**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents remained free from physical abuse for 1 of 8 residents (Resident #1) reviewed for physical abuse.The facility failed to protect Resident #1 from resident-to-resident physical abuse on 7/16/25 when Resident #2 hit Resident #1 with a television cord, a nightstand drawer, and a wheelchair footrest causing injuries including facial and scalp lacerations, a fractured globe of the left eye, and a nasal fracture.An Immediate Jeopardy (IJ) situation was determined to have begun on 7/16/2025 and ended on 7/18/25. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey.This failure could place all residents at risk for serious injury and hospitalization.Findings included: Record review of Resident #1's admission record, dated 8/12/25, indicated he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included vascular dementia (decline in cognitive function), muscle wasting (atrophy), muscle weakness, and unspecified lack of coordination. Record review of Resident #1's significant change MDS, dated [DATE], indicated he had severely impaired thinking with a BIMS of 7. He required moderate assistance with personal hygiene, putting on/taking off footwear, lower body dressing, and showering/bathing; he required supervision assistance with toileting hygiene and upper body dressing; he required setup or cleanup assistance with oral hygiene and eating. He was frequently incontinent of bowel and bladder.Record review of Resident #1's comprehensive care plan, revised 7/15/25, indicated he had limited ability to walk related to impaired gait. Appropriate interventions were in place including providing dependent assistance for walking, instruct in use of a rolling walker, and remind resident not to walk without assistance. Record review of Resident #2's admission record, dated 8/12/25, indicated he was a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses of vascular dementia, mood disorder, unspecified symptoms involving cognitive functions and awareness. Record review of Resident #2's optional state assessment MDS dated [DATE] indicated he had severely impaired cognition with a BIMS of 5. He required supervision for most ADLs. Record review of Resident #2's comprehensive care plan dated 9/04/24 indicated he had exhibited socially inappropriate and disruptive behaviors including aggression and verbal aggression towards others. Appropriate interventions were in place including avoid over-stimulating environments, intervene early if resident behavior endangers the resident or others, and maintain a calm, slow, understandable approach with resident. During an interview on 8/12/25 at 9:10 a.m., the ADM said Resident #2 was admitted to the facility from a state facility and was required to be housed in a nursing facility as a condition of his release. The ADM said Resident #2 had no history of physical aggression towards other residents but had been verbally aggressive at times. The ADM said the facility acted immediately upon learning of the resident-to-resident altercation. The ADM said the facility performed all appropriate notifications and Resident #2 was placed under arrest by city police department. The ADM said Resident #1 was transported to the ER for evaluation and treatment and later returned to the facility. During an interview and observation on 8/12/25 at 3:30 p.m., Resident #1 was observed in his room, lying in bed. He appeared clean and well-groomed with no offensive odors detected. His left eye was closed, and he showed no fear interacting with staff or other residents. Resident #1 said on the night of the resident-to-resident altercation he woke up to use the bathroom. Resident #1 said he was sitting on the side of his bed using a hand-held urinal when Resident #2 told him to quit shaking my dick at him. Resident #1 said he told Resident #2 to stop staring at him, finished using the urinal, and laid back down in bed. Resident #1 said Resident #2 came over to his bed and started hitting him in the face and head with an electrical cord, which he believed was from the television in the room. Resident #1 said he tried to get up from bed but fell onto the floor. Resident #1 said Resident #2 picked up the television and threw it on top of him. Resident #1 said Resident #2 removed the metal footrest from Resident #1's wheelchair and began hitting him in the legs with it. Resident #1 said Resident #2 then pulled a drawer out of the bedside table and hit him in the left side of his face/head with it. Resident #1 said he was unable to get up or defend himself and yelled for help. Resident #1 said he still has pain in his left eye and can not see out of it well. Resident #1 said he had to have surgery, and it would be a few weeks before he could see well.Record review of a witness statement dated 7/17/25 by CNA Q indicated .On July 16, 2025, around midnight I just finished rounds.I heard the ice machine drop ice then another boom then 3 more [NAME].When I got about halfway down c hall, about where the wooden phone booth is, [Resident #2] met me in the hall coming out of his room and said, He attacked me. I asked who attacked him and he said his roommate.I continued to their room where I saw [Resident #1] lying face down in the floor.he was still in his gown with a brief on and bleeding.I kneeled beside [Resident #1] and asked him if he was okay and he said No, he beat me. I started yelling for [LVN L]. [Resident #1]'s nightstand drawer was pulled out and busted up, the chest of drawers pulled out and busted up on the floor.The TV cord was laying across the back of [Resident #1]'s thighs.During an interview on 8/13/25 at 1:15 p.m., LVN L said she worked 7/16/25 and was assigned to Resident #1's hallway. She said she was working at the nurse's station when she was called to the secured men's unit. She said she entered the secured unit and saw Resident #2 walking in the hallway and directed him to go sit in the dining room away from other residents. LVN L said she went into Resident #1's room and noted him lying face down with blood on his head and a pool of blood under him. LVN L said she completed an assessment noting facial lacerations, swelling and bleeding to his left cheek and eye, and redness to his legs and abdomen. LVN L said 911 was called and resident was transported to the ER. LVN L said local police were also notified. LVN L said local police came to the facility and investigated which resulted in Resident #2 being placed under arrest for aggravated assault and transported to the ER for clearance to be transported to the county justice center.Record review of a progress note dated 7/16/25 at 2:14 a.m. by the LVN L, indicated she was called to Resident #1's room and noted him lying in front of his roommate's bed, face down. LVN L noted a large amount of blood on the floor and on his head. LVN L noted resident was slow to respond to verbal stimuli but responsive to physical stimuli. Resident #1 was noted with swelling to his left eye and left side of his head, skin tears to both arms, redness noted to upper legs and abdomen. EMS was called to transport Resident #1 to the ER for evaluation and treatment. Record review of an arrest report dated 7/16/25 at 12:09 a.m. indicated an officer was dispatched to the nursing facility in reference to an assault. The arrest report indicated the following .