**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents' right to be free from abuse and neglect for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to provide incontinent care to Resident #1 for more than 8 hours on 09/24/23. Resident #1 sustained excoriation (injury to the skin), swollen labia, and a blister to her peri-area (delicate portion of skin between your genitals and anus). An Immediate Jeopardy (IJ) situation was identified on 09/28/23 at 1:43 p.m. While the IJ was removed on 09/29/23, the facility remained out of compliance at a severity level of 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 of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated 09/27/23 indicated Resident #1 was a [AGE] year old female, admitted on [DATE], and her diagnoses included Alzheimer's (most common cause of dementia) - a gradual decline in memory, thinking, behavior and social skills, muscle wasting and atrophy-multiple sites (muscles appear smaller than usual due to a lack of muscle tissue), other abnormalities of gait and mobility, difficulty in walking, depression (serious mood disorder), altered mental status (change in mental function), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions), need for assistance with personal care, muscle weakness, ataxic gait (failure of muscle coordination and is characterized by an irregular foot placement), diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) with diabetic polyneuropathy (type of nerve damage), kidney disease (disorder characterized by gradual and usually permanent loss of kidney function resulting in renal failure), affective mood disorder (marked disruptions in emotions -severe lows called depression or highs called hypomania or mania), and anxiety (feeling of fear, dread, and uneasiness). Record review of an MDS assessment dated [DATE] indicated Resident #1 had clear speech, was usually able to make herself understood and understand others, had severe cognitive impairment (BIMS score of 6), required extensive assist of one staff for toilet use (includes incontinent care), was always incontinent of bladder and frequently incontinent of bowel. Resident #1 was at risk of developing pressure ulcers. Record review of a care plan dated 09/06/22 indicated Resident #1 had an ADL self-care deficit and limitations in physical mobility related to Alzheimer's, dementia, cognitive deficits, confusion, forgetfulness, impaired balance, limited mobility, ROM, and musculoskeletal impairment. Goals included: Resident will remain free of complications related to limitations in mobility, including skin-breakdown. Interventions included: toilet use- resident requires extensive assist of one staff for toileting and skin inspection-during resident general care and incontinent care inspect resident's skin and observe for redness, open areas, scratches, bruises and report changes to nurse. Record review of a care plan dated 09/06/22 indicated Resident #1 had the potential for alteration in skin integrity related to pressure ulcer/pressure injury secondary to impaired mobility and incontinency. Interventions included to keep skin clean and dry, provide incontinent care as quickly as possible following episodes of voiding or bowel movement. Record review of a care plan dated 07/20/23 indicated Resident #1 was on diuretic (reduce fluid buildup in the body; increase urinary frequency and may cause urinary urgency and incontinence) therapy Spironolactone (a potassium-sparing diuretic) and Lasix (diuretic that prevents your body from absorbing too much salt) related to edema. Interventions included administer medications as ordered and monitor for effectiveness every shift. Record review of a care plan dated 07/20/23 indicated Resident #1 had bowel and bladder incontinence related to Alzheimer's/dementia, impaired mobility, physical limitations, and inability to communicate needs. Interventions included clean peri-area with each incontinence episode. Record review of a care plan revised 07/20/23 indicated Resident #1 would remain in LTC. Interventions included Resident #1 was at risk for skin breakdown and required assistance with pressure relieving position changes and toileting. Record review of a care plan revised 08/14/23 indicated Resident #1 had the potential for impairment to skin integrity related to fragile skin and incontinency of bladder and bowel. Interventions included avoid scratching and keep hands and body parts from excessive moisture. Record review of video dated 09/24/23 at 4:13 a.m. indicated CNA C provided incontinent care for Resident #1. Family member arrived at 12:13 p.m. At 12:49 p.m. family member finds Resident #1 is incontinent and her peri-area is red. At 12:50 p.m. the family member walks out of Resident #1's room and returns to the room at 12:51 p.m. At 12:55 p.m. family member places a white wash cloth on Resident #1's peri-area. Resident #1 is crying in pain. At 12:58 p.m., the family member walks out of the room. At 12:59 p.m., the family member walks back into the room and staff followed into the room. At 1:03 p.m., staff brought in towels and Resident #1 was crying and upset. Record review of a progress note dated 09/25/23 on 10:49 a.m., completed by LVN B indicated Resident #1's family member wanted Resident #1 to go to the ER due to rash in peri-area. LVN B spoke to family member about treatment already in place with zinc oxide and would contact the physician to get new orders. Family member agreed. Physician notified and ordered nystatin cream(antifungal) and zinc (medicated cream, ointment or paste that treats or prevents skin irritation) to peri-area TID. Physician would see Resident #1 in the facility. Record review of a skin assessment dated [DATE] indicated Resident #1 had redness and a blister on her right labia and redness and excoriation of her peri-area. During observation and interview on 09/26/23 at 1:30 p.m., CNA G provided Resident #1's incontinent care. Resident #1 was able to assist with repositioning and turning. CNA G said Resident #1 developed some redness over the weekend in her peri-area. Resident #1 grimaced and appeared in pain and discomfort during incontinent care. Resident #1 said ouch while being wiped by CNA G. Resident #1's right and left labia were red and inflamed and swollen, the right labia had a blister on the outer area, the left abdominal fold/crease has red and macerated (skin is in contact with moisture for too long), and the left inner thigh was reddened. After she completed incontinent care she called for LVN B to apply Nystatin (antifungal)/Zinc (medicated cream, ointment or paste that treats or prevents skin irritation) compound to Resident #1's peri-area. LVN B indicated Resident #1's physician assessed Resident #1 on 09/26/23 and ordered the Nystatin/Zinc compound TID. During an interview on 09/27/23 at 12:45 p.m., a family member indicated Resident #1 was upset and crying when she arrived on 09/24/23. She said she arrived after 12:00 p.m. She said she found Resident #1's undergarment soaking wet and very heavy with urine. She said Resident #1's labia was swollen and had a blister. She said Resident #1's entire peri-area was very red and excoriated. She said she had applied a cold cloth and attempted to find staff two times before a CNA E and an MA P came in to provide incontinent care. She said Resident #1 was very upset and crying and saying ouch when she was wiped. She said LVN A came in later (after incontinent care was completed) to assess Resident #1. She said she reviewed video and found the last time Resident #1 received incontinent care was 4:13 a.m. on 09/24/23. She said Resident #1 was neglected. During an interview on 09/28/23 at 10:15 a.m., The DON said she began investigating a grievance from Resident #1's family member on 09/25/23. She said Resident #1's family member was upset with staffing because Resident #1 did not have an assigned CNA on 09/24/23. She said her investigation of the grievance revealed LVN A did not assign an aide to Resident #1 until after 11 a.m. on 09/24/23. She said she directed LVN A on 09/24/23 at 6:45 a.m. via text to assign CNAs and MAs to provide resident care. She said she directed LVN A to pass medications. She said LVN A refused to pass medications to the residents on her assigned hall (Hall 400). She said Resident #1 was not provided incontinent care until after 12:30 p.m., after Resident #1's family member notified LVN A of Resident #1 being in pain and incontinent. She said LVN A was suspended and subsequently terminated for insubordination on 09/26/23. She said she inserviced staff on following orders, providing incontinent care, reporting skin issues, and documentation. She said the nurses were supposed to monitor the aides to ensure residents received care as required. She said staff were supposed to check and change residents every 2 hours and as needed. She said residents were at risk of neglect if care was not provided as required. She said not providing care as required was neglect. She said skin assessments of all residents on hall 400 were completed as of 09/28/23. During an interview on 09/28/23 at 11:39 a.m. LVN A said she did not assign aides to provide resident care. She said she expected they would assign themselves. She said she finished passing medications on Hall 100 and noticed Resident #1 was in the same position. She said she asked who was assigned to Resident #1 and no one knew. She said she did not follow the DON's orders. She said after Resident #1's family member came to the nurse station, she said MA P and CNA E provided care to Resident #1. She said she talked to Resident #1's physician about Resident #1's red skin and received new orders for Nystatin. She said Resident #1 was neglected because she did not receive care as required and she developed a rash. She said staff were to check and change residents every 2 hours and PRN. During an interview on 09/28/23 at 12:45 p.m., LVN I said she assessed Resident #1 on 09/25/23. She said Resident #1 had a tendency to be red but she did not have a rash or a blister previously. She said the blister could be caused by lying in urine and feces for an extended period. She said residents should be checked and changed every 2 hours and as needed. During an interview on 09/28/23 at 1:11 p.m., LVN F said LVN A refused to do her own medication pass and did not assign aides. She said Resident #1 did not have an assigned CNA on 09/24/23 for the morning shift (6:00 am) and did not receive care as required. She said Resident #1 was neglected. She said residents were to be checked and changed every 2 hours and as needed. During an interview on 09/28/23 at 2:37 p.m., CNA G said she was not assigned to provide care for Resident #1 09/24/23. She said she was not directed to care for Resident #1. She said there was usually a book at the nurse station with assignments. She said residents were supposed to be checked and changed every 2 hours and as needed. She said a resident was neglected if the resident did not receive care as required. She said she provided care for Resident #1 on 09/24/23 later in the day. Resident #1 was crying and saying she hurt (peri-area). She said Resident #1's labia was swollen, the peri area was red and inflamed, and there was a blister on her right labia. She said there was a little bleeding when she wiped feces from Resident #1's peri-area. She said Resident #1's peri-area was not swollen, inflamed, or bleeding the previous day. During an interview on 09/28/23 at 3:04 p.m., CNA E said she was originally scheduled to work as a medication aide on 09/24/23. She said LVN A re-assigned her (CNA E) to work as an aide on hall 300. She said she stopped by MA P after 12:00 p.m. on 09/24/23 and asked to assist with Resident #1's incontinent care. She said Resident #1's family member had removed the incontinent brief and applied a cold cloth to Resident #1's peri-area. She said Resident #1's abdominal creases and inner thighs were red and inflamed. She said Resident #1 was crying and upset. She said residents should be checked and changed every 2 hours and as necessary. She said failure to provide timely incontinent care could result in skin breakdown. CNA E said it was neglect if care was not provided as required. During an interview on 09/28/23 at 3:14 p.m., MA P said she was at the nurse station and Resident #1's family member came to the nurse station. She said Resident #1's family member was in tears and informed LVN A of Resident #1 needing care and she (Resident #1) had not been tended to. LVN A said she would find someone. She said CNA E came by the nurse station and (MA P) told CNA E to assist with providing care to Resident #1. She said Resident #1 cried and whimpered and said it hurt when she was being wiped. She said residents should be checked and changed every 2 hours and as necessary. She said failure to provide timely incontinent care could result in skin breakdown. CNA C said it was neglect if care was not provided as required. Record review of LVN A's personnel file indicated she was terminated on 09/26/23 for insubordination. Record review of the facility's Abuse Prevention Program dated 2001 (revised December 2016) provided by the facility and included the Long-Term Care Regulatory Provider Letter (PL 19-17) indicated Our residents have the right to be free of abuse, neglect, misappropriation of resident property and exploitation.Abuse also includes the deprivation by an individual, including caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being.Neglect . failure to provide goods and services that are necessary to avoid physical or emotional harm, pain, . The Administrator and the DON were notified of the Immediate Jeopardy on 09/28/23 at 1:43 p.m. and the Administrator was provided the Immediate Jeopardy template. The Administrator was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 09/29/23 at 5:42 p.m. and reflected the following: Immediate action: Resident # 1 was assessed by the charge nurse on duty on September 25, 2023 @10:15 a.m. The attending physician was contacted by Charge Nurse, new order to add Nystatin Cream to the existing Zinc Oxide order to be applied three times per day, was received and initiated on 09/25/2023. Upon receipt of the grievance from Resident #1's representative on 09/25/2023, the Assistant Director of Nursing and Director of Nursing began investigating the cause of the grievance on 09/25/2023. Upon investigation it was noted that the division of duties was not carried out by the charge nurse as directed by the Director of Nursing on 09/24/2023 @ 6:45 a.m. The charge nurse that was instructed to divide the resident care duties was interviewed and terminated from employment for refusal to obey orders of a supervisor on 09/26/2023 @ 5:07 p.m. via telephone by the Director of Nursing. On 09/26/2023 The Director of Nursing provided the information regarding the practice of the terminated nurse to the Director of Clinical Operations from the corporate office for further review regarding potential referral to the Texas Board of Nursing. The decision to make the referral was referred to legal counsel on 09/28/2023 when the investigation of the nurse was completed. On 09/26/2023 @ 5:30 p.m., The Director of Nursing initiated an in-service with nursing staff: both direct and licensed regarding following directives given by the supervisor during their shift and the consequences that might arise from failure to adhere to direction given. The in-service education will continue until all nursing staff: direct care and licensed, have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. On 09/26/2023, upon identification of the directive from the supervisor not being carried out, further investigation by the Director of Nursing revealed CNAs were not assigned to provide care on the 400 hall on 09/24/2023 from approximately 6:00 a.m. until 12:30 p.m. On 09/26/2023 at 5:45 p.m., The Director of Nursing and Designees completed full body skin assessments on all residents on the 400 hall. No adverse findings were noted on completion for residents' residing on 400 Hall on 09/26/23 at 7:50 p.m. On 09/26/2023 @ 5:30 p.m., the Director of Nursing initiated an in-service with nursing staff: regarding direct and licensed regarding resident care rounds. This in-service directed nursing staff: direct care and licensed, that residents should be rounded on/checked on at least every two hours to ensure their needs are being met timely and appropriately, with emphasis on residents with higher acuity and dependent on care. The in-service education will continue until all nursing staff: both licensed and direct care, have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. On 09/26/2023 @ 5:30 p.m., the Director of Nursing initiated an in-service with the nursing staff: both direct and licensed and therapy staff regarding the importance of incontinent care and general ADL care. The in-service education will continue until all nursing staff: direct care and licensed, and therapy staff have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. On 09/26/2023, the Director of Nursing and Designees conducted resident life satisfaction surveys on residents residing who are able to be interviewed on the 400 hallway; no concerns regarding care were noted upon completion on 09/28/2023. Facilities Plan to Ensure Compliance Quickly Impromptu QAPI was held September 28, 2023 @ 6:18 p.m. with the facility Medical Director and informed him of the two immediate jeopardies that the Facility obtained for F600-Neglect and F677-ADL