with a list of Agency staff, their discipline and when they received the training. She said she would monitor what agency staff had been trained and prior to each agency staff beginning work they would receive training if they were not in the book. Observation of the book showed the training a list of staff. There was a list of 5 agency LVNs and two agency CNAs indicating they had been trained on labs, physician notification, identification of change in condition and physician notification. During interviews on 02/04/23 between 3:30p.m. and 5:15 p.m. three CNAs said they were educated on the Stop and Watch tool (a form used by aides to identify changes in a resident such as different symptoms, change in need for assistance, eating less, agitated, more confused or change in skin color.) to help identify early signs of condition change to the charge nurse. They said they are to fill out the form and give it to the nurse, so they have verification they told the nurse of the change in condition. They were told they could make a copy of the form and place it under department heads doors if they felt their concerns were not addressed. During interviews on 02/04/23 between 3:3 0p.m. and 5:15 p.m. were conducted with 3 facility LVNs and 1 RN and 2 agency LVNs that indicated they were knowledgeable on following physician orders, identification of resident change in condition. The nurses said they would follow guidelines for monitoring. They would monitor residents with possible UTIs for any symptoms. If a resident refused treatment, they would educate the resident on possible consequences and let the physician know of the resident status. The nurses were able to demonstrate through interviews their understanding of those policies, procedures, and in services. Record Review of a Resident record identified as needing a UA was reviewed and the facility put measures in place, such as notifying the physician, getting a timely UA. Detailed documentation of the resident condition was noted in the record to include the INTERACT assessment tool( an assessment form that is used to help nursing staff evaluate the resident for change in condition). The physician was notified of the lab results and the resident place on an antibiotic. With additional physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain timely laboratory services to meet the needs of 1 of 2 residents reviewed for laboratory services (Resident #1.) The facility failed to obtain an UA as ordered. Resident #1 did not receive a timely UA and was hospitalized due to sepsis. An Immediate Jeopardy (IJ) situation was identified on 02/03/23 at 1:30 p.m. While the IJ was removed on 02/04/23 at 5:22 p.m., the facility remained out of compliance at actual harm with a scope identified as isolated, due to the facility's need to evaluate the effectiveness of the corrective systems This failure could place residents at risk for a delay in identifying or diagnosing medical issues, hospitalization and possible death. Findings Included. Record review of Resident #1's face sheet indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His admitting diagnoses were depression diabetes, obesity, anxiety, high blood pressure, and kidney disease. Resident #1 also had a diagnosis of benign prostatic hyperplasia(an age associated prostate gland enlargement tach can cause urination difficulty.) Record review of Resident #1's quarterly MDS dated [DATE] indicated he had intact cognition. The MDS indicated he was extensive assist with bed mobility, and transfer with the assistance of two people. Record review of Resident #1's care plan Indicated the resident had a problem of being incontinent of bladder. One of the interventions was monitor and document for signs and symptoms of UTI, pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in eating patterns. Record review of nursing progress note dated 1/6/22 Resident #1 was alert, lying in bed with involuntary jerking movements of the BUE, unable to hold cell phone in his hand. He denied any pain or discomfort. His vital signs were within normal limits. The NP was notified an indicated a new order for a UA with culture and sensitivity if indicated. If the resident condition got worse to notify the NP. Resident #1 and his family were notified. Written by LVN A. Record review of a physician telephone order dated 01/06/23 at 7:06 PM indicated resident number one was to receive a UA with culture and sensitivity if indicated one time only until 1/8/2023. Record review of a nursing progress note dated 01/10/23 at 6:22 a.m. indicated the UA was collected. The note was signed by an agency LVN B. Record review of nursing progress note dated 01/10/23 at 7:05 a.m. said Resident #1 was lying in bed, hard to arose resident would open eyes briefly, but not answer questions that were asked, involuntary jerking movements noted to BUE. His blood pressure was 128/54, his pulse was 75, his temp was 97.3, pulse oximetry was 88 on CPAP, blood sugar was 389. He was sent to the emergency room. Written by LVN A. Record review of resident #1 hospital physician progress notes dated 1/11/2023 indicated Resident #1 was a [AGE] year-old male who presented to the hospital on 01/10 23 with Sepsis. (a life threatening complication of an infection) He presented to the hospital with altered mental status and hypoxia. (absence of enough oxygen in the tissues to sustain body functions.) oxygen saturation in the 80s on a CPAP (Continuous Positive Airway Pressure) and revealed his creatinine was 1.5 (normal level 0.74-1.35 high level indicated kidney failure.)the potassium was 6.8. (normal lever 3.6 to 5.2- potassium levels higher than 6.0 can be dangerous and required immediate treatment) He was encephalopathic (altered brain function) but arousable and able to maintain airway. The notes indicated the resident had acute respiratory failure with hypoxia secondary to volume overload status. chronic kidney disease stage 3 now with worsening renal function with a plan for dialysis. Resident #1 had acute metabolic encephalopathy and sepsis with