[Officer] began examining the room where the assault had occurred.There appeared to be a large puddle of blood next to the bed where [Resident #2] sleeps. There were also 3 broken wooden drawers from the furniture inside the room and a broken TV that was across the room from it's original location.There was blood spatter on the drawers next to the bathroom door, as well as on the floor with a blood belt buckle.Based on the evidence I observed on scene, I determined [Resident #2] was the aggressor the assault. I placed [NAME] under arrest for Aggravated Assault Causes Serious Bodily Injury. Record review of an ER admission record form dated 7/16/25 indicated Resident #1 was admitted to the ER with the chief complaint of assault victim and primary findings of rupture of globe of left eye following blunt trauma. A physical exam in the ER revealed resident had multiple small facial and scalp lacerations, significant swelling around his left eye. Imaging revealed Resident #1 had a nasal fracture, a hematoma (abnormal collection of blood) to his left cheek, and additional findings of ruptured globe of left eye which required surgical intervention. Resident #1 said his pain was well controlled with his current pain medications. Record review of an after-visit summary dated 7/17/25 from a local emergency room indicated Resident #1 was diagnosed with blunt head trauma, rupture of globe of eye, nasal bone fracture, and scalp laceration. He was discharged back to the facility. Record review of a progress note on 7/17/25 at 5:59 p.m. by LVN K indicated Resident #1 was readmitted to the facility. A head-to-toe assessment was conducted and noted Resident #1's left eye swollen shut, covered by an eye patch. Resident #1 had skin tears to his forehead, right eyebrow, and on both ears. Resident #1 had 4 staples on the left side of his head near the front of his hairline, swollen nose, swollen left cheek, swollen bottom lip with a purple bruise, and scratches to both shins. Resident #1 complained of pain at 9 on a 0-10 numerical scale. New orders were received for pain medication three times daily as needed. During an interview on 8/13/25 at 2:45 p.m., the DON said changes were made to the facilities staffing which included adding a second staff member to the secured men's and women's units. The DON said the facility is utilizing a hospitality aid who functions as a sitter and monitor. The DON said the hospitality aid's job duties include monitoring residents so the CNA can enter resident rooms and provide care without the resident's being unsupervised. The DON said administration review the schedule every weekday with Friday encompassing the weekend shift reviews. The DON said there was a monitoring log which is to be signed daily by the administrative staff who reviewed staffing. The DON said an on-call rotation was established to cover for callouts. The DON said additional corrective actions included staff education on resident-to-resident altercations, staffing requirements, de-escalation techniques and managing aggressive behaviors, weekly random abuse/neglect interviews with staff and residents. The DON said all residents on the men's secure unit were given safe surveys and skin assessments were conducted on residents who could not respond to interview questions to identify potential abuse. The DON said residents with similar behaviors were also reviewed to ensure they were properly placed and there was no risk to resident safety. The DON said an ad hoc QAPI meeting was held to discuss further changes or corrective action if needed. Record review of a facility policy titled Resident-to-Resident Altercations revised in December 2016 indicated .Facility staff will monitor residents for aggressiveness/inappropriate behavior towards other residents. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator. It was determined these failures placed residents in an IJ situation on 7/16/25 to 7/18/25. The facility corrected the noncompliance on 7/18/25 by the following: Review of minutes from an ad hoc QAPI meeting held on 7/16/25 indicated the following actions had been taken: Residents were already separated. Nurse assessed both residents and ambulance contacted due to extent of non-aggressors injuries.Skin assessments and Safe Surveys to be completed on Male Secure Unit.Notifications to RP, MD, NP, Mental Health NP, Ombudsman, and [NAME] County Judges office completed.[Local] Police Department notified and entered facility resulting in [Resident #2] being arrested. ([Resident #2] will not be returning.Care Plan reviewed and updated.In-services planned: AN&E, Managing residents with Behaviors, and de-escalation tactics, Supervision.Review of in-service titled Secure Unit Staffing Plan conducted on 7/17/25 was attended by all staff and indicated Both male and female secure unit will be staff with two staff members and the charge nurse/designee will cover staff member on the unit breaks.Review of in-service titled Abuse and Neglect, Res to Res Altercation, De-escalation, COC (Reporting) conducted on 7/17/25 was attended by all staff.Skin assessments were completed on all residents residing on men's secure hall who were unable to be interviewed. Review of monitoring document dated 7/19/25 - 8/12/25 titled 5 staff members to be interviewed over abuse policy and education provided indicated ongoing staff interviews were being conducted weekly. Review of monitoring document dated 7/24/25 - 8/12/25 titled Staffing Reviews indicated ongoing staff reviews were being conducted daily. Review of monitoring document dated 7/18/25 - 8/12/25 titled 5 staff members to be interviewed over abuse policy and education provided indicated ongoing staff interviews were being conducted. Record review of a psychiatric visit summary dated 7/18/25 indicated Resident #1's was evaluated by psychiatric services following the resident-to-resident altercation. Record review of document Identification of residents with prior incidents. Review with MD and psych provider. Indicated residents residing on secured men's halls with similar behaviors were reviewed for placement on 7/18/25. Record review of facility staffing assignment sheets revealed two staff members were assigned to both men's and women's secured units. Observations at various times throughout the investigation revealed two staff members were always on both men's and women's secured units. During staff interviews on multiple shifts at various times and of varying disciplines throughout the investigation indicated all Staff interviewed 5 LVNs (LVN B, LVN J, LVN K, LVN L, LVN O), 4 CNAs (CNA C, CNA E, CNA H, CNA M), 1 Sitter (Sitter D), 1 LCSW, 1 ADON, 1 DA, 1 DON. said they received in-service training following Resident #1's resident-to-resident altercation which included resident-to-resident altercations, managing aggressive resident behaviors, and protecting residents from harm. All staff said they were trained in resident-to-resident altercations and dealing with aggressive resident behaviors. All staff said they were trained to separate residents and to use de-escalation techniques including physical and verbal redirection. All staff verbalized to report any instances of abuse to the facility administrator who is the abuse coordinator. All staff members interviewed said the secure units were to be staffed with two staff members at all times and staff must be relieved before going on break or leaving the unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 8 residents (Resident #3) reviewed for accidents.The facility failed to keep Resident #3 in a safe environment to prevent an elopement on 7/27/2025 when he followed visitors out of the facility.An Immediate Jeopardy (IJ) situation was determined to have begun on 07/27/2025 and ended on 08/01/2025. It was determined to be past non-compliance due to the facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury and accidentsFindings included: Review of an undated admission record for Resident #3 indicated he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (progressive cognitive decline) and schizoaffective disorder, bipolar type (combines schizophrenia and bipolar features). Review of a quarterly MDS dated [DATE] indicated he had a BIMS of 0 which indicated severe cognitive impairment. He required total assistance with toileting and personal hygiene; he required substantial assistance with showering/bathing; he required moderate assist putting on/taking off footwear, and with upper and lower body dressing; he required setup or cleanup assistance eating and with oral hygiene. Review of the comprehensive care plan dated 9/4/25 indicated Resident #3 was at risk for elopement related to diagnoses of Alzheimer's disease, dementia (cognitive decline), and schizoaffective disorder. Appropriate interventions were in place including wearing a Wander Guard bracelet (device that alarms if wearer was close to the facility exit doors), checking placement and function every shift, and quarterly or as needed elopement assessments to be completed.During an interview on 8/12/25 at 9:05 a.m., the DON said Resident #3 followed visitors out of the facility on 7/27/25. The DON said Resident #3 had a wander guard bracelet in place at the time of the elopement, but the alarm did not activate. The DON said when a resident had interventions to wear a wander guard the nursing staff checked the device every shift for placement and functionality and signed the wander guard logbook to indicate the checks were completed. The DON said she was not sure why the wander guard alarm system did not activate, but repairs were made to the system. The DON said the maintenance man had begun checking all alarms and door locks daily in addition to continuing the scheduled weekly maintenance checks. During an interview on 8/12/25 at 9:10 