Care for Dependent Residents. The Medical Director was informed of the facility efforts to correct the alleged violations including assessments, interviews, disciplinary action, education, and initiation of procedural changes. On September 28, 2023, the facility will implement a new procedure for assigning staff to residents based on the number of staff present. This procedure will provide instruction on how to divide the resident care duties efficiently and equally to ensure adequate care of residents. The division of duties will be specific to different staffing numbers and instances. Each day on the daily assignment sheet one charge nurse will be assigned to be the person responsible for ensuring the correct division of duties is confirmed with all staff at the beginning of the shift. The Director of Nursing shall provide an in-service to all staff regarding the process of staff assignments. The in-service education will continue until all nursing staff, direct care and licensed, have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. The Director of Nursing and/or Designee shall review the daily assignment sheets for adequate division of duties Monday through Friday and the weekend supervisor shall review on Saturday and Sunday. On 09/29/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 09/29/23 from 4:30 p.m. through 6:55 p.m. and included 3 alert residents, nurses including 5 LVNs, 6 CNAs, 2 MA, (who work all shifts), the ADON, and the DON. Staff indicated residents were checked every 2 hours for incontinence, lines (moisture indicators) were checked for wetness, water and ADL care provided PRN. Residents were monitored during rounds. Residents were asked about their needs. The lead nurse assigns aides as necessary and if aides were not available, aides would split halls based on guide in book at nurse station. They indicated if staff refused direct orders from their supervisor they would report to the DON and the administrator. Staff were required to check their assigned residents at the start of their shift and end of their shift. Staff would be suspended and possibly terminated for refusing direct orders. During an interview on 09/29/23 at 4:42 p.m. the DON said lead nurse assignments were in place to ensure all residents had assigned CNA's. She said all in-services were completed. She said skin assessments were completed for Hall 400 and the entire facility. She said there was no additional negative findings. During observation and interview on 09/29/23 at 5:52 p.m., Resident #1 said staff were keeping her changed and dry. Resident #1's undergarment was dry and the Nystatin/Zinc compound was applied to her per-area. Redness was observed on Resident #1's peri-area and she was clean and dry. Record review of the facility implemented a monitoring system effective 09/29/23. The facility Administrator and/or Director of Nursing indicated they were responsible for the monitoring and would conduct observation rounds and conduct interviews related to resident care, duties and assignments, and lead nurse responsibilities. Record review of Resident #1's skin assessment dated [DATE], physician orders, and TAR indicated Resident #1 received care as required. Record review of 100% of hall 400 skin assessments indicated the facility reviewed all residents to ensure no adverse findings. Record review of grievances for previous three months through 09/29/23 indicated the facility addressed grievances as required. The grievance from Resident #1's family member on 09/25/23, the ADON and DON determined LVN A had not assigned duties as directed by the DON on 09/24/23. CNAs were not assigned to provide care on the 400 hall on 09/24/23 from approximately 6:00 a.m. until 12:30 p.m. Record review of staff in-service dated 09/29/23 indicated all licensed and direct care staff were trained on following directives from their supervisors. Record review of staff in-service dated 09/26/23 indicated direct care and licensed staff were trained that residents should be rounded on/checked on at least every two hours to ensure their needs are being met timely and appropriately, with emphasis on residents with higher acuity and dependent on care. Record review of staff in-service dated 09/26/23 indicated direct and licensed and therapy staff were trained regarding the importance of incontinent care and general ADL care. Record review of resident life satisfaction surveys on residents residing who are able to be interviewed on the 400 hallway indicated no concerns regarding care were noted upon completion on 09/28/2023. Record review of the facility's new procedure dated 09/28/23 for assigning staff to residents based on the number of staff present indicated the following: on the daily assignment sheet one charge nurse would be assigned responsible for ensuring the correct division of duties was confirmed with all staff at the beginning of the shift. The DON inserviced all staff regarding the process of staff assignments. The DON and/or Designee would review the daily assignment sheets for adequate division of duties Monday through Friday and the weekend supervisor would review on Saturday and Sunday. Record of staff post tests were reviewed for accuracy and knowledge. No concerns noted. On 09/29/23 at 6:55 p.m., the Administrator was informed the IJ was removed; however, 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 of 10 residents (Resident #1) reviewed for ADL care. The facility failed to provide incontinent care to Resident #1 for more than 8 hours on 09/24/23. Resident #1 sustained excoriation (injury to the skin), swollen labia, and a blister to her peri-area (delicate portion of skin between your genitals and anus). An Immediate Jeopardy (IJ) situation was identified on 09/28/23 at 1:43 p.m. While the IJ was removed on 09/29/23, the facility remained out of compliance at a severity level of actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failures could place residents at risk of embarrassment, discomfort, and skin breakdown. Findings included: Record review of a face sheet dated 09/27/23 indicated Resident #1 was a [AGE] year old female, admitted on [DATE], and her diagnoses included Alzheimer's (most common cause of dementia) - a gradual decline in memory, thinking, behavior and social skills, muscle wasting and atrophy-multiple sites (muscles appear smaller than usual due to a lack of muscle tissue), other abnormalities of gait and mobility, difficulty in walking, depression (serious mood disorder), altered mental status (change in mental function), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately, understanding jokes or metaphors, or following directions), need for assistance with personal care, muscle weakness, ataxic gait (failure of muscle coordination and is characterized by an irregular foot placement), diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine) with diabetic polyneuropathy (type of nerve damage), kidney disease (disorder characterized by gradual and usually permanent loss of kidney function resulting in renal failure), affective mood disorder (marked disruptions in emotions -severe lows called depression or highs called hypomania or mania), and anxiety (feeling of fear, dread, and uneasiness). Record review of an MDS assessment dated [DATE] indicated Resident #1 had clear speech, was usually able to make herself understood and understand others, had severe cognitive impairment (BIMS score of 6), required extensive assist of one staff for toilet use (includes incontinent care), was always incontinent of bladder and frequently incontinent of bowel. Resident #1 was at risk of developing pressure ulcers. Record review of a care plan dated 09/06/22 indicated Resident #1 had an ADL self-care deficit and limitations in physical mobility related to Alzheimer's, dementia, cognitive deficits, confusion, forgetfulness, impaired balance, limited mobility, ROM, and musculoskeletal impairment. Goals included: Resident will remain free of complications related to limitations in mobility, including skin-breakdown. Interventions included: toilet use- resident requires extensive assist of one staff for toileting and skin inspection-during resident general care and incontinent care inspect resident's skin and observe for redness, open areas, scratches, bruises and report changes to nurse. Record review of a care plan dated 09/06/22 indicated Resident #1 had the potential for alteration in skin integrity related to pressure ulcer/pressure injury secondary to impaired mobility and incontinency. Interventions included to keep skin clean and dry, provide incontinent care as quickly as possible following episodes pf voiding or bowel movement. Record review of a care plan dated 07/20/23 indicated Resident #1 was on diuretic (reduce fluid buildup in the body; increase urinary frequency and may cause urinary urgency and incontinence) therapy Spironolactone (a potassium-sparing diuretic) and Lasix (diuretic that prevents your body from absorbing too much salt) related to edema. Interventions included administer medications as ordered and monitor for effectiveness every shift. Record review of a care plan dated 07/20/23 indicated Resident #1 had bowel and bladder incontinence related to Alzheimer's/dementia, impaired mobility, physical limitations, and inability to communicate needs. Interventions included clean peri-area with each incontinence episode. Record review of a care plan revised 07/20/23 indicated Resident #1 would remain in LTC. Interventions included Resident #1 was at risk for skin breakdown and required assistance with pressure relieving position changes and toileting. Record review of a care plan revised 08/14/23 indicated Resident #1 had the potential for impairment to skin integrity related to fragile skin and incontinency of bladder and bowel. Interventions included avoid scratching and keep hands and body parts from excessive moisture. Record review of video dated 09/24/23 at 4:13 a.m. indicated CNA C provided incontinent care for Resident #1. Family member arrived at 12:13 p.m. At 12:49 p.m. family member finds Resident #1 is incontinent and her peri-area is red. At 12:50 p.m. the family member walks out of Resident #1's room and returns to the room at 12:51 p.m. At 12:55 p.m. family member places a white wash cloth on Resident #1's peri-area. Resident #1 is crying in pain. At 12:58 p.m., the family member walks out of the room. At 12:59 p.m., the family member walks back into the room and staff followed into the room. At 1:03 p.m., staff brought in towels and Resident #1 was crying and upset. Record review of a progress note dated 09/25/23 on 10:49 a.m., completed by LVN B indicated Resident #1's family member wanted Resident #1 to go to the ER due to rash in peri-area. LVN B spoke to family member about treatment already in place with zinc oxide and would contact the physician to get new orders. Family member agreed. Physician notified and ordered nystatin cream(antifungal) and zinc (medicated cream, ointment or paste that treats or prevents skin irritation) to peri-area TID. Physician would see Resident #1 in the facility. Record review of a skin assessment dated [DATE] indicated Resident #1 had redness and a blister on her right labia and redness and excoriation of her peri-area. During observation and interview on 09/26/23 at 1:30 p.m., CNA G provided Resident #1's incontinent care. Resident #1 was able to assist with repositioning and turning. CNA G said Resident #1 developed some redness over the weekend in her peri-area. Resident #1 grimaced and appeared in pain and discomfort during incontinent care. Resident #1 said ouch while being wiped by CNA G. Resident #1's right and left labia were red and inflamed and swollen, the right labia had a blister on the outer area, the left abdominal fold/crease has red and macerated (skin is in contact with moisture for too long), and the left inner thigh was reddened. After she completed incontinent care she called for LVN B to apply Nystatin (antifungal)/Zinc (medicated cream, ointment or paste that treats or prevents skin irritation) compound to Resident #1's peri-area. LVN B indicated Resident #1's physician assessed Resident #1 on 09/26/23 and ordered the Nystatin/Zinc compound TID. During an interview on 09/27/23 at 12:45 p.m., a family member indicated Resident #1 was upset and crying when she arrived on 09/24/23. She said she arrived after 12:00 p.m. She said she found Resident #1's undergarment soaking wet and very heavy with urine. She said Resident #1's labia was swollen and had a blister. She said Resident #1's entire peri-area was very red and excoriated. She said she had applied a cold cloth and attempted to find staff two times before a CNA E and an MA P came in to provide incontinent care. She said Resident #1 was very upset and crying and saying ouch when she was wiped. She said LVN A came in later (after incontinent care was completed) to assess Resident #1. She said she reviewed video and found the last time Resident #1 received incontinent care was 4:13 a.m. on 09/24/23. She said Resident #1 was neglected. During an interview on 09/28/23 at 10:15 a.m., The DON said she began investigating a grievance from Resident #1's family member on 09/25/23. She said Resident #1's family member was upset with staffing because Resident #1 did not have an assigned CNA on 09/24/23. She said her investigation of the grievance revealed LVN A did not assign an aide to Resident #1 until after 11 a.m. on 09/24/23. She said she directed LVN A on 09/24/23 at 6:45 a.m. via text to assign CNAs and CMAs to provide resident care. She said she directed LVN A to pass medications. She said LVN A refused to pass medications to the residents on her assigned hall (Hall 400). She said Resident #1 was not provided incontinent care until after 12:30 p.m., after Resident #1's family member notified LVN A of Resident #1 being in pain and incontinent. She said LVN A was suspended and subsequently terminated for insubordination on 09/26/23. She said she inserviced staff on following orders, providing incontinent care, reporting skin issues, and documentation. She said the nurses were supposed to monitor the aides to ensure residents received care as required. She said staff were supposed to check and change residents every 2 hours and as needed. She said residents were at risk of neglect if care was not provided as required. She said not providing care as required was neglect. She said skin assessments of all residents on hall 400 were completed as of 09/28/23. During an interview on 09/28/23 at 11:39 a.m. LVN A said she did not assign aides to provide resident care. She said she expected they would assign themselves. She said she finished passing medications on Hall 100 and noticed Resident #1 was in the same position. She said she asked who was assigned to Resident #1 and no one knew. She said she did not follow the DON's orders. She said after Resident #1's family member came to the nurse station, she said MA P and CNA E provided care to Resident #1. She said she talked to Resident #1's physician about Resident #1's red skin and received new orders for Nystatin. She said Resident #1 was neglected because she did not receive care as required and she developed a rash. She said staff were to check and change residents every 2 hours and PRN. During an interview on 09/28/23 at 12:45 p.m., LVN I said she assessed Resident #1 on 09/25/23. She said Resident #1 had a tendency to be red but she did not have a rash or a blister previously. She said the blister could be caused by lying in urine and feces for an extended period. She said residents should be checked and changed every 2 hours and as needed. During an interview on 09/28/23 at 1:11 p.m., LVN F said LVN A refused to do her own medication pass and did not assign aides. She said Resident #1 did not have an assigned CNA on 09/24/23 for the morning shift (6:00 am) and did not receive care as required. She said Resident #1 was neglected. She said residents were to be checked and changed every 2 hours and as needed. During an interview on 09/28/23 at 2:37 p.m., CNA G said she was not assigned to provide care for Resident #1 09/24/23. She said she was not directed to care for Resident #1. She said there was usually a book at the nurse station with assignments. She said residents were supposed to be checked and changed every 2 hours and as needed. She said a resident was neglected if the resident did not receive care as required. She said she provided care for Resident #1 on 09/24/23 later in the day. Resident #1 was crying and saying she hurt (peri-area). She said Resident #1's labia was swollen, the peri area was red and inflamed, and there was a blister on her right labia. She said there was a little bleeding when she wiped feces from Resident #1's peri-area. She said Resident #1's peri-area was not swollen, inflamed, or bleeding the previous day. During an interview on 09/28/23 at 3:04 p.m., CNA E said she was originally scheduled to work as a medication aide on 09/24/23. She said LVN A re-assigned her (CNA E) to work as an aide on hall 300. She said she stopped by MA P after 12:00 p.m. on 09/24/23 and asked to assist with Resident #1's incontinent care. She said Resident #1's family member had removed the incontinent brief and applied a cold cloth to Resident #1's peri-area. She said Resident #1's abdominal creases and inner thighs were red and inflamed. She said Resident #1 was crying and upset. She said residents should be checked and changed every 2 hours and as necessary. She said failure