evidence of Leukocytosis (high white blood cell count), tachypnea (fast breathing) secondary to UTI. Record Review of a report written by the DON regarding an investigation of why Resident #1'a labs were not completed. Stated, On 01/10/23 at 6:22 a.m. the UA was finally collected by an agency nurse. On 01/10/23 at 7:45 a.m. Resident #1 was sent to the emergency room with altered mental status. On 01/10/23 at 2:00 PM the NP said her rationale for ordering the UA was Resident #1 had previously experienced jerking movements and the jerking movements were related a UTI. However, the UA had not been ordered as stat. The report indicated education was provided on UTI's and UA's which indicated when a nurse received the order for the UA. They must immediately contact the DON and attempt the same shift to obtain the urine sample. the nurse must not pass the order or the next shift hoping it will get done. Delaying care for possible infection can lead to complications such as sepsis. The plan of correction for the investigation was the DON would write the LVN A up for failure to obtain the UA order. By her own admission she did not attempt to get the sample on 01/06/23 or 01/09/23. LVN A's failure to communicate the change of condition and new order for UA immediately to the DON also delayed patient care. In the future the nurse who received the order would be responsible for obtaining the urine sample. Nurses must no longer pass the order to the next shift. The nurses should also utilize urine dipsticks per MD standard order while waiting for UA to return for quick results and contact the physician with the results. During an interview on 01/12/23 a 10:20 a.m. LVN A said she worked at the facility since 2004. She said on 01/06/23 Resident #1had some jerking motions. She said CNA C called her to his room. She said she assessed Resident #1 and his vital signs were normal. He was shaking quite a bit and unable to hold his cell phone. LVN A said she called the NP and received an ordered for a UA with culture and sensitivity. She did not attempt to collect the UA. She was off work over the weekend. She said she came back on to work on 01/09/23 and Resident #1 was fine. She did not attempt to obtain a UA on 01/09/23. On the morning of 01/10/23 she sent Resident #1 to the hospital because he was basically unresponsive and his O2 stat was low. She called the NP and family. During an interview o 01/12/23 at 2:20 p.m. the DON said on 01/06/23 LVN A contacted the NP and received an order on 01/06/23. The DON said the first time she was aware of the NP order for a UA was on 1/9/23. The LVN said the resident was still in need of a UA because it had not been completed. The DON said LVN A had not completed the UA and had not tried. The DON said after the VA Representative contacted the facility on 01/10/23 they began their investigation. The DON said she started in services on that day and was developing a plan of action for QA as part of their QA measures for correction. During a telephone interview on 01/24/22 at 8:09 a.m. Resident #1 said he was sick all weekend prior to going to the hospital. He did not remember anyone trying to collect urine from him during the weekend. He said sometimes he felt better than others, but he felt sick the whole weekend. Resident #1 said he did not remember what happen on the morning of 01/10/23, he was mostly out of it. Record review of an in service dated 01/10/23 at 4:30 p.m. indicated nurses were trained on Education on UTI's and UA's, Change in Condition and Documentation, and Labs. The in service on Labs indicated, When we obtained an order for a UA or any other type of labs. You need to notify the DON by phone right away and family members. When trying to get a UA sample and not able to obtain it. Make sure you put a progress note about how many times you tried and the reason of why you were not able to obtain the sample. (signed by 7 nurses to include LVN A.) Record Review of the facility weekend lab policy indicated the company provided daily route services Monday through Friday. No routine draws will be collected on weekends to schedule of necessary Saturday and Sunday draws must be called into the laboratory. UA-C/s are not considered stat test. If a resident is in distress and or in a critical state, we will pick up a UA while we are there drawing blood on the weekend. Record review of the facility Lab and Diagnostic Test Results policy late revised November 2018. Indicated the physician will identify in order diagnostic and lab testing based on the residence diagnostic and monitoring needs. the team will process test requisitions and arrange for test. the laboratory, diagnostic radiology provider, or other testing sources will report test results to the facility. During an interview on 020/2/23 at 1:30 p.m. agency LVN I said this was her third time working at the facility. When she first came, she was given a brief overview of the nurses station. However, she had not received any recent in service about labs or UAs. During an interview on 02/02/23 at 2:26 p.m. 2:26 p.m. the MD said he was not made aware Resident #1 did not receive his UA until after he went to the hospital. He said the UA was requested because when an elderly person had any change in condition it is most frequently due to a UTI. The MD said he was not aware of any issues related to Resident #1 having prostate problems, there was no indication he had a blockage. The MD said Resident #1 had a multitude of complex problems. He said the nurse could have suggested to the NP the UA be Stat. The MD said apparently, the nurse did not convey any emergency to have the UA done quickly. He said either way they wanted it done sooner rather than later. The MD said if Resident #1 had a UTI and it seemed apparent, he did his condition would only decompensate the longer they waited to provide treatment. He said he had some concerns that it was not done within a day or so. The MD said that is what they expect of an order for a UA. He said usually a UA results will come back in a few hours or the next