a.m., the ADM said at the time of the elopement on 7/27/25, Resident #3 was being housed on Hall A and was wearing a wander guard bracelet. The ADM said the wander guard alarm system was tested daily by the nursing staff when a resident was wearing one in the facility, and the door locks and alarms were checked weekly by the maintenance man. The ADM said he was unsure why the wander guard alarm did not activate. The ADM said he had service technicians come to the facility on 7/31/25 and make repairs to the alarm system. The ADM said Resident #3 was moved onto the secure men's unit following the elopement.Review of a witness statement dated 7/28/25 at 1:21 p.m., indicated at approximately 6:20 p.m. a woman visiting the facility rang the doorbell and asked LVN A if the man in the parking lot was a resident. LVN A said she immediately went outside and located Resident #3 walking by the dumpsters. LVN A said she led Resident #3 back inside the building. Review of a witness statement dated 7/30/25 by a visitor indicated on 7/27/25 she and several other visitors exited the facility through the front door. She said Resident #3 was near the nurse's station when they were walking up the hall to the lobby. She said after they exited the facility another visitor noted Resident #3 in the parking lot and went back inside the facility to alert facility staff. Review of an Elopement Event Report dated 7/31/25 at 2:16 p.m., completed by the DON indicated Resident #3 eloped from the facility on 7/27/25 at approximately 6:31 p.m. and was located in the front parking area. The report indicated there had been no recent changes in mental status, no recent traumatic events, new diagnosis, new stressors, or medication changes prior to the elopement. The report indicated Resident #3 was assessed for secure unit placement and moved to the men's secure unit.During an observation and interview on 8/12/25 at 10:52 a.m., Resident #3 was in sitting in the dining room of the men's secured unit. He appeared clean and well-groomed with no offensive odors; he had no visible skin tears, marks, or bruising. Resident #3 said he went outside the facility but could not provide any detail as to when, why or how. During an interview on 8/12/25 at 10:30 a.m., LVN B said Resident #3 was the only resident in the facility care planned for a wander guard. LVN B said nurses were responsible for checking the placement and function of wander guards every shift and signing the wander guard book to indicate checks were completed. LVN B said she was not aware of any problems with the wander guard alarm system prior to the elopement on 7/27/25. During an interview on 8/13/25 at 10:45 a.m., the maintenance man said prior to the elopement he was responsible for checking the door locks and all alarm systems weekly. He said he had not identified any problems with the alarm system or door locks prior to the elopement. He said following the elopement a service technician came to the facility and completed repairs. He said he verified all door locks and alarms were functioning following the repairs. He said following the elopement he was now responsible for completing daily checks of door locks and alarms in addition to the scheduled weekly checks. He said he was logging these checks on paper but was now logging the checks in the facility electronic maintenance system.Review of logbook report dated 8/12/25for Task Name: Doors, Locks, Gates & Alarms: Test operation of doors and locks for the last 6 months indicated all weekly checks had been completed and no problems were identified.Review of wander guard logbook from 3/1/2025 to 7/27/25 indicated all daily wander guard alarm tests were completed with no problems identified.Review of facility policy revised on 9/1/23 titled Wandering and Elopements indicated .The facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents.Review of facility policy revised in December of 2021 titled Emergency Procedure - Missing Resident indicated .Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety. It was determined these failures placed residents in an IJ situation on 7/27/25 to 8/1/25.The facility corrected the noncompliance on 8/1/25 by the following: An observation on 8/12/25 at 9:00 a.m., revealed a sign hung on the facility exit door at eye level which stated .Visitors and staff please be cautious of our residents who may be in the foyer or following you to the front entrance/exit door. Notify staff to redirect residents away from the door if needed.During an observation on 8/13/25 from 11:00 a.m. - 11:45 a.m., the maintenance man checked all door magnetic locks and alarms; the locks functioned properly, and alarms were audible. The maintenance man checked wander guard alarm system by holding a wander guard bracelet and walking toward the facility exit; the alarm system sounded audibly. Review of a resident headcount conducted on 7/27/25 indicated all 49 residents in-house were accounted for. Review of Facility Observation Summary Report dated 7/28/25 indicated all residents in the facility received updated elopement assessments. Review of minutes from an all-staff meeting on 7/30/25 indicated all staff received education on exiting doors (be sure that residents were not following them through exit or secure unit doors), Code Pink (staff response to a missing resident), Wandering and Elopement, and Caring for Residents Exhibiting Behavior.Review of an invoice dated 7/30/25 from a service call indicated Roam Alert front door alarm system and two push-bars were repaired/replaced.Review of Code Pink Drill for missing resident dated 7/30/25 indicated a drill took place at 3:30 p.m.Review of Code Pink Drill for missing resident dated 7/30/25 a drill took place at 6:44 p.m. Review of an in-service dated 8/1/25 titled Exit Doors instructed staff to make sure exit doors were closed when exiting the facility and do not block exit doors.Review of document titled Door Alarms Records indicated daily checks were performed on all door locks and alarms from 8/5/25 to 8/9/25.Review of electronic logbook report indicated daily checks were performed on all door locks and alarms on 8/11/25 and 8/12/25.Interviews with staff of various disciplines and shifts were conducted during the investigation and were all able to verbalize signs of exit seeking behavior and appropriate interventions. All staff were able to verbalize appropriate action to take in the event of a missing resident. Staff interviews included 5 LVNs (LVN B, LVN J, LVN K, LVN L, LVN O), 4 CNAs (CNA C, CNA E, CNA H, CNA M), 1 Sitter (Sitter D), 1 LCSW, 1 ADON, 1 DA, 1 DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents were free from neglect for 1 of 5 residents (Resident #1) reviewed for neglect. RN A did not call 911 for emergency services for Resident #1 until approximately 29 minutes after discovering Resident #1 unresponsive on [DATE]. CPR was not initiated on Resident #1 on [DATE] until approximately 9:52 PM when Fire Department arrived and began resuscitation attempts. Resident #1 was pronounced deceased at approximately 10:27 PM after Justice of the Peace arrived. The facility staff failed to provide life saving measures to Resident #1 who was identified as being full code after he was found unresponsive in his room. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 5:50 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for neglect due to not receiving necessary life-saving measures, decline in health, and death. Findings include: 1. Record review of an undated face sheet indicated Resident #1 was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (movement disorder of the nervous system that worsens over time), hypertension (elevated blood pressure), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). The face sheet indicated Resident #1 was a full code (in the event of cardiac arrest, CPR will be initiated). Record review of MDS dated [DATE] indicated Resident #1 was rarely understood by others and rarely understood others. The MDS indicated Resident #1 BIMS was not conducted due to resident being rarely/never understood. The MDS did not indicate Resident #1 had a DNR advanced directive in place. Record review of the care plan revised on [DATE] indicated Resident #1's code status as .