to provide timely incontinent care could result in skin breakdown. CNA E said it was neglect if care was not provided as required. During an interview on 09/28/23 at 3:14 p.m., MA P said she was at the nurse station and Resident #1's family member came to the nurse station. She said Resident #1's family member was in tears and informed LVN A of Resident #1 needing care and she (Resident #1) had not been tended to. LVN A said she would find someone. She said CNA E came by the nurse station and (MA P) told CNA E to assist with providing care to Resident #1. She said Resident #1 cried and whimpered and said it hurt when she was being wiped. She said residents should be checked and changed every 2 hours and as necessary. She said failure to provide timely incontinent care could result in skin breakdown. CNA E said it was neglect if care was not provided as required. Record review of LVN A's personnel file indicated she was terminated on 09/26/23 for insubordination. Record review of the facility's Abuse Prevention Program dated 2001 (revised December 2016) provided by the facility and included the Long-Term Care Regulatory Provider Letter (PL 19-17) indicated Our residents have the right to be free of abuse, neglect, misappropriation of resident property and exploitation.Abuse also includes the deprivation by an individual, including caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being.Neglect . failure to provide goods and services that are necessary to avoid physical or emotional harm, pain, . The Administrator and the DON were notified of the Immediate Jeopardy on 09/28/23 at 1:43 p.m. and the Administrator was provided the Immediate Jeopardy template. The Administrator was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 09/29/23 at 5:42 p.m. and reflected the following: Immediate action: Resident # 1 was assessed by the charge nurse on duty on September 25, 2023 @10:15 a.m. The attending physician was contacted by Charge Nurse, new order to add Nystatin Cream to the existing Zinc Oxide order to be applied three times per day, was received and initiated on 09/25/2023. Upon receipt of the grievance from Resident #1's representative on 09/25/2023, the Assistant Director of Nursing and Director of Nursing began investigating the cause of the grievance on 09/25/2023. Upon investigation it was noted that the division of duties was not carried out by the charge nurse as directed by the Director of Nursing on 09/24/2023 @ 6:45 a.m. The charge nurse that was instructed to divide the resident care duties was interviewed and terminated from employment for refusal to obey orders of a supervisor on 09/26/2023 @ 5:07 p.m. via telephone by the Director of Nursing. On 09/26/2023 The Director of Nursing provided the information regarding the practice of the terminated nurse to the Director of Clinical Operations from the corporate office for further review regarding potential referral to the Texas Board of Nursing. The decision to make the referral was referred to legal counsel on 09/28/2023 when the investigation of the nurse was completed. On 09/26/2023 @ 5:30 p.m., The Director of Nursing initiated an in-service with nursing staff: both direct and licensed regarding following directives given by the supervisor during their shift and the consequences that might arise from failure to adhere to direction given. The in-service education will continue until all nursing staff: direct care and licensed, have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. On 09/26/2023, upon identification of the directive from the supervisor not being carried out, further investigation by the Director of Nursing revealed CNAs were not assigned to provide care on the 400 hall on 09/24/2023 from approximately 6:00 a.m. until 12:30 p.m. On 09/26/2023 at 5:45 p.m., The Director of Nursing and Designees completed full body skin assessments on all residents on the 400 hall. No adverse findings were noted on completion for residents' residing on 400 Hall on 09/26/23 at 7:50 p.m. On 09/26/2023 @ 5:30 p.m., the Director of Nursing initiated an in-service with nursing staff: regarding direct and licensed regarding resident care rounds. This in-service directed nursing staff: direct care and licensed, that residents should be rounded on/checked on at least every two hours to ensure their needs are being met timely and appropriately, with emphasis on residents with higher acuity and dependent on care. The in-service education will continue until all nursing staff: both licensed and direct care, have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. On 09/26/2023 @ 5:30 p.m., the Director of Nursing initiated an in-service with the nursing staff: both direct and licensed and therapy staff regarding the importance of incontinent care and general ADL care. The in-service education will continue until all nursing staff: direct care and licensed, and therapy staff have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. On 09/26/2023, the Director of Nursing and Designees conducted resident life satisfaction surveys on residents residing who are able to be interviewed on the 400 hallway; no concerns regarding care were noted upon completion on 09/28/2023. Facilities Plan to Ensure Compliance Quickly Impromptu QAPI was held September 28, 2023 @ 6:18 p.m. with the facility Medical Director and informed him of the two immediate jeopardies that the Facility obtained for F600-Neglect and F677-ADL Care for Dependent Residents. The Medical Director was informed of the facility efforts to correct the alleged violations including assessments, interviews, disciplinary action, education, and initiation of procedural changes. On September 28, 2023, the facility will implement a new procedure for assigning staff to residents based on the number of staff present. This procedure will provide instruction on how to divide the resident care duties efficiently and equally to ensure adequate care of residents. The division of duties will be specific to different staffing numbers and instances. Each day on the daily assignment sheet one charge nurse will be assigned to be the person responsible for ensuring the correct division of duties is confirmed with all staff at the beginning of the shift. The Director of Nursing shall provide an in-service to all staff regarding the process of staff assignments. The in-service education will continue until all nursing staff, direct care and licensed, have been provided with this education and staff will not be able to begin their next scheduled shift without acknowledgment of understanding. The in-service education will be completed no later than 09/29/2023. The Director of Nursing and/or Designee shall review the daily assignment sheets for adequate division of duties Monday through Friday and the weekend supervisor shall review on Saturday and Sunday. On 09/29/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on 09/29/23 from 4:30 p.m. through 6:55 p.m. and included 3 alert residents, nurses including 5 LVNs, 6 CNAs, 2 MA, (who work all shifts), the ADON, and the DON. Staff indicated residents were checked every 2 hours for incontinence, lines were checked for wetness, water and ADL care provided PRN. Residents were monitored during rounds. Residents were asked about their needs. The lead nurse assigns aides as necessary and if aides were not available, aides would split halls based on guide in book at nurse station. They indicated if staff refused direct orders from their supervisor they would report to the DON and the administrator. Staff were required to check their assigned residents at the start of their shift and end of their shift. Staff would be suspended and possibly terminated for refusing direct orders. During an interview on 09/29/23 at 4:42 p.m. the DON said lead nurse assignments were in place to ensure all residents had assigned CNA's. She said all in-services were completed. She said skin assessments were completed for Hall 400 and the entire facility. She said there was no additional negative findings. During observation and interview on 09/29/23 at 5:52 p.m., Resident #1 said staff were keeping her changed and dry. Resident #1's undergarment was dry and the Nystatin/Zinc compound was applied to her per-area. Redness was observed on Resident #1 and she was clean and dry. The facility implemented a monitoring system effective 09/29/23. The facility Administrator and/or Director of Nursing indicated they were responsible for the monitoring and would conduct observation rounds and conduct interviews related to resident care, duties and assignments, and lead nurse responsibilities. Record review of Resident #1's skin assessment dated [DATE], physician orders, and TAR indicated Resident #1 received care as required. Record review of 100% of hall 400 skin assessments indicated the facility reviewed all residents to ensure no adverse findings. Record review of grievances for previous three months from through 09/29/23 indicated the facility addressed grievances as required. The grievance from Resident #1's family member on 09/25/23, the ADON and DON determined LVN A had not assigned duties as directed by the DON on 09/24/25. CNAs were not assigned to provide care on the 400 hall on 09/24/23 from approximately 6:00 a.m. until 12:30 p.m. Record review of LVN A's personnel file LVN A was terminated for insubordination on 09/26/23. Record review of staff in-service dated 09/29/23 indicated all licensed and direct care staff were trained on following directives from their supervisors. Record review of staff in-service dated 09/26/23 indicated direct care and licensed staff were trained that residents should be rounded on/checked on at least every two hours to ensure their needs are being met timely and appropriately, with emphasis on residents with higher acuity and dependent on care. Record review of staff in-service dated 09/26/23 indicated direct and licensed and therapy staff were trained regarding the importance of incontinent care and general ADL care. Record review of resident life satisfaction surveys on residents residing who are able to be interviewed on the 400 hallway indicated no concerns regarding care were noted upon completion on 09/28/2023. Record review of the facility's new procedure dated 09/28/23 for assigning staff to residents based on the number of staff present indicated the following: on the daily assignment sheet one charge nurse would be assigned responsible for ensuring the correct division of duties was confirmed with all staff at the beginning of the shift. The DON inserviced all staff regarding the process of staff assignments. The DON and/or Designee would review the daily assignment sheets for adequate division of duties Monday through Friday and the weekend supervisor would review on Saturday and Sunday. Record of staff post tests were reviewed for accuracy and knowledge. No concerns noted. On 09/29/23 at 6:55 p.m., the Administrator was informed the IJ was removed; however, 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.

**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 to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the abuse coordinator and/or designee reported immediately to HHSC after Resident #1 was found deceased on the floor of her bathroom with injuries of unknown origin. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:42 p.m. While the IJ was removed on [DATE] at 2:27 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 of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old female, admitted on [DATE], and her diagnoses included heart failure, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), abnormalities of gait and mobility, diabetes, ataxic gait (difficulty walking in a straight line, lateral veering, poor balance, a widened base of support, inconsistent arm motion, and lack of repeatability), muscle weakness, lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), pseudobulbar affect (a condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), COPD (a group of diseases that cause airflow blockage and breathing-related problems), and difficulty walking. Record review of an MDS assessment dated [DATE] indicated Resident #1 was usually able to make herself understood, was usually able to understand others, had short term and long-term memory problems, was not able to recall current season, location of her own room, staff names and faces, or that she was in a nursing facility. She required extensive physical assist of one person for bed mobility and transfers. She was totally dependent on staff assistance for toilet use. She was not steady and only able to stabilize with staff assistance when moving from moving from seated to standing position and surface to surface transfer. She utilized a wheelchair for mobility. She always incontinent of bowel and bladder. Record review of a care plan revised on [DATE] indicated Resident #1 had ADL self-care performance deficit and limitations in physical mobility related to impaired balance and limited mobility/ROM, and musculoskeletal impairment (injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and spinal discs). Interventions included limited assistance of one staff to transfer and total assistance of one staff for toileting (revised [DATE]). Record review of a care plan revised on [DATE] indicated Resident #1 was at risk for falls related to confusion and gait/balance problems. Interventions included follow fall precautions protocol (revised [DATE]). Record review of a care plan revised on [DATE] indicated Resident #1 had falls on [DATE], [DATE], [DATE], [DATE], and [DATE]. Interventions included investigate to determine and address causative factors of the fall and obtain statements for witnessed falls (revised [DATE]). There were no statements available for review. Record review of a care plan revised [DATE] indicated Resident #1 was on anticoagulant therapy related to heart disease. Interventions included to take precautions to avoid falls (revised [DATE]). Record review of a progress note dated [DATE] at 6:37 p.m., completed by LVN A indicated Resident #1 had an unwitnessed fall in her bathroom. LVN A was passing medication on another hall when she was called by the CNAs on the hall stating Resident #1 had fallen. Hurry up she is bleeding and there is a lot of blood on her face. LVN A witnessed two CNAs turned Resident #1 from a prone position to a supine position, facing the ceiling. Resident #1's head was close to the wall of the shower and her legs were stretched out toward the toilet seat. She had a large hematoma to the right temple and a 3 cm laceration. There was a large amount of blood on the face and neck. There was no rise or drop of her chest wall, no audible heart rate, no pulse. Resident #1's pants were midway to her waits and her diaper was pulled up completely. Resident #1's shoes were on her feet. The call light was not activated and was in reach. Resident #1 was moved from the shower area to the entrance way between her room and the bathroom. LVN A noted the wheelchair was under the sink with the brakes not locked. Four paramedics arrived and pronounced Resident #1 deceased as of 3:30 p.m. MD and family made aware of Resident #1's expiring. Record review of an incident report dated [DATE] at 3:00 p.m., Completed by LVN A, indicated Resident #1 had an unwitnessed fall in her bathroom. LVN A was passing medication on another hall when she was called by the CNAs on the hall stating Resident #1 had fallen. Hurry up she is bleeding and there is a lot of blood on her face. LVN A witnessed two CNAs turned Resident #1 from a prone position to a supine position, facing the ceiling. Resident #1's head was close to the wall of the shower and her legs were stretched out toward the toilet seat. She had a large hematoma to the right temple and a 3 cm laceration. There was a large amount of blood on the face and neck. There was no rise or drop of her chest wall, no audible heart rate, no pulse. Resident #1's pants were midway to her waits and her diaper was pulled up completely. Resident #1's shoes were on her feet. The call light was not activated and was in reach. Resident #1 was moved from the shower area to the entrance way between her room and the bathroom. LVN A noted the wheelchair was under the sink with the brakes not locked. Four paramedics arrived and pronounced Resident #1 deceased as of 3:30 p.m. MD and family made aware of Resident #1's expiring. DON and ADON were made aware. There was no facility investigation available for review as of [DATE]. During an interview on [DATE] at 1:12 p.m., the DON said Resident #1 had a wheelchair and was mobile and would go to the bathroom on her own. She said Resident #1 was found with no life signs at approximately 3:00 p.m. on [DATE]. She said Resident #1 was administered medication at 2:43 p.m. She said Resident #1 was not supposed to transfer without assistance. She said Resident #1 did have a history of falls. She said fall interventions included a low bed, call light in reach, and signs hung up in Resident #1's room to remind her (Resident #1) to call for assistance to transfer. An observation on [DATE] at 2:50 p.m. of Resident #1's bathroom area reflected there was not observed fall hazards. The toilet was situated across from a walk-in shower. The floor was tiled. There was a working call light adjacent to the toilet. There was a grab bar adjacent to the toilet. During an interview on [DATE] at 3:30 p.m., the DON said she did not report Resident #1's fall and injury or death to the state because