day. The MD said he and DON had talked and would do better communication in the future and make sure UAs are done timely. During a telephone interview on 2/2/23 at 2:37 p.m. the lab technician at the Laboratory company the facility utilized, said the UA's do not have to be Stat on the weekend. All the facility needed to do was call and they would pick them up. During an interview on 02/03/23 12: 10 p.m. DON said she just did a verbal counseling with LVN A and a one on one in service with her. The DON said with this company do not have anything written. She said she had done some in servicing on 01/10/23 about labs and change in condition. However, she did not have a current system in place to train all agency staff. During a telephone interview on 2/3/23 at 12:22 p.m. LVN H said she remembered LVN A told her during report on 1/6/23 that Resident #1 was doing some jerking and need a UA. She said she said not notice any kind of jerking. LVN H said she did not get the UA as order. She said when she got to Resident #1's room his brief was wet. LVN H said the note about getting the UA was in the 24-hour report as well. LVN H said she could not remember if she had written a note about Resident #1 or not, she really did not remember that incident well. LVN H said she received in services regarding change in condition, labs. LVN H said she would not have done anything any different with Resident #1. She said she let the next shift know she was unable to get the UA. This was determined to be an Immediate Jeopardy (IJ) on 02/03/23 at 1:30 p.m. The facility Administrator, MDS nurse, DON, and ADON were notified. The Administrator was provided with the IJ template on 02/03/23 at 1:30 p.m. The facility plan of removal was accepted on 02/04/23 at 3:22 p.m. was as follows. [Laboratory Services The facility failed to provide timely laboratory services as ordered by the Physician on 1 Resident on 1/6/23. The Physician was not notified that lab was not drawn, resulting in a COC that resulted in his hospitalization on 1/10/23. Identify residents who could be affected All Residents have the potential to be affected. The Facility census on 1/6/23 was 43. A lab audit was initiated on 2/3/23, and no residents have been identified as having incomplete lab, and this will be completed by 2/4/23. In-Service conducted Nurses were in-serviced on 1/10/23 by DON when concern identified. All nurses will receive further education on the following: Carrying out Physicians/NP orders and education on procedures for notifying Physicians/NP when a lab order is not able to be carried out and any changes in condition related to inability to complete ordered lab. Implementation Date of Changes In-servicing was initiated on 2/3/23 and will be completed by 2/4/23. Agency staff, new nurses and nurses on leave that work in the facility will have in-servicing completed prior to working the floor. Involvement of Medical Director The Medical Director, Dr. [NAME] was notified about the immediate Jeopardy on 2/3/23. Involvement of QA QAPI will review and approve Plan of Removal on 2/4/23 Who is responsible for implementation of process? Administrator and DON (Director of Nursing).] On 02/04/23 the investigator confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of the facility employee roster indicated they have 5 full time LVNs, one part time LVN and two weekend RNs and the ADON who is an LVN. They have 9 nurses total. They had 7 CNAs. During an observation and interview on 02/04/23 at 3: 39 p.m. DON said she had a binder with a list of Agency staff, their discipline and when they received the training. She said she would monitor what agency staff had been trained and prior to each agency staff beginning work they would receive training if they were not in the book. Observation of the book showed the training a list of staff. There was a list of 5 agency LVNs and two agency CNAs indicating they had been trained on labs, physician notification, identification of change in condition and physician notification. During interviews on 02/04/23 between 3:30p.m. and 5:15 p.m. three CNAs said they were educated on the Stop and Watch tool (a form used by aides to identify changes in a resident such as different symptoms, change in need for assistance, eating less, agitated, more confused or change in skin color.) to help identify early signs of condition change to the charge nurse. They said they are to fill out the form and give it to the nurse, so they have verification they told the nurse of the change in condition. They were told they could make a copy of the form and place it under department heads doors if they felt their concerns were not addressed. During interviews on 02/04/23 between 3:3 0p.m. and 5:15 p.m. were conducted with 3 facility LVNs and 1 RN and 2 agency LVNs that indicated they were knowledgeable on following physician orders, identification of resident change in condition. The nurses said they would follow guidelines for monitoring. They would monitor residents with possible UTIs for any symptoms. If a resident refused treatment, they would educate the resident on possible consequences and let the physician know of the resident status. The nurses were able to demonstrate through interviews their understanding of those policies, procedures, and in services. Record Review of a Resident record identified as needing a UA was reviewed and the facility put measures in place, such as notifying the physician, getting a timely UA. Detailed documentation of the resident condition was noted in the record to include the INTERACT assessment tool( an assessment form that is used to help nursing staff evaluate the resident for change in condition). The physician was notified of the lab results and the resident place on an antibiotic. With additional physician orders. During exit on 02/04/23 at 5:42 p.m. the Administrator, DON, and ADON were informed the IJ was removed; however, the facility remained out of compliance at level of actual harm with a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems that were put in place.