[resident] is a Full Code. He wishes to be resuscitated if he should stop breathing. Record review of physician orders reflected an order of Code Status: Full Code with starting date of [DATE] with no end date. Record review of the nursing progress note dated [DATE] written by RN A indicated that RN A found Resident #1 unresponsive at approximately 9:00 PM on [DATE]. The progress note indicated RN A assessed Resident #1 and he was without pulse or respirations. The progress note indicated RN A called the facility ADM, DON, and ADON but did not initiate CPR or call 911. The progress note indicated RN A called NP at 9:29 and was directed to call 911 due to resident Full Code status. The progress note indicated Emergency Services arrived at 9:50 PM and initiated CPR at 9:52 PM. The progress note indicated Justice of the Peace arrived at 10:20 PM and CPR was stopped at 10:27 PM and Resident #1 was pronounced deceased . During a telephone interview on [DATE] at 12:30 PM, RN A said on [DATE] she discovered Resident #1 lying in his bed and he did not respond to her voice. RN A said she assessed Resident #1, and he had no palpable pulse, no respirations, pupils were fixed, dilated, and nonreactive to light, and resident's lips and fingertips were cold to the touch. RN A said she did not start CPR because Resident #1 was already deceased . RN A said she called the facility ADM, ADON, and DON for guidance on funeral home notification but only the ADON responded, and she did not know the policy. RN A said she called NP for further guidance and NP directed her to call 911 due to Resident #1 Full Code status. RN A said the 911 operator asked her to start CPR on Resident #1, but she declined to do so because he was already gone. RN A said she was familiar with Resident #1's code status because she was responsible for updating the resident code status book nightly at midnight. RN A said she had never received any training from the facility regarding Emergency Procedures or CPR. Record Review of an in-service education form dated [DATE] included topics Code Status Guidelines and Advanced Directives and Code Blue reflected RN A was in attendance. Record review of a National CPR Foundation Provider Card indicated RN A was certified in Standard - CPR / AED issued [DATE] and expiring [DATE] . During an interview on [DATE] at 1:00 PM the ADON said she remembered Resident #1 expiring. The ADON said RN A called her that night and told her Resident #1 was deceased and asked what Justice of the Peace and funeral home to notify. The ADON said if there was no preference in Resident #1's chart she was unsure and would call her back. The ADON said she assumed RN A had initiated CPR for Resident #1 due to his Full Code status and did not ask for clarification. During a telephone interview on [DATE] at 2:30 PM, NP said she first learned that Resident #1 was deceased on the morning of [DATE] when she received a message left with her answering service. She said RN A never called her on the night of [DATE] and she did not give RN A any directions or guidance. She said CPR should have been initiated immediately on a nonresponsive resident who is a full code. During an interview on [DATE] at 3:00 PM the ADM said he remembered Resident #1 expiring. The ADM said he was not at the facility but was given report regarding Resident #1's death. The ADM said he had been informed CPR was not initiated on Resident #1. The ADM said staff are expected to follow facility policy and initiate CPR for any resident who is Full Code. He said an RN may pronounce death if there are obvious signs of irreversible death . (e.g., rigor mortis, decomposition, decapitation) The ADM said the facility had begun disciplinary action with RN A for failing to follow policy when she self-terminated her employment at the facility. He said all staff receive education in Abuse, Neglect, and Exploitation on hire and the facility has frequent in-services to reinforce training. During a telephone interview on [DATE] at 4:00 PM . CNA B said she worked the overnight shift on [DATE]. CNA A said she checked on Resident #1 at approximately 8:00 PM and assisted him to the restroom and he did not appear to be in distress. She said RN A was Resident #1's nurse that night. Record review of the facility's Abuse, Neglect, and Exploitation policy last revised [DATE] indicated: .The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents . Record review of the facility's Emergency Procedure - Cardiopulmonary Resuscitation policy last revised February 2018 indicated: .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) . The Administrator was notified that an Immediate Jeopardy situation was identified due to the above failure and provided with the Immediate Jeopardy template on [DATE] at 5:22 PM. A Plan of Removal was requested. The facility's Plan of Removal was accepted on [DATE] 8:23 AM and included: Plan of Removal: 600: Free from Abuse & Neglect Ensure staff performed CPR for Resident #1 until emergency services arrived. Utilize the AED when Resident #1 was found unresponsive. Immediately call 911 when the resident was found unresponsive - waited approximately 29 minutes until calling emergency services. 1. Immediate Actions Taken for Those Residents Identified: What immediate/direct action was taken for the staff involved? Action: Charge Nurse no longer works for [facility] as of [DATE]. Nurse self-termed themself. Action: Resident #1 was noted as unresponsive, CPR initiated by emergency services, Resident #1 was pronounced as deceased . Person(s) Responsible: Charge Nurse Date: [DATE] 2. How the Facility Identified Other Possibly Affected Residents:? Action: Completed a DNR and Full Code audit:? Reviewed Physician orders, vs the face sheet, vs the care plan, vs the Out of Hospital DNR (if applicable) to ensure all are matching and correct. ? Person(s) Responsible: Regional Nurse Consultant, Director of Nursing, and/or Designee ? Date: [DATE] 8AM Action: Audit staff CPR cards to ensure proper number of certified employees present each shift. ? Person(s) Responsible: Human Resources, Administrator, and/or Designee ? Date: [DATE]? 10AM 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred:? Action: Ensured the crash cart has an updated list of full code and DNR residents. ? Person(s) Responsible: Administrator and/or Designee ? Date: [DATE] 10PM Action: ?Education- All Nurses educated regarding Emergency Management Code Procedure Policy to include the following, in which would be the response in an emergency situation for a full code resident requiring CPR: 1. If an individual is found unresponsive, the nurse to first arrive to the resident will briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: The first responding nurse will- Instruct a staff member to activate the emergency response system (code) and call 911. The first responding nurse will- Instruct a staff member to retrieve the automatic external defibrillator. The first responding nurse will- Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). 3. Chest compressions: Following initial assessment, begin CPR with chest compressions. Push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute; Allow full chest recoil after each compression; and Minimize interruptions in chest compressions. 4. Airway: Tilt head back and lift chin to clear airway. 5. Breathing: After 30 chest compressions provide 2 breaths via ambu bag or manually (with CPR shield). 6. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. 7. When the AED arrives, assess for need and follow AED protocol as indicated. 8. Continue with CPR/BLS until emergency medical personnel arrive. All above-mentioned staff will be educated prior to working their next shift. ? Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, &/or Designee Date: [DATE] 10AM Action: All direct care staff educated over the abuse and neglect policy. All above-mentioned staff will be educated prior to working their next shift. ? Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, &/or Designee Date: [DATE] 10AM 4. How the Corrective Actions Will be Monitored, by whom and for how long:? - Action: 1 mock code drill to be performed once a shift, for each Charge Nurse shift, to ensure proper reaction and that staff are following protocols educated on above. Charge Nurses work 12-hour shifts. Person(s) Responsible: Administrator, Director of Nurses, and/or Designee Date: [DATE] 10AM QAPI- Action: Ad hoc QAPI performed with Medical Director to review the IJ Template and the facility's plan to lower the immediacy. ? Person(s) Responsible: Administrator ? Date: [DATE]? 