she did not know if Resident #1 fell and sustained the injury and then expired or if something caused Resident #1 to expire and then fall. She said she spoke to the LVN A, CNA B, and CNA C but did not obtain any statements. During an interview on [DATE] at 3:49 p.m., CNA B said on [DATE] Resident #1 was in the hall and had vomited. She said she brought Resident #1 to the bathroom and then went to tell LVN A of Resident #1 vomiting and gather a basin and supplies to clean her up. She said she could not recall what the time was when Resident #1 vomited or when she took her to the bathroom. She said she returned to the bathroom a few minutes later and found Resident #1 on the floor. She said Resident #1's head was on the floor of the shower, and she was lying on her side. She said Resident #1's feet were in front of the toilet. She said Resident #1 did not respond to her name and she called for LVN A. She said she could not recall where the wheelchair was or if it was locked. She said the wheelchair was between the toilet and the hand sink. She said she left out of the bathroom to call for the nurse. She said there was blood on her head and her neck. She said her pants were down around her knees, but her diaper was not down. During an interview on [DATE] at 8:05 a.m. CNA C said on [DATE] Resident #1 said she was sick and asked us (CNA B and CNA C) to bring her to the bathroom. She said she could not recall the exact time Resident #1 vomited or was taken to the bathroom. Resident #1 was still in her wheelchair, and it was locked. She said the wheelchair was between the sink and the toilet. She said she told Resident #1 to pull the call light when she was done (vomiting.) She said she and CNA C left the bathroom to get a basin and towels. She said she realized after a few minutes Resident #1 had not pulled the call light and went to check on her and found her on the floor. She said Resident #1's head was on the floor of the shower, and she was lying on her side. She said Resident #1's feet were in front of the toilet. She said her pants were down around her knees, but her diaper was not down. She said Resident #1 did not respond to her name and she called for LVN A. She said Resident #1 was left in the bathroom for approximately two or three minutes. She said they (CNA B and CNA C) notified LVN A of Resident #1 vomiting and LVN A said she would check the resident after she completed BP check. She said by the time LVN A was coming to check on Resident #1, they (CNA B and CNA C) had already found Resident #1 on the floor of the bathroom. She said Resident #1 was a one-person assist for transfers. She said Resident #1 required supervision to use the toilet. She said Resident #1 could stand and was limited assist to use the toilet. She said if she had taken her to the bathroom to use the toilet, she would not have left her alone and would have helped her in the bathroom until she was able to get another staff to get a nurse. During an interview on [DATE] at 9:00 a.m., LVN A said she was the nurse station when she was approached by CNA B, She said CNA B said Resident #1 had vomited. LVN A said she told CNA B she (LVN A) was going to check another resident's BP on a different hall and would be right back to check on Resident #1. She said she was on her way back to check on Resident #1 when she heard CNA B calling out her name. She said CNA B said Resident #1 was on the floor. She said she immediately went to Resident #1's bathroom. She said Resident #1 was lying on her right side on the floor. She said her head was laying towards the shower and her feet were by the toilet. She said the wheelchair was locked and between the toilet and the sink. She said she unblocked the wheelchair and moved it under the sink. She said two aides turned Resident #1 to lay flat on her back. She said she checked for pulse and breathing. She said there was no signs of life. She said there was a 3 cm laceration on her forehead and blood was coming out of her mouth. There was blood on the floor. She was a DNR, so no CPR was performed. Another nurse called the police, and we were instructed not to touch her, but we had already moved her from the bathroom floor to the floor between the bathroom and the bedroom in case we had to do CPR. EMS arrived and they checked, and she had no signs of life. LVN A said from the time CNA B informed her Resident #1 had vomited to the time she was called, and informed Resident #1 was on the floor was approximately 10-15 minutes. She said Resident #1 would go to the bathroom on her own but would require staff assist to use the toilet. She said Resident #1 was not steady on her legs. She said Resident #1 had a history of falls. She said Resident #1's bedroom had signs to remind her to use the call light for help. She said Resident #1 would scream for help but when asked, she did not know what she needed. She said Resident #1 was totally dependent on staff to use the toilet. She said Resident #1 required supervision in the bathroom. She said Resident #1 should not have been left alone in the bathroom. During an interview on [DATE] at 10:29 a.m., the DON said she was made aware of Resident #1's fall and death immediately on [DATE]. She said she did not report the incident because she was not sure if Resident #1 fell and expired or what caused Resident #1 to fall. She said she did not investigate the incident. She said she was aware injuries of unknown origin were supposed to be reported to the state if there was possible neglect. She said not reporting and investigating could place other residents at risk of abuse and neglect. During an interview on [DATE] at 10:29 a.m., the administrator said all allegations of abuse or neglect, or injuries of unknown sources should be reported to the state within 2 hours. He said he was the abuse coordinator. He said he was made aware of the incident immediately on the [DATE] but could not give a reason Resident #1's fall and death were not reported or investigated. He said not reporting and investigating could place other residents at risk of abuse and neglect. During an interview on [DATE] at 11:00 a.m., the ADON said staff were not supposed to leave Resident #1 unsupervised in the bathroom. She said Resident #1 required staff assist for transfers and toileting. She said residents were at risk of injuries if they were left alone and required supervision. During an interview on [DATE] at 12:59 p.m., MDS LVN J said supervision of residents meant they were not left alone if the resident required assist for transfers in the bathroom or was totally dependent on staff for toileting. She said residents were at risk of injuries if they were left alone and required supervision. During an interview on [DATE] at 4:03 p.m. CNA C said Resident #1 would normally go around the facility in her wheelchair and do her own thing. She said if we could not see Resident #1 and we would look for her we would find her in the bathroom. She said we would have to remind her to ask for assistance. She said she did not know if she should have left Resident #1 alone in the bathroom to wait for CNA B. She said if she had known Resident #1 should not be left alone, she would have stayed with her in the bathroom until CNA B brought LVN A to the bathroom. During an interview on [DATE] at 11:30 a.m., CNA E said Resident #1 was not able to stand without assist to use the toilet. She said Resident #1 required supervision in the bathroom. She said she required assist and prompts to use the support bars. She said Resident #1 was not supposed to go to the bathroom alone because she would attempt to use the toilet without assist. She said Resident #1 required supervision in the bathroom. During an interview on [DATE] at 11:43 a.m., CNA F said Resident #1 was not supposed to be left alone in the bathroom. She said staff had to watch Resident #1 because if she went towards her room, she would try to use the bathroom without calling for staff or try to transfer to her bed without calling for staff. She said staff would offer different activities or snacks and coffee to keep Resident #1 away from her room and in view of staff. She said staff would offer to take her to the bathroom if she was headed to her room or she would try to do it by herself. CNA F said Resident #1 always required supervision in the bathroom. During an interview on [DATE] at 12:32 p.m., CNA G said Resident #1 needed assistance to transfer. He said Resident #1 required supervision in the bathroom. He said with supervision meant she was not supposed to be left alone. During an interview on [DATE] at 12:45 p.m. CNA H said Resident #1 was not supposed to be left alone in the rest room because she would try to transfer on her own. She said staff kept Resident #1 in their sight because she would try to go to the bathroom and use the toilet without supervision. During an interview on [DATE] at 1:09 p.m., CNA I said Resident #1 required assist for transfers and supervision in the bathroom. She said Resident #1 would head to the bathroom and staff would have to watch her and offer to help or she would go in there by herself and attempt to transfer without assistance. She said Resident #1 would hold on to the support bars and staff would pull her pants and undergarments down before Resident #1 would turn to sit on the toilet. CNA I said staff were supposed to gather all supplies necessary before going to the bathroom. She said staff should not have left Resident #1 in the bathroom alone. Record review of the facility's Abuse Prevention Program dated 2001 (revised [DATE]) indicated Our 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 resident's symptoms. 3. Develop and impellent policies and procedures to aide out facility in preventing abuse, neglect, or mistreatment of our residents. 6. Identify and assess all possible incidents of abuse. 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Record review of the facility's Abuse Investigation and Reporting Policy dated 2002 (revised [DATE]) indicated: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. 1. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual. 4. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation.Reporting - 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor of Record); . e. Law enforcement officials; f, The resident's attending physician; and g. The facility's medical director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source) and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; . An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:42 p.m. While the IJ was removed on [DATE] at 2:27 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. The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] and indicated the following: Immediate action: Immediately upon notification of the alleged deficient practice on [DATE] @ (2:02 p.m.) the Facility Administrator, Director of Nursing, and Assistant Director of Nursing were provided an in-service by the Director of Clinical Operations from the Corporate Office. The in-service consisted of the facility abuse and neglect policy, conducting thorough investigations of any fall with injury/death to determine cause of injury/death, reporting incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. During this in-service each F tag was taken from Appendix-PP and presented, along with Texas HHSC provider letter number 19-17 dated [DATE], and Texas HHSC provider letter 18-20 dated [DATE]. The Facility Administrator and/or Director of Nursing are to contact the Director of Clinical Operations from the Corporate office with any incident that results in serious bodily injury/death. On [DATE] @ (4:00 p.m.) the Facility Administrator and the Director of Nursing began auditing all incidents from the previous 90 days to ensure any incidents that resulted in serious bodily injury were investigated and reported if necessary. No incidents of injury of unknown source resulting in injury/death were identified. Beginning on [DATE] @ (5:30 p.m.) all staff (nursing and non-nursing) present were provided with an in-service by the Director of Nursing regarding the facility abuse and neglect policy, the procedure for reporting incidents of unknown source with serious harm and/or death, suspected abuse/neglect and staff was offered the opportunity to report any known allegation at that time. No known allegations or suspected events were reported. This in-service will be repeated to every staff member prior to the start of their next scheduled shift and with each new hire. Following the in-service, a quiz will be administered to each employee which consists of 6 questions and a score of 80 will be considered passing. Any staff member who does not pass this quiz will be re-educated prior to working. In-servicing will continue until all staff have completed them but no later than [DATE] @ (7:00 p.m.). A log of test scores shall be presented to the QAPI committee for review during the next scheduled QAPI meeting on [DATE]. Facilities Plan to Ensure Compliance Quickly Impromptu QAPI was held [DATE] @ (5:30 p.m.) with the facility Medical Director and informed him of the three immediate jeopardies that the facility obtained for F607-Implementing Abuse and Neglect Policies and Procedures, F689-Accidents/Supervision, F610-Alleged Violations-Investigate/Prevent/Correct. The Medical Director was informed of the facility efforts to correct the alleged violations including audits of all resident records to ensure correct ADL coding was passed to the C.N.A.'s through to the [NAME], supervision of residents for safety, ensuring the abuse and neglect policy is implemented and incidents are reported and investigated. The Medical Director enforced supervision with toileting and room location for frequent fallers when possible. The facility will implement a new incident investigation tool to be followed for each incident to ensure potential reportable incidents are identified, falls are investigated to determine cause and the addition of any necessary interventions, and to allow for an interdisciplinary approach to resident care planning. On [DATE], the Facility Administrator and Director of Nursing were provided with an in-service by the Director of Clinical Operations regarding the use of this tool. The nursing staff will be provided the same in-service and the system will be implemented [DATE]. The Facility Administrator and Director of Nursing will ensure staff knowledge is retained through reviewing the tool following each individual incident. The QAPI committee will review the results of each investigation tool to ensure any patterns of predisposing factors identified through root cause analysis are addressed and any sign of abuse/neglect discovered is reported according to State and Federal regulations. On [DATE], the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on [DATE] from 9:00 a.m. through 2:00 p.m. with 5 LVNs, 9 CNAs, 3 MA, (who work all shifts), the ADON, the DON and the Administrator indicated staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report all falls and fall with injuries and allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse, and immediate intervention procedures. During interviews conducted on [DATE] from 9:00 a.m. through 2:00 p.m., the Administrator, DON and ADON said they were monitoring all incident and accidents daily during morning meeting. They would contact the Director of Clinical Operations from the Corporate office with any incident that results in serious bodily injury/death. During an interview on [DATE] at 1:30 p.m. the Administrator said he was in-serviced on [DATE] by the Director of Clinical Operations from the Corporate Office. He was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of any fall with injury/death to determine cause of injury/death. He understood he was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. During an interview on [DATE] at 2:02 p.m. the DON said she was in-serviced on [DATE] by the Director of Clinical Operations from the Corporate Office. She was able to verbalize the facility abuse, and neglect policy and would conduct a thorough investigation of any fall with injury/death to determine cause of injury/death. The DON understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. Record review of all incidents from the previous 90 days indicated there were no additional incidents of injury of unknown source or falls and death identified. Record review of all staff (nursing and non-nursing) in-serviced by the Director of Nursing regarding the facility abuse and neglect policy, the procedure for reporting incidents of unknown source with serious harm and/or death, and suspected abuse/neglect. Record review of quiz results indicated all staff passed the quiz regarding abuse, neglect, and reporting. Record review of the facility's new incident and investigation tool (date pending utilization) to be followed for each incident indicated it would ensure potential reportable incidents were identified, falls were investigated to determine cause and the addition of any necessary interventions and would allow for an interdisciplinary approach to resident care planning. Record review of an in-service dated [DATE] regarding the new incident and investigation tool indicated the administrator, DON, and nursing staff were provided with an in-service by the Director of Clinical Operations regarding the use of this tool. The administrator, DON and nursing staff were able to verbalize how to use the new incident and investigation tool to ensure any patterns of predisposing factors identified through root cause analysis were addressed and any sign of abuse/neglect discovered was reported according to State and Federal regulations. During interviews on [DATE] from 9:00 a.m. through 2:00 p.m., the Administrator and DON said the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/or neglect. During interviews on [DATE] from 9:00 a.m. through 2:00 p.m., the Administrator and DON stated the RN Supervisor and/or the Manager on duty would act as designees for the Administrator and Director of Nursing on the weekend. This was effective [DATE] and on-going. On [DATE] at 2:27 p.m., the Administrator and DON were informed the IJ was removed; however, 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to thoroughly investigate and take measures to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation was in process, and failed to ensure corrective action was taken for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to investigate allegations of abuse and neglect and ensure corrective actions were in place after Resident #1 was found deceased on the floor of her bathroom, with injuries of unknown origin. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:42 p.m. While the IJ was removed on [DATE] at 2:27 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 of abuse, physical harm, mental anguish, and emotional distress. Findings included: Record review of a face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old female, admitted on [DATE], and her diagnoses included heart failure, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), abnormalities of gait and mobility, diabetes, ataxic gait (difficulty walking in a straight line, lateral veering, poor balance, a widened base of support, inconsistent arm motion, and lack of repeatability), muscle weakness, lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), pseudobulbar affect (a condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), COPD (a group of diseases that cause airflow blockage and breathing-related problems), and difficulty walking. Record review of an MDS assessment dated [DATE] indicated Resident #1 was usually able to make herself understood, was usually able to understand others, had short term and long-term memory problems, was not able to recall current season, location of her own room, staff names and faces, or that she was in a nursing facility. She required extensive physical assist of one person for bed mobility and transfers. She required full staff assistance for toilet use. She was not steady and only able to stabilize with staff assistance when moving from moving from seated to standing position and surface to surface transfer. She utilized a wheelchair for mobility. She always incontinent of bowel and bladder. Record review of a care plan revised on [DATE] indicated Resident #1 had ADL self-care performance deficit and limitations in physical mobility related to impaired balance and limited mobility/ROM, and musculoskeletal impairment. Interventions included limited assistance of one staff to transfer and total assistance of one staff for toileting (revised [DATE]). Record review of a care plan revised on [DATE] indicated Resident #1 was at risk for falls related to confusion and gait/balance problems. Interventions included follow fall precautions protocol (revised [DATE]). Record review of a care plan revised on [DATE] indicated Resident #1 had falls on [DATE], [DATE], [DATE], [DATE], and [DATE]. Interventions included investigate to determine and address causative factors of the fall and obtain statements for witnessed falls (revised [DATE]). There were no statements available for review. Record review of a care plan revised [DATE] indicated Resident #1 was on anticoagulant therapy related to heart disease. Interventions included to take precautions to avoid falls (revised [DATE]). Record review of a progress note dated [DATE] at 6:37 p.m., completed by LVN A indicated Resident #1 had an unwitnessed fall in her bathroom. LVN A was passing medication on another hall when she was called by the CNAs on the hall stating Resident #1 had fallen. Hurry up she is bleeding and there is a lot of blood on her face. LVN A witnessed two CNAs turned Resident #1 from a prone position to a supine position, facing the ceiling. Resident #1's head was close to the wall of the shower and her legs were stretched out toward the toilet seat. She had a large hematoma to the right temple and a 3 cm laceration. There was a large amount of blood on the face and neck. There was no rise or drop of her chest wall, no audible heart rate, no pulse. Resident #1's pants were midway to her waits and her diaper was pulled up completely. Resident #1's shoes were on her feet. The call light was not activated and was in reach. Resident #1 was moved from the shower area to the entrance way between her room and the bathroom. LVN A noted the wheelchair was under the sink with the brakes not locked. Four paramedics arrived and pronounced Resident #1 deceased as of 3:30 p.m. MD and family made aware of Resident #1's expiring. Record review of an incident report dated [DATE] at 3:00 p.m., Completed by LVN A, indicated Resident #1 had an unwitnessed fall in her bathroom. LVN A was passing medication on another hall when she was called by the CNAs on the hall stating Resident #1 had fallen. Hurry up she is bleeding and there is a lot of blood on her face. LVN A witnessed two CNAs turned Resident #1 from a prone position to a supine position, facing the ceiling. Resident #1's head was close to the wall of the shower and her legs were stretched out toward the toilet seat. She had a large hematoma to the right temple and a 3 cm laceration. There was a large amount of blood on the face and neck. There was no rise or drop of her chest wall, no audible heart rate, no pulse. Resident #1's pants were midway to her waits and her diaper was pulled up completely. Resident #1's shoes were on her feet. The call light was not activated and was in reach. Resident #1 was moved from the shower area to the entrance way between her room and the bathroom. LVN A noted the wheelchair was under the sink with the brakes not locked. Four paramedics arrived and pronounced Resident #1 deceased as of 3:30 p.m. MD and family made aware of Resident #1's expiring. DON and ADON were made aware. There was no facility investigation available for review as of [DATE]. An observation on [DATE] at 2:50 p.m. of Resident #1's bathroom area indicated there was not observed fall hazards. The toilet was situated across from a walk-in shower. The floor was tiled. There was a working call light adjacent to the toilet. There was a grab bar adjacent to the toilet. During an interview on [DATE] at 3:30 p.m., the DON said she did not report Resident #1's fall and injury or death to the state because she did not know if Resident #1 fell and sustained the injury and then expired or if something caused Resident #1 to expire and then fall. She said she spoke to the LVN A, CNA B, and CNA C but did not obtain any statements. She said she did not complete a full investigation of Resident #1's fall, injury of unknown origin or death. During an interview on [DATE] at 3:49 p.m., CNA B said on [DATE] Resident #1 was in the hall and had vomited. She said she brought Resident #1 to the bathroom and then went to tell LVN A of Resident #1 vomiting and gather a basin and supplies to clean her up. She said she could not recall what the time was when Resident #1 vomited or when she took her to the bathroom. She said she returned to the bathroom a few minutes later and found Resident #1 on the floor. She said Resident #1's head was on the floor of the shower and she was lying on her side. She said Resident #1's feet were in front of the toilet. She said Resident #1 did not respond to her name and she called for LVN A. She said she could not recall where the wheelchair was or if it was locked. She said the wheelchair was between the toilet and the hand sink. She said she left out of the bathroom to call for the nurse. She said there was blood on her head and her neck. She said her pants were down around her knees but her diaper was not down. During an interview on [DATE] at 8:05 a.m. CNA C said on [DATE] Resident #1 said she was sick and asked me and CNA C to bring her to the bathroom. She said she could not recall the exact time Resident #1 vomited or was taken to the bathroom. Resident #1 was still in her wheelchair and it was locked. She said the wheelchair was between the sink and the toilet. She said she told Resident #1 to pull the call light when she was done (vomiting.) She said she and CNA C left the bathroom to get a basin and towels. She said she realized after a few minutes Resident #1 had not pulled the call light and went to check on her and found her on the floor. She said Resident #1's head was on the floor of the shower and she was lying on her side. She said Resident #1's feet were in front of the toilet. She said her pants were down around her knees but her diaper was not down. CNA C said Resident #1 did not respond to her name and she called for LVN A. She said Resident #1 was left in the bathroom for approximately two or three minutes. She said they (CNA B and CNA C) notified LVN A of Resident #1 vomiting and LVN A said she would check the resident after she completed BP check. She said by the time LVN A was coming to check on Resident #1, they (CNA B and CNA C) had already found Resident #1 on the floor of the bathroom. She said Resident #1 was a one-person assist for transfers. CNA C said Resident #1 required supervision to use the toilet. She said Resident #1 could stand and was limited assist to use the toilet. She said if she had taken her to the bathroom to use the toilet, she would not have left her alone and would have helped her in the bathroom until she was able to get another staff to get a nurse. During an interview on [DATE] at 9:00 a.m., LVN A said she was the nurse station when she was approached by CNA B, She said CNA B said Resident #1 had vomited. LVN A said she told CNA B she (LVN A) was going to check another resident's BP on a different hall and would be right back to check on Resident #1. She said she was on her way back to check on Resident #1 when she heard CNA B calling out her name. She said CNA B said Resident #1 was on the floor. She said she immediately went to Resident #1's bathroom. She said Resident #1 was lying on her right side on the floor. She said her head was laying towards the shower and her feet were by the toilet. She said the wheelchair was locked and between the toilet and the sink. She said she unblocked the wheelchair and moved it under the sink. She said two aides turned Resident #1 to lay flat on her back. She said she checked for pulse and breathing. She said there was no signs of life. She said there was a 3 cm laceration on her forehead and blood was coming out of her mouth. There was blood on the floor. She was a DNR so no CPR was performed. Another nurse called the police and we were instructed not to touch her but we had already moved her from the bathroom floor to the floor between the bathroom and the bedroom in case we had to do CPR. EMS arrived and they checked and she had no signs of life. LVN A said from the time CNA B informed her Resident #1 had vomited to the time she was called and informed Resident #1 was on the floor was approximately 10-15 minutes. She said Resident #1 would go to the bathroom on her own but would require staff assist to use the toilet. She said Resident #1 was not steady on her legs. She said Resident #1 had a history of falls. She said Resident #1's bedroom had signs to remind her to use the call light for help. She said Resident #1 would scream for help but when asked, she did not know what she needed. She said Resident #1 was totally dependent on staff to use the toilet. She said Resident #1 required supervision in the bathroom. She said Resident #1 should not have been left alone in the bathroom. During an interview on [DATE] at 10:29 a.m., the DON said she was made aware of Resident #1's fall and death immediately . She said she did not report the incident because she was not sure if Resident #1 fell or did not fall. She said she did not investigate the incident. She said she was aware injuries of unknown origin were supposed to be reported to the state if there was possible neglect. She said not reporting and investigating could place other residents at risk of abuse and neglect. During an interview on [DATE] at 10:29 a.m., the administrator said all allegations of abuse or neglect or injuries of unknown sources should be reported to the state within 2 hours. He said he was the abuse coordinator. He said he was made aware of the incident immediately on the [DATE] but could not give a reason Resident #1's fall and death were not reported or investigated. He said not reporting and investigating could place other residents at risk of abuse and neglect. During an interview on [DATE] at 4:03 p.m. CNA C said Resident #1 would normally go around the facility in her wheelchair and do her own thing. She said if we could not see Resident #1 and we would look for her we would find her in the bathroom. She said we would have to remind her to ask for assistance. She said she did not know if she should have left Resident #1 alone in the bathroom. She said if she had known Resident #1 should not be left alone she would have stayed with her in the bathroom until CNA B brought LVN A to the bathroom. Record review of the facility's Abuse Prevention Program dated 2001 (revised [DATE]) indicated Our 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 resident's symptoms. 3. Develop and impellent policies and procedures to aide out facility in preventing abuse, neglect, or mistreatment of our residents. 6. Identify and assess all possible incidents of abuse. 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements. Record review of the facility's Abuse Investigation and Reporting Policy dated 2002 (revised [DATE]) indicated: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. 1. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual. 4. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation.Reporting - 1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor of Record); . e. Law enforcement officials; f, The resident's attending physician; and g. The facility's medical director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source) and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; . An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:42 p.m. While the IJ was removed on [DATE] at 2:27 p.m., the facility remained out of compliance at ----- with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] and indicated the following: Immediate action: Immediately upon notification of the alleged deficient practice on [DATE] @ (2:02 p.m.) the Facility Administrator, Director of Nursing, and Assistant Director of Nursing were provided an in-service by the Director of Clinical Operations from the Corporate Office. The in-service consisted of the facility abuse and neglect policy, conducting thorough investigations of any fall with injury/death to determine cause of injury/death, reporting incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. During this in-service each F tag was taken from Appendix-PP and presented, along with Texas HHSC provider letter number 19-17 dated [DATE], and Texas HHSC provider letter 18-20 dated [DATE]. The Facility Administrator and/or Director of Nursing are to contact the Director of Clinical Operations from the Corporate office with any incident that results in serious bodily injury/death. On [DATE] @ (4:00 p.m.) the Facility Administrator and the Director of Nursing began auditing all incidents from the previous 90 days to ensure any incidents that resulted in serious bodily injury were investigated and reported if necessary. No incidents of injury of unknown source resulting in injury/death were identified. Beginning on [DATE] @ (5:30 p.m.) all staff (nursing and non-nursing) present were provided with an in-service by the Director of Nursing regarding the facility abuse and neglect policy, the procedure for reporting incidents of unknown source with serious harm and/or death, suspected abuse/neglect and staff was offered the opportunity to report any known allegation at that time. No known allegations or suspected events were reported. This in-service will be repeated to every staff member prior to the start of their next scheduled shift and with each new hire. Following the in-service, a quiz will be administered to each employee which consists of 6 questions and a score of 80 will be considered passing. Any staff member who does not pass this quiz will be re-educated prior to working. In-servicing will continue until all staff have completed them but no later than [DATE] @ (7:00 p.m.). A log of test scores shall be presented to the QAPI committee for review during the next scheduled QAPI meeting on [DATE]. Facilities Plan to Ensure Compliance Quickly Impromptu QAPI was held [DATE] @ (5:30 p.m.) with the facility Medical Director and informed him of the three immediate jeopardies that the facility obtained for F607-Implementing Abuse and Neglect Policies and Procedures, F689-Accidents/Supervision, F610-Alleged Violations-Investigate/Prevent/Correct. The Medical Director was informed of the facility efforts to correct the alleged violations including audits of all resident records to ensure correct ADL coding was passed to the C.N.A.'s