10PM On [DATE] at 12:50 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a random selection of staff CPR certifications indicated 8 of 8 staff reviewed had a current and appropriate CPR certification, sample included 3 RN, 2 LVN, 3 CNA. Record review of a random selection of resident charts indicated 15 of 15 residents reviewed had code status that matched on the face sheet and orders and had DNR's on file for residents who had chosen to be a DNR. Record review of AED/Crash Cart checklist sheet for the month of [DATE] indicated the crash cart had been checked daily. Record review of AED Competency Check Lists, DDU-100 Life Line Semi-Automatic External Defibrillator Post Tests. Record review of mock Code Blue drill sheet dated [DATE] including both overnight and day shift staff. Review of Ad Hoc QAPI meeting minutes. Attendees: ADM, DON, Medical Director, topics discussed included IJ templates and Plan of Removal. Review of In-service Education Form titled Abuse, Neglect, and Misappropriation (Other Occurrences That Are Reportable to HHSC/DADS) dated [DATE] 14 staff members of varying departments attended including nursing, human resources, and housekeeping. Observed mock code blue drill performed on [DATE] at 12:30 PM. During an interview on [DATE] at 9:20 AM, the DON said nurses and direct care certified in CPR had been in-serviced on CPR and AED use, she had run mock code blue (unresponsive resident) drills with both overnight and day shift staff, and they had a QAPI (Quality Assurance and Performance Improvement) meeting where the topics of emergency procedures and CPR were discussed. She said all staff has received additional in-service training in Abuse, Neglect, and Misappropriation. During an interview on [DATE] at 9:25 AM. the Administrator said the facility had audited all resident code statuses and verified all were correct in code status binder, audited crash cart check-off, audited direct care staff CPR cards, conducted training with nurses and direct care staff regarding emergency procedures, AED, CPR, and Abuse and Neglect training. He said the facility also ran mock code blue drills with both overnight and day shift staff. He said not all staff had been trained due to being unavailable but those who have not been would not be allowed to work until completing training. He said he held an ad hoc QAPI meeting with ADON and Medical Director to review IJ templates and discuss plan of removal. Staff interviewed on [DATE] between 10:30 AM and 12:30 PM (CNA B, CNA C, LVN D, CNA E, CNA F, RN G, CNA H, LVN J, CNA K, LVN L) were able to name where to find the code status for a resident. Staff interviewed said they should call for help and initiate CPR immediately for an unresponsive resident who is Full Code and not breathing normally. CPR certified staff were able to verbalize correct usage for AED. Staff interviewed were able to define neglect and who to report witnessed incidents to. ADM was notified of IJ removal on [DATE] at 12:50 PM. While the IJ was removed on [DATE] , the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and 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 ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 5 (Resident #1) residents reviewed for CPR. The facility failed to ensure staff performed CPR on [DATE] for Resident #1 who was identified as a full code . CPR was not initiated prior to emergency services arrival. The facility failed to ensure staff utilized the AED on [DATE] when Resident #1 was found unresponsive. The facility failed to follow their policy and procedure for Emergency Procedure - Cardiopulmonary Resuscitation. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 5:50 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary life-saving measures, decline in health, and death. Findings include: 1. Record review of an undated facesheet indicated Resident #1 was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (movement disorder of the nervous system that worsens over time), hypertension (elevated blood pressure), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). The face sheet indicated Resident #1 was a full code (in the event of cardiac arrest, CPR will be initiated). Record review of MDS dated [DATE] indicated Resident #1 was rarely understood by others and rarely understood others. The MDS indicated Resident #1 BIMS was not conducted due to resident being rarely/never understood. The MDS did not indicate Resident #1 had a DNR advanced directive in place. Record review of the care plan last revised [DATE] indicated Resident #1's code as .[resident] is a Full Code. He wishes to be resuscitated if he should stop breathing. Record review of the physician orders reflected order of Code Status: Full Code with starting date of [DATE] with no end date. Record review of the nursing progress note dated [DATE] written by RN A indicated that RN A found Resident #1 unresponsive at approximately 9:00 PM on [DATE] . The progress note indicated RN A assessed Resident #1 and he was without pulse or respirations. The progress note indicated RN A called the facility ADM, DON, and ADON but did not initiate CPR or call 911. The progress note indicated RN A called the facility NP at 9:29 and was directed to call 911 due to resident Full Code status. The progress note indicated Emergency Services arrived at 9:50 PM and initiated CPR at 9:52 PM. The progress note indicated Justice of the Peace arrived at 10:20 PM and CPR was stopped at 10:27 PM and Resident #1 was pronounced deceased . During a telephone interview on [DATE] at 12:30 PM, RN A said on [DATE] she discovered Resident #1 lying in his bed and he did not respond to her voice. RN A said she assessed Resident #1, and he had no palpable pulse, no respirations, pupils were fixed, dilated, and nonreactive to light, and resident's lips and fingertips were cold to the touch. RN A said she did not start CPR because Resident #1 was already deceased . RN A said she called the facility ADM, ADON, and DON for guidance on funeral home notification but only the ADON responded, and she did not know the policy. RN A said she called NP for further guidance and NP directed her to call 911 due to Resident #1 Full Code status. RN A said the 911 operator asked her to start CPR on Resident #1, but she declined to do so because he was already gone. RN A said she was familiar with Resident #1's code status because she was responsible for updating the resident code status book nightly at midnight. RN A said she had never received any training from the facility regarding Emergency Procedures or CPR. Record Review of an in-service education form dated [DATE] included topics Code Status Guidelines and Advanced Directives and Code Blue reflected RN A was in attendance. Record review of a National CPR Foundation Provider Card indicated RN A was certified in Standard - CPR / AED issued [DATE] and expiring [DATE]. During an interview on [DATE] at 1:00 PM the ADON said she remembered Resident #1 expiring. The ADON said RN A called her that night and told her Resident #1 was deceased and asked what Justice of the Peace and funeral home to notify. The ADON said she assumed RN A had initiated CPR for Resident #1 due to his Full Code status and did not clarify. During a telephone interview on [DATE] at 2:30 PM, She said RN A never called her on the night of [DATE] and she did not give RN A any directions or guidance. The NP said CPR should have been initiated immediately on a nonresponsive resident who is full code. During an interview on [DATE] at 3:00 PM the ADM said he remembered Resident #1 expiring. The ADM said he was not at the facility but was given report regarding Resident #1's death. The ADM said he had been informed CPR was not initiated on Resident #1. The ADM said staff are expected to follow facility policy and initiate CPR for any resident who is Full Code unless there are obvious signs of irreversible death. During a telephone interview on [DATE] at 4:00 PM. CNA B said she worked the overnight shift on [DATE]. CNA A said she checked on Resident #1 at approximately 8:00 PM and assisted him to the restroom and he did not appear to be in distress. She said RN A was Resident #1's nurse that night. Record review of the facility's Emergency Procedure - Cardiopulmonary Resuscitation policy last revised February 2018 indicated: .