through to the [NAME], supervision of residents for safety, ensuring the abuse and neglect policy is implemented and incidents are reported and investigated. The Medical Director enforced supervision with toileting and room location for frequent fallers when possible. The facility will implement a new incident investigation tool to be followed for each incident to ensure potential reportable incidents are identified, falls are investigated to determine cause and the addition of any necessary interventions, and to allow for an interdisciplinary approach to resident care planning. On [DATE], the Facility Administrator and Director of Nursing were provided with an in-service by the Director of Clinical Operations regarding the use of this tool. The nursing staff will be provided the same in-service and the system will be implemented [DATE]. The Facility Administrator and Director of Nursing will ensure staff knowledge is retained through reviewing the tool following each individual incident. The QAPI committee will review the results of each investigation tool to ensure any patterns of predisposing factors identified through root cause analysis are addressed and any sign of abuse/neglect discovered is reported according to State and Federal regulations. On [DATE], the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During interviews conducted on [DATE] from 9:00 a.m. through 2:00 p.m. with 5 LVNs, 9 CNAs, 3 MA, (who work all shifts), the ADON, the DON and the Administrator indicated staff were able to identify the Abuse Coordinator as the administrator. Staff indicated they were to report all falls and fall with injuries and allegations of abuse and neglect immediately to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse, and immediate intervention procedures. During interviews on [DATE] from 9:00 a.m. through 2:00 p.m., the Administrator, DON and ADON said they were monitoring all incident and accidents daily during morning meeting. They would contact the Director of Clinical Operations from the Corporate office with any incident that results in serious bodily injury/death. During an interview on [DATE] at 1:30 p.m. the Administrator said he was in-serviced on [DATE] by the Director of Clinical Operations from the Corporate Office. He was able to verbalize the facility abuse, and neglect policy and they would conduct a thorough investigation of any fall with injury/death to determine cause of injury/death. He understood he was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. During an interview on [DATE] at 2:02 p.m. the DON said she was in-serviced on [DATE] by the Director of Clinical Operations from the Corporate Office. She was able to verbalize the facility abuse, and neglect policy and would conduct a thorough investigation of any fall with injury/death to determine cause of injury/death. The DON understood she was required to report incidents according to regulatory compliance, and reporting incidents of abuse or neglect that result in serious bodily injury/death. Record review of all incidents from the previous 90 days indicated there were no additional incidents of injury of unknown source or falls and death identified. Record review of all staff (nursing and non-nursing) in-serviced by the Director of Nursing regarding the facility abuse and neglect policy, the procedure for reporting incidents of unknown source with serious harm and/or death, and suspected abuse/neglect. Record review of quiz results indicated all staff passed the quiz regarding abuse, neglect, and reporting. Record review of the facility's new incident and investigation tool (date pending utilization) to be followed for each incident indicated it would ensure potential reportable incidents were identified, falls were investigated to determine cause and the addition of any necessary interventions and would allow for an interdisciplinary approach to resident care planning. Record review of an in-service dated [DATE] regarding the new incident and investigation tool indicated the administrator, DON, and nursing staff were provided with an in-service by the Director of Clinical Operations regarding the use of this tool. The administrator, DON and nursing staff were able to verbalize how to use the new incident and investigation tool to ensure any patterns of predisposing factors identified through root cause analysis were addressed and any sign of abuse/neglect discovered was reported according to State and Federal regulations. During interviews on [DATE] from 9:00 a.m. through 2:00 p.m., the Administrator and DON said the facility 24 Hour Report and Incident Reports would be reviewed in the morning clinical meeting attended by the Administrator and Director of Nursing to review for any allegation or instances of abuse and/or neglect. During interviews on [DATE] from 9:00 a.m. through 2:00 p.m., the Administrator and DON stated the RN Supervisor and/or the Manager on duty would act as designees for the Administrator and Director of Nursing on the weekend. This was effective [DATE] and on-going. On [DATE] at 2:27 p.m., the Administrator and DON were informed the IJ was removed; however, 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents. On [DATE] CNA B left Resident #1 in the bathroom unsupervised. She was found on the floor deceased with a right temporal hematoma and 3 cm laceration to her head. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:42 p.m. While the IJ was removed on [DATE] at 2:27 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 falls resulting in injury, pain, and hospitalization. Findings included: Record review of a face sheet dated [DATE] indicated Resident #1 was an [AGE] year-old female, admitted on [DATE], and her diagnoses included heart failure, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), abnormalities of gait and mobility, diabetes, ataxic gait (difficulty walking in a straight line, lateral veering, poor balance, a widened base of support, inconsistent arm motion, and lack of repeatability), muscle weakness, lack of coordination (uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements), dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), pseudobulbar affect (a condition characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), Parkinson's (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), COPD (a group of diseases that cause airflow blockage and breathing-related problems), and difficulty walking. Record review of an MDS assessment dated [DATE] indicated Resident #1 was usually able to make herself understood, was usually able to understand others, had short term and long-term memory problems, was not able to recall current season, location of her own room, staff names and faces, or that she was in a nursing facility. She required extensive physical assist of one person for bed mobility and transfers. She required full staff assistance for toilet use. She was not steady and only able to stabilize with staff assistance when moving from moving from seated to standing position and surface to surface transfer. She utilized a wheelchair for mobility. She always incontinent of bowel and bladder. Record review of a care plan revised on [DATE] indicated Resident #1 had ADL self-care performance deficit and limitations in physical mobility related to impaired balance and limited mobility/ROM, and musculoskeletal impairment. Interventions included limited assistance of one staff to transfer and total assistance of one staff for toileting (revised [DATE]). Record review of a care plan revised on [DATE] indicated Resident #1 was at risk for falls related to confusion and gait/balance problems. Interventions included follow fall precautions protocol (revised [DATE]). Record review of a care plan revised on [DATE] indicated Resident #1 had falls on [DATE], [DATE], [DATE], [DATE], and [DATE]. Interventions included investigate to determine and address causative factors of the fall and obtain statements for witnessed falls (revised [DATE]). There were no statements available for review. Record review of a care plan revised [DATE] indicated Resident #1 was on anticoagulant therapy related to heart disease. Interventions included to take precautions to avoid falls (revised [DATE]). Record review of a progress note dated [DATE] at 6:37 p.m., completed by LVN A indicated Resident #1 had an unwitnessed fall in her bathroom. LVN A was passing medication on another hall when she was called by the CNAs on the hall stating Resident #1 had fallen. Hurry up she is bleeding and there is a lot of blood on her face. LVN A witnessed two CNAs turned Resident #1 from a prone position to a supine position, facing the ceiling. Resident #1's head was close to the wall of the shower and her legs were stretched out toward the toilet seat. She had a large hematoma to the right temple and a 3 cm laceration. There was a large amount of blood on the face and neck. There was no rise or drop of her chest wall, no audible heart rate, no pulse. Resident #1's pants were midway to her waits and her diaper was pulled up completely. Resident #1's shoes were on her feet. The call light was not activated and was in reach. Resident #1 was moved from the shower area to the entrance way between her room and the bathroom. LVN A noted the wheelchair was under the sink with the brakes not locked. Four paramedics arrived and pronounced Resident #1 deceased as of 3:30 p.m. MD and family made aware of Resident #1's expiring. Record review of an incident report dated [DATE] at 3:00 p.m., Completed by LVN A, indicated Resident #1 had an unwitnessed fall in her bathroom. LVN A was passing medication on another hall when she was called by the CNAs on the hall stating Resident #1 had fallen. Hurry up she is bleeding and there is a lot of blood on her face. LVN A witnessed two CNAs turned Resident #1 from a prone position to a supine position, facing the ceiling. Resident #1's head was close to the wall of the shower and her legs were stretched out toward the toilet seat. She had a large hematoma to the right temple and a 3 cm laceration. There was a large amount of blood on the face and neck. There was no rise or drop of her chest wall, no audible heart rate, no pulse. Resident #1's pants were midway to her waits and her diaper was pulled up completely. Resident #1's shoes were on her feet. The call light was not activated and was in reach. Resident #1 was moved from the shower area to the entrance way between her room and the bathroom. LVN A noted the wheelchair was under the sink with the brakes not locked. Four paramedics arrived and pronounced Resident #1 deceased as of 3:30 p.m. MD and family made aware of Resident #1's expiring. DON and ADON were made aware. During an interview on [DATE] at 1:12 p.m., the DON said Resident #1 had a wheelchair and was mobile and would go to the bathroom on her own. She said Resident #1 was found with no life signs at approximately 3:00 p.m. on [DATE]. She said Resident #1 was administered medication at 2:43 p.m. She said Resident #1 was not supposed to transfer without assistance. She said Resident #1 did have a history of falls. She said fall interventions included a low bed, call light in reach, and signs hung up in Resident #1's room to remind her (Resident #1) to call for assistance to transfer. An observation on [DATE] at 2:50 p.m. of Resident #1's bathroom area indicated there was not observed fall hazards. The toilet was situated across from a walk-in shower. The floor was tiled. There was a working call light adjacent to the toilet. There was a grab bar adjacent to the toilet. During an interview on [DATE] at 3:49 p.m., CNA B said on [DATE] Resident #1 was in the hall and had vomited. She said she brought Resident #1 to the bathroom and then went to tell LVN A of Resident #1 vomiting and gather a basin and supplies to clean her up. She said she could not recall what the time was when Resident #1 vomited or when she took her to the bathroom. She said she returned to the bathroom a few minutes later and found Resident #1 on the floor. She said Resident #1's head was on the floor of the shower and she was lying on her side. She said Resident #1's feet were in front of the toilet. She said Resident #1 did not respond to her name and she called for LVN A. She said she could not recall where the wheelchair was or if it was locked. She said the wheelchair was between the toilet and the hand sink. She said she left out of the bathroom to call for the nurse. She said there was blood on her head and her neck. She said her pants were down around her knees but her diaper was not down. During an interview on [DATE] at 8:05 a.m. CNA C said on [DATE] Resident #1 said she was sick and asked us (CNA B and CNA C) to bring her to the bathroom. She said she could not recall the exact time Resident #1 vomited or was taken to the bathroom. Resident #1 was still in her wheelchair and it was locked. She said the wheelchair was between the sink and the toilet. She said she told Resident #1 to pull the call light when she was done (vomiting.) She said she and CNA C left the bathroom to get a basin and towels. She said she realized after a few minutes Resident #1 had not pulled the call light and went to check on her and found her on the floor. She said Resident #1's head was on the floor of the shower and she was lying on her side. She said Resident #1's feet were in front of the toilet. She said her pants were down around her knees but her diaper was not down. She said Resident #1 did not respond to her name and she called for LVN A. She said Resident #1 was left in the bathroom for approximately two or three minutes. She said they (CNA B and CNA C) notified LVN A of Resident #1 vomiting and LVN A said she would check the resident after she completed BP check. She said by the time LVN A was coming to check on Resident #1, they (CNA B and CNA C) had already found Resident #1 on the floor of the bathroom. She said Resident #1 was a one-person assist for transfers. She said Resident #1 required supervision to use the toilet. She said Resident #1 could stand and was limited assist to use the toilet. She said if she had taken her to the bathroom to use the toilet, she would not have left her alone and would have helped her in the bathroom until she was able to get another staff to get a nurse. During an interview on [DATE] at 9:00 a.m., LVN A said she was at the nurse station on [DATE] when she was approached by CNA B. She said she could not recall the exact time but it was before 3:00 p.m. She said CNA B said Resident #1 had vomited. LVN A said she told CNA B she (LVN A) was going to check another resident's BP on a different hall and would be right back to check on Resident #1. She said she was on her way back to check on Resident #1 a few minutes later, when she heard CNA B calling out her name. She said CNA B said Resident #1 was on the floor. She said she immediately went to Resident #1's bathroom. She said Resident #1 was lying on her right side on the floor. She said her head was laying towards the shower and her feet were by the toilet. She said the wheelchair was locked and between the toilet and the sink. She said she unblocked the wheelchair and moved it under the sink. She said two aides turned Resident #1 to lay flat on her back. She said she checked for pulse and breathing. She said there was no signs of life. She said there was a 3 cm laceration on her forehead and blood was coming out of her mouth. There was blood on the floor. She was a DNR so no CPR was performed. Another nurse called the police and we were instructed not to touch her but we had already moved her from the bathroom floor to the floor between the bathroom and the bedroom in case we had to do CPR. EMS arrived and they checked and she had no signs of life. LVN A said from the time CNA B informed her Resident #1 had vomited to the time she was called and informed Resident #1 was on the floor was approximately 10-15 minutes. She said Resident #1 would go to the bathroom on her own but would require staff assist to use the toilet. She said Resident #1 was not steady on her legs. She said Resident #1 had a history of falls. She said Resident #1's bedroom had signs to remind her to use the call light for help. She said Resident #1 would scream for help but when asked, she did not know what she needed. She said Resident #1 was totally dependent on staff to use the toilet. She said Resident #1 required supervision in the bathroom. She said Resident #1 should not have been left alone in the bathroom. During an interview on [DATE] at 10:29 a.m., the DON said she was made aware of Resident #1's fall and death immediately on [DATE]. She said she did not investigate the incident. She said she talked to LVN A, CNA B and CNA C. She said residents were at risk of injuries if they were left alone and required supervision. During an interview on [DATE] at 11:00 a.m., the ADON said staff were not supposed to leave Resident #1 unsupervised in the bathroom. She said Resident #1 required staff assist for transfers and toileting. She said residents were at risk of injuries if they were left alone and required supervision. During an interview on [DATE] at 12:59 p.m., MDS LVN J said supervision of residents meant they were not left alone if the resident required assist for transfers in the bathroom or was totally dependent on staff for toileting. She said residents were at risk of injuries if they were left alone and required supervision. During an interview on [DATE] at 4:03 p.m. CNA C said Resident #1 would normally go around the facility in her wheelchair and do her own thing. She said if we could not see Resident #1 and we would look for her we would find her in the bathroom. She said we would have to remind her to ask for assistance. She said she did not know if she should have left Resident #1 alone in the bathroom to wait for CNA B. She said if she had known Resident #1 should not be left alone she would have stayed with her in the bathroom until CNA B brought LVN A to the bathroom. During an interview on [DATE] at 3:45 p.m., LVN K said Resident #1 require supervision in the bathroom. She said Resident #1 was totally dependent on staff for toileting and required assist to transfer. She said supervision meant eyes on the resident. She said Resident #1 should not have been left alone in the bathroom. During an interview on [DATE] at 11:30 a.m., CNA E said Resident #1 was not able to stand without assist to use the toilet. She said Resident #1 required supervision in the bathroom. She said she require assist and prompts to use the support bars. She said Resident #1 was not supposed to go to the bathroom alone because she would attempt to use the toilet without assist. She said Resident #1 required supervision in the bathroom. During an interview on [DATE] at 11:43 a.m., CNA F said Resident #1 was not supposed to be left alone in the bathroom. She said staff had to watch Resident #1 because if she went towards her room she would try to use the bathroom without calling for staff or try to transfer to her bed without calling for staff. She said staff would offer different activities or snacks and coffee to keep Resident #1 away from her room and in view of staff. She said staff would offer to take her to the bathroom if she was headed to her room or she would try to do it by herself. CNA F said Resident #1 always required supervision in the bathroom. During an interview on [DATE] at 12:32 p.m., CNA G said Resident #1 needed assistance to transfer. He said Resident #1 required supervision in the bathroom. He said with supervision meant she was not supposed to be left alone. During an interview on [DATE] at 12:45 p.m. CNA H said Resident #1 was not supposed to be left alone in the rest room because she would try to transfer on her own. She said staff kept Resident #1 in their sight because she would try to go to the bathroom and use the toilet without supervision . During an interview on [DATE] at 1:09 p.m., CNA I said Resident #1 required assist for transfers and supervision in the bathroom. She said Resident #1 would head towards the bathroom and staff would have to watch her and offer to help or she would go in there by herself and attempt to transfer without assistance. She said Resident #1 would hold on to the support bars and staff would pull her pants and undergarments down before Resident #1 would turn to sit on the toilet. CNA I said staff were supposed to gather all supplies necessary before going to the bathroom. She said staff should not have left Resident #1 in the bathroom alone. During an interview on [DATE] at 1:41 p.m., LVN K said supervision of residents meant they were not left alone if the resident required assist for transfers in the bathroom or was totally dependent on staff for toileting. She said residents were at risk of injuries if they were left alone and required supervision. Record review of the facility's Safety and Supervision of Residents policy dated 2001 (Revised [DATE]) indicated Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. Record review of Managing Falls and Fall Risk policy dated 2001 (revised [DATE]) indicated: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 2. Resident conditions that may contribute to the risk of falls include: . c. delirium and other cognitive impairment; . e. lower extremity weakness; f. poor grip strength; g. medication side effects, h. orthostatic hypotension, i. functional impairments; j. visual deficits; and k. incontinence. 3. Medical factors that contribute to the risk of falls include: arthritis; b. heart failure; c. anemia; d. neurological disorders; and e. balance and gait disorders; etc. Resident-Centered Approaches to Managing Falls and Fall Risk-1. The staff, with the input of the attending physician, will implement a resident-centered prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:42 p.m. While the IJ was removed on [DATE] at 2:27 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. The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] and indicated the following: Immediate action: Immediately upon notification of the alleged deficient practice on [DATE] @ (2:42 p.m.), the Director of Clinical Operations from the Corporate Office provided an in-service to the Facility Administrator, Director of Nursing, Assistant Director of Nursing, and MDS coordinator with an in-service regarding F689 including: the definition of supervision, how to determine each residents level of supervision, accident prevention/reduction interventions, identification of changes in resident condition that may change their level of supervision needed with examples provided, current professional standards of practice, how to audit resident records to ensure the correct level of supervision is indicated, and what to do if an accident occur as a result of the incorrect level of supervision being practiced. Following the in-service education and knowledge check provided to the Facility Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator, the Director of Nursing and designees provided an in-service to all nursing staff present regarding supervision of residents during toileting and other ADL's, being aware of where to locate the level of assistance needed for care (electronic [NAME]), when and how to notify the supervising nurse of changes in resident condition including changes in residents physical ability to perform ADL task(s). This in-service will begin with the day shift (0600-1800) on [DATE] and all nursing staff will be required to attend this in-service before the start of their next scheduled shift. The process of in-servicing will continue until all active nursing employees are educated or before [DATE], at 1900. In addition to current staff, the in-service conducted on [DATE], regarding supervision will be provided to newly hired employees prior to being assigned residents. Beginning on [DATE], the Director of Nursing and/or designee will provide an updated in-service to all nursing staff on shift, prior to beginning their next shift and at the time of hire. This updated in-service will include the definition of supervision, why it is important to know each resident's individual need/level of supervision, how we determine the residents need for supervision, and how supervision plays an integral role in the mitigation/reduction of accidents. Staff will be provided with scenarios of negative outcomes when adequate supervision was not provided and consequences of not following the resident plan of care as indicated in the [NAME]. Following the completion of both in-services, each nursing staff member will be provided with a quiz which will consist of ten questions related to the in-service education provided over both days. A grade of 80 or above will be considered passing. Any staff member that scores below 80 will be re-educated and observed to ensure knowledge is retained. The updated in-service will be completed no later than [DATE], at 1900. A log of test scores shall be presented to the QAPI committee for review during the next scheduled QAPI meeting on [DATE]. The Director of Nursing contacted the C.N.A. that was providing care to Resident #1 on [DATE] @ (4:12 p.m.) to inform her that she was suspended pending the outcome of the investigation and provided with education regarding resident supervision. The Director of Nursing, the MDS Coordinator, and the Assistant Director of Nursing, began an audit of all resident plans of care to ensure the correct level of care and supervision consistent with each individual resident's needs. This audit will ensure the resident [NAME] is updated with the correct information. The audit was initiated on [DATE], and will be completed no later than [DATE] @ (7:00 p.m.). Any noted changes made to existing resident's plans of care will be noted on the audit log and presented to the QAPI committee on [DATE], to determine if there is a system failure or a limited resident failure and make recommendations as necessary. The Director of Nursing and the Assistant Director of Nursing conducted interviews with staff to ensure residents with a recent change of condition were identified and evaluated to ensure there has not been a change in their level of assistance or necessary supervision. At the time of the interviews on [DATE], and [DATE], there were no identified changes in condition reported. Facilities Plan to Ensure Compliance Quickly Impromptu QAPI was held [DATE] @ (5:30 p.m.) with the Medical Director and informed him of the three immediate jeopardies that the Facility obtained for F607-Implementing Abuse and Neglect Policies and Procedures, F689-Accidents/Supervision, F610-Alleged Violations-Investigate/Prevent/Correct. The Medical Director was informed of the facility efforts to correct the alleged violations including audits of all resident records to ensure correct ADL coding is passed to the C.N.A.'s through to the [NAME], supervision of residents for safety, ensuring the abuse and neglect policy is implemented and incidents are reported and investigated. The Medical Director enforced supervision with toileting and room location for frequent fallers when possible. Beginning [DATE], The Director of Nursing and/or designee will walk the halls in real time and ask questions to random nursing staff regarding their role in resident supervision and where to find a resident's level of assistance required prior to rendering care to ensure knowledge from education provided was retained. On [DATE], the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: The administrator, DON, ADON, and MDS coordinator were able to define supervision, how to determine each resident's level of supervision, list accident prevention/reduction interventions, identify of changes in resident condition that may change their level of supervision needed with examples provided, were aware of current professional standards of practice, audited resident records to ensure the correct level of supervision was indicated, and were aware of what to do if an accident occurred due to the incorrect level of supervision. Record review of the in-services dated [DATE] and [DATE] included the definition of supervision, why it was important to know each resident's individual need/level of supervision, how to determine the resident's need for supervision, and how supervision played an integral role in the mitigation/reduction of accidents. Staff were provided with scenarios of negative outcomes when adequate supervision was not provided and consequences of not following the resident plan of care as indicated in the [NAME]. During interviews conducted on [DATE] from 9:00 a.m. through 2:00 p.m. with 5 LVNs, 9 CNAs, 3 MA, (who work all shifts), the MDS coordinator, the ADON, the DON and the Administrator. Staff were aware of where to locate the level of assistance needed for care (electronic [NAME]), when and how to notify the supervising nurse of changes in resident condition including changes in residents physical ability to perform ADL task(s). Staff were able to define supervision, why it was important to know each resident's individual need/level of supervision, how to determine the resident's need for supervision, and how supervision played an integral role in the mitigation/reduction of accidents. Staff were provided with scenarios of negative outcomes when adequate supervision was not provided and consequences of not following the resident plan of care as indicated in the [NAME]. Record review of quiz results indicated all staff passed the quiz related to resident level of supervision and prevention of accidents. Record review of the facility's audit of all resident care plans indicated all residents' level of supervision corresponded with their need. Record review of 6 resident electronic records indicated all care plans included level of supervision based on resident needs. Staff interviews indicated there were no identified changes in condition reported. Observations conducted on [DATE] from 9:00 a.m. through 2:00 p.m. indicated no observed concerns related to supervision or assistance. On [DATE] at 2:27 p.m., the Administrator and DON were informed the IJ was removed; however, 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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete and accurate admission orders for the resident's immediate care for 2 of 19 residents reviewed (CR #138, and Resident #241). *The facility failed to ensure Resident CR#138, a new admission with a diagnosis of diabetes was provided with a physician's order for insulin or blood sugar checks. The facility did not receive any intervention until resident family intervened on 09/15/22 (6 days after admission). Resident CR#138's blood sugar on 09/15/22 was 528 mg/dl. * The facility failed to ensure Resident #241's hospital discharge medication order for Betapace (anti-arrhythmic med used to treat a-fib) was transcribed and followed. Resident CR#241's Betapace medication was omitted 6 days after admission. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/11/22 at 3:10 p.m. and was removed on 10/13/22, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. These failures could place residents at risk for not receiving appropriate care, treatment, and services to prevent serious harm or serious impairment. Findings included: CR #138 Record review of CR# 138's face sheet indicated he was [AGE] years old and was admitted on [DATE] with diagnoses which included type 2 diabetes (an impairment in the way the body regulates and uses sugar (glucose) as a fuel) CR #138 was discharged to the hospital on [DATE]. Record review of CR #138's previous facility discharge packet dated 09/09/22 indicated his primary diagnosis was type 2 diabetes and included orders for finger stick blood sugar checks before meals and at bedtime and Insulin Glargine Solution (Lantus) 100 Unit/ml, inject 10 unit subcutaneously one time a day for diabetes (hold if blood sugar <80). Record review of CR #138's Nursing admission Evaluation and History dated 09/09/22 at 9:09 p.m. and signed by LVN F indicated Resident was transferred from another long-term facility accompanied by transport, had relevant history of diabetes, and orders were received /clarified from admitting physician. Record review of CR #138's nurse's progress note dated 09/15/22 at 8:24 p.m. and signed by LVN C indicated LVN C received a call at 11:00 a.m. from Resident's family who asked if Resident had been getting his blood sugar checked regularly. LVN C wrote she told the family she would check Resident's blood sugar and call her back. LVN C arrived in resident room, and he was on a video call with the family member. Blood sugar was 528 mg/dl. Family called the DON and Administrator who then went to CR #138's room. LVN C reviewed orders from previous facility and notified physician of order for Lantus and Resident's blood sugar of 528 mg/dl. Physician gave order for FSBS before meals and at bedtime. Physician ordered Humalog 15 units now, start sliding scale insulin, and Lantus 10 units at bedtime. LVN administered 15 units Humalog to Resident CR #138 and rechecked blood sugar after 15 minutes. Blood sugar had decreased to 474 mg/dl. LVN informed Resident's family she would review medications further to make sure medications were not missed upon admission. Record review of admission MDS dated [DATE] CR #138 had severely impaired cognition, required extensive assistance with most activities of daily living, had an active diagnosis of diabetes, and had received insulin 2 days out of 7 during the 7-day look back period. Record review of #CR 138's cumulative physician orders, dated 10/11/22, indicated the following medications were added in the electronic medical record on 09/15/22: *09/15/22 Lantus Solution 100 Unit/ml (Insulin Glargine) Inject 10 unit subcutaneously at bedtime for diabetes *09/15/22 Humalog Solution 100 Unit/ml (Insulin Lispro) Inject per sliding scale - FSBS 0-70 - 0 units and initiate hypoglycemia protocol FSBS 71-130 = 0 units FSBS 131-180 = 2 units FSBS 181-240 = 4 units FSBS 241-300 = 6 units FSBS 301-350 = 8 units FSBS 351-400 = 10 units FSBS 401+ = 12 units and call doctor Subcutaneously before meals and at bedtime for diabetes. Record review of facility incident report dated 9/16/22 at 3:06 p.m., written by the Administrator indicated Resident CR #138 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes. Resident had orders to receive Lantus at bedtime. Nurse that put in orders omitted this order resulting in Resident not receiving ordered medication. Family was inquiring how resident doing and it was discovered that Resident had not been receiving medication. The attending nurse took Resident's blood sugar, and it was determined that the blood sugar was above normal limits. The doctor was notified. Nurses were in-serviced on the admissions process. It was implemented the DON/ADON will check all admissions within 24 hours of admitting. An admission check off was issued. The admitting nurse was in-serviced and re-educated. Orders for insulin and blood sugar orders were put in. Record review of the