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis) . The Administrator was notified that an Immediate Jeopardy situation was identified due to the above failure and provided with the Immediate Jeopardy template on [DATE] at 5:22 PM. A Plan of Removal was requested. The facility's Plan of Removal was accepted on [DATE] 8:23 AM and included: Plan of Removal: 678: Cardio-Pulmonary Resuscitation (CPR)? The facility failed to: Ensure staff performed CPR for Resident #1 until emergency services arrived. Utilize the AED when Resident #1 was found unresponsive. Immediately call 911 when the resident was found unresponsive - waited approximately 29 minutes until calling emergency services. Follow their policy and procedures to immediately initiate CPR. 1. Immediate Actions Taken for Those Residents Identified:? What immediate/direct action was taken for the staff involved? Action: Charge Nurse no longer works for [facility] as of [DATE]. Nurse self-termed themself. Action: Resident #1 was noted as unresponsive, CPR initiated by emergency services, Resident #1 was pronounced as deceased . Person(s) Responsible: Charge Nurse Date: [DATE] 2. How the Facility Identified Other Possibly Affected Residents:? Action: Completed a DNR and Full Code audit:? Reviewed Physician orders, vs the face sheet, vs the care plan, vs the Out of Hospital DNR (if applicable) to ensure all are matching and correct. ? Person(s) Responsible: Regional Nurse Consultant, Director of Nursing, and/or Designee ? Date: [DATE] 8AM Action: Audit staff CPR cards to ensure proper number of certified employees present each shift. ? Person(s) Responsible: Human Resources, Administrator, and/or Designee ? Date: [DATE]? 10AM 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred:? Action: Ensured the crash cart has an updated list of full code and DNR residents. ? Person(s) Responsible: Administrator and/or Designee ? Date: [DATE] 10PM Action: ?Education- All Nurses educated regarding Emergency Management Code Procedure Policy to include the following, in which would be the response in an emergency situation for a full code resident requiring CPR: 1. If an individual is found unresponsive, the nurse to first arrive to the resident will briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: The first responding nurse will- Instruct a staff member to activate the emergency response system (code) and call 911. The first responding nurse will- Instruct a staff member to retrieve the automatic external defibrillator. The first responding nurse will- Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). 3. Chest compressions: Following initial assessment, begin CPR with chest compressions. Push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute; Allow full chest recoil after each compression; and Minimize interruptions in chest compressions. 4. Airway: Tilt head back and lift chin to clear airway. 5. Breathing: After 30 chest compressions provide 2 breaths via ambu bag or manually (with CPR shield). 6. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. 7. When the AED arrives, assess for need and follow AED protocol as indicated. 8. Continue with CPR/BLS until emergency medical personnel arrive. All above-mentioned staff will be educated prior to working their next shift. ? Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, &/or Designee Date: [DATE] 10AM 4. How the Corrective Actions Will be Monitored, by whom and for how long:? - Action: 1 mock code drill to be performed once a shift, for each Charge Nurse shift, to ensure proper reaction and that staff are following protocols educated on above. Charge Nurses work 12-hour shifts. Person(s) Responsible: Administrator, Director of Nurses, and/or Designee Date: [DATE] 10AM QAPI- Action: Ad hoc QAPI performed with Medical Director to review the IJ Template and the facility's plan to lower the immediacy. ? Person(s) Responsible: Administrator ? Date: [DATE] 10PM On [DATE] at 12:50 PM the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a random selection of staff CPR certifications indicated 8 of 8 staff reviewed had a current and appropriate CPR certification, sample included 3 RN, 2 LVN, 3 CNA. Record review of a random selection of resident charts indicated 15 of 15 residents reviewed had code status that matched on the face sheet and orders and had DNR's on file for residents who had chosen to be a DNR. Record review of AED/Crash Cart checklist sheet for the month of [DATE]. Record review of AED Competency Check Lists, DDU-100 Life Line Semi-Automatic External Defibrillator Post Tests. Record review of mock Code Blue drill sheet dated [DATE] including both overnight and day shift staff. Review of Ad Hoc QAPI meeting minutes. Attendees: ADM, DON, Medical Director, topics discussed included IJ templates and Plan of Removal. Review of In-service Education Form titled Abuse, Neglect, and Misappropriation (Other Occurrences That Are Reportable to HHSC/DADS dated [DATE] Observed mock code blue drill performed on [DATE] at 12:30 PM. Staff interviewed on [DATE] between 10:30 AM and 12:30 PM (CNA B, CNA C, LVN D, CNA E, CNA F, RN G, CNA H, LVN J, CNA K, LVN L) were able to name where to find the code status for a resident. Staff interviewed said they should call for help and initiate CPR immediately for an unresponsive resident who is Full Code and not breathing normally. CPR certified staff were able to verbalize correct usage for AED. Staff interviewed were able to define neglect and who to report witnessed incidents to. During an interview on [DATE] at 9:20 AM, the DON said nurses and direct care certified in CPR had been in-serviced on CPR and AED use, she had run mock code blue (unresponsive resident) drills with both overnight and day shift staff, and they had a QAPI (Quality Assurance and Performance Improvement) meeting where the topics of emergency procedures and CPR were discussed. During an interview on [DATE] at 9:25 AM. the Administrator said the facility had audited all resident code statuses and verified all were correct in code status binder, audited crash cart check-off, audited direct care staff CPR cards, conducted training with nurses and direct care staff regarding emergency procedures, AED, CPR, and Abuse and Neglect training. He said the facility also ran mock code blue drills with both overnight and day shift staff. He said not all staff had been trained due to being unavailable but those who have not been would not be allowed to work until completing training. He said he held an ad hoc QAPI meeting with ADON and Medical Director to review IJ templates and discuss plan of removal. ADM was notified of IJ removal on [DATE] at 12:50 PM. While the IJ was removed on [DATE] , the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and 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 consult with the physician when the resident experienced a change in condition for one (Resident #3) of nine residents reviewed for a change of condition. The facility failed to notify the physician of a change in condition for Resident #3 after he had thick hardened secretions that could not be removed from his tracheostomy on [DATE] at 10:51 PM. Resident #3 was transported to the hospital in cardiac arrest and later passed away. An Immediate Jeopardy was identified on [DATE] at 7:11 PM. While the Immediate Jeopardy was removed on [DATE] at 5:31 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. This failure could affect residents by placing them at risk for a delay in medical treatment, worsening in condition, and ultimately death. Findings included: Record review of Resident #3's face sheet undated revealed Resident #3 was a [AGE] year-old male that originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #3's diagnosis included malignant neoplasm of the oropharynx (throat cancer), major depressive disorder, tracheostomy (tube to keep airway open). Record review of Resident #3's quarterly MDS dated [DATE] indicated Resident #3 was rarely/never understood and a BIMS summary score was not obtained. Section O of the MDS revealed Resident #3 had received trach care within the last 14 days while a resident at the facility. Record review of Resident #3's care plan dated [DATE] indicated tracheostomy supplies are to be kept at resident's bedside for immediate access in locked cart. The goal was to maintain airway patency. The approach was medication cart to consist of trach tube (one size smaller), one set of trach ties, ambu bag (artificial breathing device), suctioning kit, sterile yankers. Record review of Resident #3's medication administration record for [DATE] through [DATE], revealed Resident #3 had a physician's order for Ipratropium Albuterol sol solution; 1.5-2.5mg/milliliters by halation to be given as needed every 4 hours. On [DATE] the medication record indicated the medication had not been given. Record review of nurse progress note dated [DATE] at 10:51 PM written by LVN C revealed Resident #3 allowed nurse to suction trach and was very hard to insert the suction tube, the nurse educated Resident #3 that he had to take the breathing treatments and allow other nurses to do trach care so the trach will not be clogged up. LVN C indicated that the DON was updated on the matter. Record review of nurse progress note dated [DATE] at 6:21 PM written by RN D: Resident was lying on the floor on the unit. The aid on the unit stated that he purposely laid down. Observed stridor (high-pitched respiratory sound) in resident. Attempted to clear mucus plug from resident's trach without success. Resident became unconscious and CPR was started while another nurse called 911. 