Provider Investigation Report dated 9/21/22 and signed by the Administrator, indicated in investigation summary that DON/ADON went through the admission packet/orders for CR #138 and found that the admitting nurse forgot to put in the order for the Resident's insulin Lantus. Record review of Resident CR#138's undated baseline care plan, indicated Resident #CR138 was a diabetic, his interventions included: Diabetes medication as ordered by doctor and fasting serum blood sugar as ordered by doctor. Record review of Resident CR#138's Medication Administration Record (MAR) indicated Resident's blood sugar levels were as follows: *09/15/22 5:00 p.m. 303 mg/dl, *09/15/22 9:00 p.m. 196 mg/dl, *09/16/22 7:00 a.m. 149 mg/dl *09/16/22 11:00 a.m. 272 mg/dl *09/16/22 5:00 p.m. 357 mg/dl *09/16/22 9:00 p.m. 241 mg/dl *09/17/22 7:00 a.m. 267 mg/dl *09/17/22 11:00 a.m. 276 mg/dl *09/17/22 5:00 p.m. 321 mg/dl Centers for Disease Control (CDC) guidelines for diabetics indicate recommended blood sugar before meals be less than 130 mg/dl and less then 180 mg/dl two hours after eating. During an interview on 10/10/22 at 2:15 p.m., the DON said he first learned of the incident when CR #138's family called on 9/15/22 stating the facility had not been checking resident's blood sugar and now his sugar was over 500 mg/dl. The DON said he and the Administrator went to check on the Resident. The DON said LVN C had called the physician and administered insulin to CR#138. The DON said he then reviewed transfer orders and noted orders for Lantus and FSBS checks had been left off of the admission orders, so blood sugar checks and insulin administration was not done until family intervention on 09/15/22. He said an in-service had been completed with LVN F and other nurses to review each residents admitting diagnosis and ensure medication orders reflect the diagnosis. To have a second nurse review the admission orders if admitting nurse is unsure, and if resident is capable, assess Resident's history to ensure diagnosis of diabetes is not overlooked. He said an action plan had been set in place that he or the ADON would review all admission orders within 24 hours of resident admission. During an interview on 10/10/22 at 3:55 p.m., CR #138's family said the resident called her several times on 09/15/22 complaining of stomach pain and stating the facility had not been checking his blood sugar. The family said she got upset and called LVN C insisting she check his blood sugar. The family member said LVN C told her she didn't know CR #138 was diabetic. The family member said she was shocked when she learned his blood sugar was more than 500 mg/dl. The family member said the nurse told her she had called the doctor, given him insulin, and his blood sugar would be checked regularly. The family member said Resident was sent to the hospital 2 days later and admitted with diagnosis of nephritis (kidney inflammation) and UTI (urinary tract infection). The family member said CR #138 was discharged from the hospital after a 7 day stay and admitted to another facility because she did not want the resident going back to the facility. Record review of CR #138's nurse's progress note dated 9/18/22 at 12:40 a.m. indicated Resident was sent to hospital for further evaluation due to intractable pain (pain whose cause cannot be removed, and according to generally accepted medical practice, the full range of pain management modalities appropriate for this patient has been used without adequate result). During an interview on 10/10/22 at 5:07 p.m., LVN F said she had worked at the facility for 2 weeks before the incident and had received training/orientation from the ADON which included resident admission. She said on the evening of 09/09/22 she had 3 admissions and was very busy. LVN F said the transferring facility sent transfer orders and medications for CR #138. She said she compared medications received with the transfer orders, but the transferring facility had not sent Lantus insulin, so she missed the orders for FSBS and Lantus. She said she was unaware CR #138 had a diagnosis of diabetes. She said possible negative outcome for the resident not receiving blood sugar checks and insulin could be elevated blood sugar and resident decline. During an interview on 10/10/22 at 5:22 p.m., the ADON said she completed orientation training with LVN F. She said LVN F demonstrated understanding of admission process during the orientation. She stated she and the DON were responsible to reviewing all new admissions and re-admissions within 24 hours of admit, but she could not recall if CR#138's admission records had been reviewed. She said possible negative outcome of a resident not receiving blood sugar checks and insulin could be elevated blood sugar. During an interview on 10/11/22 at 2:30 p.m., MD D said he was the physician for CR#138. He said he had reviewed the transfer orders from the previous facility and approved them. He said those orders included FSBS check four times daily before meals and at bedtime and Lantus 10 units daily. He said he was unaware the resident was not receiving ordered blood sugar checks and insulin until he received a call from the facility on 09/15/22 to report blood sugar of 528 mg/dl and the resident not receiving insulin or blood sugar checks since admission. He said he gave orders to the facility for Humalog 15 units now, Humalog per sliding scale with blood sugar checks before meals and at bedtime, and Lantus 10 units daily. He said he believed the resident's elevated blood sugar was related to the resident not receiving blood sugar checks and insulin, but it was also related to the resident's Nephritis(inflammation of the kidneys) and UTI that he was hospitalized for 2 days later. During an interview on 10/12/22 at 11:02 a.m., CR#138's family said she had never known the Resident to have a blood sugar over 500 mg/dl until the nurse at the facility checked it on 09/15/22. She said the Resident's blood sugar usually stayed in the 100 mg/dl to 200 mg/dl range. During an interview on 10/12/22 at 11:10 a.m., LVN C said on 09/15/22 she received a call from CR #138's family who asked if his blood sugar was being checked. She said she checked CR#138's blood sugar and it was 528 mg/dl. She said she called MD D who gave orders for Humalog now, Humalog per sliding scale with blood sugar checks before meals and at bedtime, and Lantus daily. She said she administered 15 units Humalog subcutaneously and re-checked his blood sugar 15 minutes after the dosage was given. Blood sugar was then 474 mg/dl. She said she was unaware the Resident was diabetic until family called the facility asking if his blood sugar was being checked. During an interview on 10/13/22 at 1:14 p.m., the DON said the admission orders for CR #138 were missed by LVN F on admission and not caught by staff during morning meeting/review. He said he did not recall if CR#138's admission orders were ever reviewed in the morning meeting or by himself or the ADON. He said, we just missed those orders and dropped the ball. Resident #241 Record review of Resident #241's face sheet, dated 10/11/22, revealed an [AGE] year-old female, admitted to the facility on [DATE], had diagnoses which included paroxysmal atrial fibrillation and chronic diastolic (congestive) heart failure. Record review of Resident #241's admission MDS dated [DATE] revealed it was in progress and was not completed. Record review of Resident #241's undated care plan revealed Focus: Provide the resident and their representative with a summary of the baseline care plan within 48 hours of admission that includes(at minimum): .c) services and treatments to be administered by the facility . Interventions: .The resident medication orders and dietary instructions were reconciled upon admission . Record review of Resident #241's Nursing admission Evaluation and History dated 10/05/22 completed by RN H revealed Resident #241 was alert, oriented (person, place, time and situation) and her cognition was intact. Section O. Medications documented 1b. orders received/clarified from admitting physician. Record review of Resident #241's Hospital Medication List printed on 10/04/22 at 9:50 a.m. revealed, the resident was supposed to continue taking Betapace (sotalol) order stated dose 40mg, route oral, frequency daily. Record review of Resident #241's Order Summary Report, dated 10/11/22, revealed no order for Betapace(sotalol) until 10/11/22 sotalol 80 mg give 0.5 tablet by mouth one time a day for arrhythmia hold medication if heart rate is below 60 or sbp less than 110 dbp less than 60, on hold from 10/11/22 to 10/14/22. Record review of Residents #241's MAR dated, October 2022, revealed no documented administrations and no physician order transcribed for Betapace(sotalol) indicating Resident #241 received Betapace(sotalol) dose 40mg, route oral, frequency daily. Further review of the MAR indicated no vital signs/heart rate were obtained. In an interview on 10/11/22 at 3:37 p.m. MD D stated he was not aware of Resident #241 not receiving betapace. MD D stated the resident not having the medication poses no risk for anything because reality of things was she does not need the medication. MD D stated the medication was for heart rate control in atrial fibrillation and hers (Resident #241) looked ok. He said he reviewed the vital signs and the residents heart rate was not abnormal(while not taking) and resident didn't need it. Surveyor told him the facility had no vitals recorded for the resident, he said he had vitals/HR and they were fine. MD D said if Resident #241's heart rate was out of control it could have done her no harm. MD D said, I don't think it's harmful that she did not recieve the betapace. In an interview on 10/12/22 at 1:00 p.m. Resident #241 stated she was not aware she was not getting her heart medication, betapace. Resident #241 said she took the medication while she was in the hospital and just assumed the facility was giving her the same medications. Resident #241 said she took the medication for a fast heart, and she has not had any problems with her heart . In an attempted telephone interview with RN H on 10/11/22 at 3:00p.m., was unsuccessful and a voice message could not be recorded due to the mailbox being full. In an attempted telephone interview with RN H on 10/12/22 at 11:45a.m., was unsuccessful and a voice message could not be recorded due to the mailbox being full. In an interview on 10/13/22 at 1:30 p.m. the DON said we dropped it, we failed the process of checks and balances and the nurse(RN H) just did not do it. The DON said he was responsible for reviewing all new admissions and re-admissions within 24 hours of admit but couldn't remember if they had checked Resident #241 admission orders. He said nurses are training in admission process which included transcribing orders during orientation and annual or as the need arise. The DON also said not giving Resident #241 the medication betapace put her at risk of potential harm because that was an important medication to control her A-fib. The DON said no vital signs/heart rate were taken and heart rate was to be taken daily before administering the betapace. Record review of the facility's Admissions Policies revised December 2006 indicated The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility. Record review of the facility's policy revised dated April 2014, titled Adverse Consequences and Medication Errors .#6. Examples of medication errors include : a. omission of drug is ordered but not administered . Record review of the facility's policy revised dated February 2014, titled Verbal Orders 1. Only authorized licensed practitioners or individuals authorized to make verbal orders from practitioners shall be allowed to write orders in the medical record. 2. Verbal orders are those written by an authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf a telephone order is a verbal order given over the phone . 4. The individual receiving the verbal order must write it on a telephone on a physicians order sheet as V.O. (verbal order) or T.O. (telephone order) . Record review of the facility's policy revised dated November 2014, titled Medication Orders Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders . 3. Orders must be written and maintained in chronological order . The Administrator was notified on 10/11/22 at 2:04 p.m. an Immediate Jeopardy (IJ) situation was identified due to the above failures and an IJ template was provided. The facility's Plan of Removal was accepted on 10/12/22 at 1:09 p.m. and included: On October 11, 2022, the Corporate Director of Clinical Operations. Corporate MDS Specialist, and Corporate Health Information Manager provided in-service training regarding daily review of admission records, admission order reconciliation, review of 24/72 hour report, and communication with non-nursing disciplines to the DON, ADON, Wound Care Nurse, and MDS Coordinator. By 2:00 p.m. on 10/12/22 all nursing staff were provided in-service training regarding admission/re-admission process, the admission/re-admission medication reconciliation process, transcribing and carrying out physician orders, and following up on recommendations from other disciplines. All newly hired nurses will be educated before beginning their first shift. A complete chart audit was conducted on all resident medical records by the DON, ADON, and Wound Care Nurse on 10/11/22 for medication orders, treatment orders, recommendations from other disciplines, and admission/re-admission. The facility has re-educated all nursing staff on admission/re-admission process, the admission/re-admission medication reconciliation process, transcribing and carrying out physician orders, and following up on recommendations from other disciplines. On 10/13/22 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on 10/13/22 at 1:14 p.m., the DON said all staff have received in-service training on admission process and all new hires will be trained during orientation. He said he the corporate nurse will be providing mock admissions during training to ensure staff is following the new process. DON said the new process included: 1) Admitting nurse will verify/confirm admission orders with physician and put all orders into electronic medical record. 2) After inputting orders in electronic medical record, a hard copy of chart would be reviewed in morning meeting. If on the weekend will be reviewed by the DON or ADON. 3) If doctor did not want to continue an order that will be charted in nurse's notes. 4) There is a new tracking tool in place to make sure all steps are followed. 5) Also included in new process is to check all admitting diagnosis are addressed. During an interview on 10/13/22 at 1:55 p.m., the Administrator said all admission orders will be reviewed by DON or ADON within 24 hours of resident admission to ensure all diagnosis have been addressed and all medications have been accurately transcribed, and residents are receiving all ordered care and medications. He said this will be done during morning meetings, clinical meetings, and weekend admissions will be reviewed by either DON or the ADON remotely. The Administrator said he, the DON, ADON, wound care nurse, and MDS nurse will talk daily and will follow the new process of reviewing all admission orders within 24 hours. He said staff is trained through in-service, venders, corporate nurses, Relias (computer training) and one on one. The Administrator said the IJ happened because of oversight, orders were just missed, and the new process put in place will ensure oversights don't happen. He said possible negative outcome to a resident from not receiving ordered FSBS and insulin was hyperglycemia (high blood sugar). The Administrator said the new process will be monitored by himself and DON making rounds together every morning. Talking to residents and asking them questions. Assessing non-verbal residents. Talking to staff, asking about any problems, and having an open-door policy. Interviews on 10/12/22 at 3:10 p.m. to 4:30 p.m. with 6 LVNs (LVN C, L, M, N, O and P) indicated they were able to correctly state the protocol for admission/re-admission process, the admission/re-admission medication reconciliation process, transcribing and carrying out physician orders, and following up on recommendations from other disciplines. During interviews on 10/13/22 at 8:25a.m. to 8:36 a.m. of the Respiratory Therapy staff (RT J and RT K) the retraining related to procedure for ensuring recommendations are adequately communicated to nursing staff and followed up accordingly was confirmed. Record Review of Respiratory Policy and set guidelines of communication between contracted Respiratory Therapists and facility staff was confirmed. Record review of the facility's in-service dated 10/12/22 training indicated all nursing staff had received in-service training on admission/re-admission process, the admission/re-admission medication reconciliation process, transcribing and carrying out physician orders, and following up on recommendations from other disciplines. Record review of facility audit for medication order reviews for all residents identified and all residents admitted and re-admitted for reconciliation of hospital discharge orders/admitting orders and diagnosis/health conditions of residents was addressed/noted in the electronic health record including any diagnostic testing necessary for monitoring the health condition was confirmed. On 10/13/22 at 9:40 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.