1st responders arrived in minutes and assisted with CPR while the ambulance was in route. CPR was continued and resident was sent to the hospital at 7:25 PM. Contacted resident EC and left message to call the facility. Also contacted NP, DON, Administrator. Resident's EC returned call and was notified of resident's event and that he is in route to the hospital. Record review of hospital records dated [DATE] at 1:04 PM written by Hospital MD revealed Resident #3 admitted with out-of-hospital arrest, asystolic arrest, and etiology is likely hypoxic arrest. Resident #3 was noted with mucous plug, which has previously been prone to mucous plug noted in 2022. This would have resulted in hypoxic arrest which usually presents as PEA arrest, but after prolonged hypoxia/anoxia, would result in asystolic arrest. True downtime is unclear at this time. Record review of nurse progress note dated [DATE] at 8:10 AM indicated the case manager at the hospital called and spoke with nurse with disposition on resident. Family had a meeting with physician and decided to stop all life sustaining measures on [DATE]. Case Manager went on to state, Resident with no brain activity @ 1:40pm, and at 5:10pm was pronounced with no cardiac activity. During an interview on [DATE] at 9:15 AM the RP said she had received a call from the facility stating that Resident #3 had a mucus plug in his tracheostomy that the nurse was unable to remove. She said Resident #3 was very good at taking care of his tracheostomy himself and would suction himself. She said Resident #3 would let you know when he needed to by suctioned and tracheostomy care was needed. During an interview on [DATE] at 2:03 PM LVN C said she worked with Resident #3 2 to 3 nights a week. She said Resident #3 was hard to suction on [DATE] due to hard mucus in his trach. She said Resident #3 had a lot of buildup due to Resident #3 not allowing anyone to suction his trach. LVN C said she had to use a new suction tip each time she suctioned him due to the amount of buildup of mucus in his trach. She said she used 2 suction tips and then Resident #3 did not want her to suction him anymore. LVN C said she did not administer any as needed breathing treatments. She said she did notify the DON that Resident #3 was harder to suction but that she did not notify anyone else, and said she just charted it. LVN C said Resident #3 would let you know if he felt like he couldn't breathe. During an interview on [DATE] at 2:22 PM RN AC said on [DATE] she was not the nurse taking care of Resident #3, she said it was an agency nurse that was responsible for Resident #3's care, and it was her first time at the facility, so she was helping her out by doing the nursing progress note for the incident. RN AC said she walked into the secured unit and observed Resident #3 lying on the floor and Resident #3 was in stridor (high-pitched respiratory sound). She said they got Resident #3 back to his room and she attempted to suction his trach and Resident #3 passed out. RN AC said Resident #3's secretions were very hard, and she was not able to clear them. RN AC said she began CPR on Resident #3 while another nurse called 911. During an interview on [DATE] at 4:10 PM the NP said she remembered Resident #3 and that Resident #3 refused care frequently. She said she could not recall if the nurse had called and notified her of being unable to clear thick hardened secretions from Resident #3's trach on [DATE]. Said if she had been notified, she would have given an order for a nebulizer treatment to attempt to loosen secretions and attempt 1 more suction pass to clear secretions and if unsuccessful then she would have given an order to send to the emergency room. She said she was unsure if it would have made a difference in resulting in Resident #'s death. She said that Resident #3 had significantly declined over the previous 6 months with his cancer and felt like resident would have died soon. She said she was aware that resident frequently refused care and was not complainant with his diet and peg tube. During an interview on [DATE] at 4:48 PM the Medical Director said he did not recall being called on [DATE] and notified regarding the thick hardened secretions of Resident #3's trach. He said if he would have been notified, he would have given an order for Resident #3 to be sent out to the emergency room. He said that he was aware that Resident #3 had refused care in the past. He said he could not say if being sent out to the emergency room would have made a difference in the ultimate demise of Resident #3. During an interview on [DATE] at 8:35 AM the DON said she had worked at the facility since [DATE]. She said she was not in the facility when Resident #3 went out to the hospital. She said the only notification that she received was that Resident #3 had refused to let the nurse suction him. She said that he would refuse trach care and suctioning from time to time but would later let the nurse clean and suction his trach. The DON said that the NP was aware that Resident #3 refused care at times. She said that Resident #3 never suctioned himself or cleaned his trach himself, and said it was always a nurse. The DON said she was not notified of resident's secretions being hard to suction or that there was anything wrong with his trach. Record review of facility policy dated [DATE] titled Change in a Resident's Condition or Status revealed Our facility promptly notifies the resident, his or her attending physician, health care provider and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights etc.). The nurse will notify the resident's attending physician, health care provider or physician on call when there has been a (an): D. significant change in the resident's physical/emotional/mental condition; E. need to alter the resident's medical treatment significantly; F. refusal of treatment or medications G. need to transfer the resident to a hospital/treatment center;. 2. A significant change of condition is major decline or improvement in the resident's status that: A. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). Record review of the facility policy dated [DATE] titled Tracheostomy Care The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. General Guidelines 4. Tracheostomy tubes should be changed as ordered and as needed (at least monthly). 5. Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies. 7. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. The Administrator and the DON were notified of the Immediate Jeopardy on [DATE] at 7:11 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on [DATE] at 2:34 PM and reflected the following: Resident #3 no longer resides at the facility (discharged : [DATE]) and will not return. Action: No residents residing at the facility at this time require suctioning. Person(s) Responsible: Director of Nursing Date: [DATE] Action: Nurses educated regarding change in condition and physician notification. The charge nurse should report all signs & symptoms, obtain vital signs if possible, and give a report of assessment findings. With respiratory residents, the charge nurse should assess respirations, observe for signs of cyanosis, listen to lung sounds, note any SOB or dyspnea, check the resident's SPO2, and provide oxygen if the airway is possibly obstructed. If the resident appears to be in respiratory distress, apply oxygen and send the resident out 9-1-1 to be evaluated and receive treatment at the emergency department. After the resident has been transported to the ED, notify the physician and responsible party/POA of the emergent transfer secondary to the change in condition. When caring for residents with a trach, notify the physician when there are changes in the respirations, difficulty with suctioning the trach, difficulty in removing thick secretions/mucus plugs, or shortness of breath or dyspnea. Do not force the suctioning catheter into the trach during suctioning and gently rotate the catheter when withdrawing. With any issues with suctioning a resident's trach, assess the SPO2, apply oxygen if SPO2 is less than 95%, and activate 9-1-1 for transport to the ED for treatment. **Key Takeaway: Nurses will understand the importance of notifying and when to notify the physician immediately following the change in condition/when residents have a thick hardened secretions that are unable to be cleared with suctioning. All current nurses will be educated prior to working their next shift. All temporary and new nurses will be educated prior to working their first/next shift. Person(s) Responsible: Director of Nursing Date: [DATE] by 10AM Action: Ad Hoc QAPI performed with Medical Director to notify him/her of the IJ Template and to share the Plan of Removal. MD has no additional steps to perform at this time. Person(s) Responsible: Administrator, Director of Nursing, and Medical Director Date: [DATE] by 11:30AM On [DATE] between 2:34 PM and 5:31 PM, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Record review of in-service dated [DATE] titled Change in condition and Physician Notification revealed 19 signatures with a change in condition quiz. Record review of Ad Hoc QAPI completed on [DATE] at 10:30 AM revealed 8 signatures including the Medical Director. During interviews on [DATE] between 2:34 PM and 5:31 PM the following nurses were able to verbalize understanding of change of condition and physician notification: DON, ADON, LVN S, and RN L. On [DATE] at 5:31 pm, the Administrator, DON and corporate representatives was informed the IJ was removed; however, the facility remained out of compliance at a severity of actual harm with harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and assistance to prevent accidents for 3 of 3 residents reviewed for accidents/supervision (Resident #3, Resident #20, and Resident #26) in that: 1. The facility failed to provide adequate supervision to prevent resident #3's exit from the secured unit on 8/18/23 and 9/2/23. Resident #3 was able to get out of a side door when opened from other side by other staff/residents on 8/18/23 and 9/2/23. 2. The facility failed to provide adequate supervision to prevent resident #20's exit from the secured unit on 5/27/23, 6/1/23, and 6/6/23. Resident #20 was able to get out of side door to secured unit when opened from other side by staff or other residents on 5/27/23 and 6/1/23. The facility failed to ensure emergency exit doorway at end of secured unit was locked when Resident #20 eloped on 6/6/23 and was able to get outside the facility. 3. The facility failed to provide adequate supervision to prevent resident #26's exit from the secured unit on 5/28/23. Resident #26 was able to get out of a side door when opened from other side by other staff/residents on 5/28/23. 4. The facility failed to ensure a resident environment was free of accidents/hazards as possible due to not ensuring the locks were engaged on the secure unit and not ensuring that residents were adequately supervised to prevent elopements from the secured unit. An IJ (immediate jeopardy) was identified on 10/18/2023 at 7:11 pm. While the IJ was removed on 10/19/2023 at 05:31 pm, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm with a scope of isolated due to the facility's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. This failure could place all residents at risk of eloping which could lead to severe injuries or death. Findings included: During an observation of male secured unit on 10/17/23 at 12:00 pm, multiple residents were observed gathered in the common area of unit. No altercations or behaviors seen at this time. One CNA was present on the unit at this time, she was observed entering unit through side door from hallway before secured glass doorways. Side door was observed to open freely from hallway into the common area where residents were gathered but locked from inside so as not to allow residents to exit unassisted. 1. Record review of facility face sheet dated 10/20/23 indicated Resident #3 was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with a primary diagnosis of malignant neoplasm of oropharynx (type of cancer that affects the tonsils, back of the throat, tongue, or roof of the mouth), hypertension (high blood pressure), and tracheostomy status (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs). Record review of a quarterly MDS dated [DATE] indicated Resident #3 was unable to complete interview for BIMS status due to rarely/never being understood. Section C for cognition indicated Resident #3 had inattention and disorganized thinking. Section E for behaviors indicated Resident #3 had no verbal or physical behaviors directed toward others. Record review of care plan dated 05/10/2023 indicated Resident #3 required psychotropic medications for diagnosis of mood disorder and anxiety. Resident #3 had impaired cognitive function and dementia and required the secured unit due to wandering and poor safety awareness. Record review of a facility progress note dated 8/18/23 at 9:22 am for Resident #3 indicated that resident got out of secured unit and went into dining room, poured himself a cup of regular coffee and ran back into the unit through the side door. Record review of a facility progress note dated 9/2/23 at 6:10 pm for Resident #3 indicated that he snuck out of unit as another resident opened the door to enter the unit. Resident #3 then went to dining room seeking food and soda, and refused to go back to the secured unit. 3 staff members tried explaining to him that he was not allowed to eat or drink anything by mouth per doctors orders because he could not swallow. He aggressively tried to get to soda machine, he became physically combative to the CN and the DON, he tried to throw an object at another resident but was stopped by the CN and DON. The resident left the dining room, went to nurses station and begain picking up objects to throw at others, began exit seeking to the front door and hallway emergency exits. Law enforcement was called by administrator. An officer responded and tried to reason with resident and was successful getting resident back to secured unit. Record review of a secured unit evaluation dated 9/1/23 for Resident #3 read .Resident remains on the secure unit due to displaying elopement behaviors. He is ambulatory and attempts to get out of the exit and secure unit doors . 2. Record review of facility face sheet dated 7/11/2023 indicated Resident #20 was a [AGE] year-old male admitted to the facility 05/24/23 with the diagnosis of Alzheimer's disease. Record review of quarterly MDS dated [DATE] indicated Resident #20 had a BIMS of 9 indicating Resident #20 had moderate cognitive impairment. Section E for behaviors indicated Resident #20 wandered 1 to 3 days of previous 7 days. Record review of comprehensive care plan dated 10/17/2023 indicated that Resident #20 wandered and was not easily re-directed related to dementia/bipolar disorder. Care plan interventions included increased supervision for safety of self and others if needed. Record review of a facility progress note dated 5/27/23 at 8:25 am for Resident #20 indicated that he had walked out of the exit door to the unit twice that morning. Record review of a facility progress note dated 6/1/23 at 8:56 am for Resident #20 indicated that he had walked off of secured mens unit and was safely redirected back to mens unit without issues. Record review of a facility progress note dated 6/6/23 at 9:43 pm for Resident #20 read .nurse notified by gesture to come to unit by other resident, other resident opens the emergency door to outside, pointing at this resident walking outside away from the facility passing the brown fence, nurse and staff rushed to resident to redirect resident back to facility, resident safely redirected, without hesitation to facility and back inside C unit. This resident previously noted to push on emergency door . signed LVN AB. Record review of a facility incident report dated 6/6/23 for Resident #20 indicated that he had gotten out the fire-exit door at the end of C-Hall and was found in the driveway outside the facility. 3. Record review of a facility face sheet dated 10/23/23 for Resident #26 indicated that he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hallucinations (hearing or seeing things that are not there) and dementia. Record review of a comprehensive MDS dated [DATE] for Resident #26 indicated that he had a BIMS score of 8, which indicated that he had moderate cognitive impairment. Section E for behaviors indicated that he exhibited wandering which could place the resident at significant risk of getting to a potentially dangerous place. Record review of a comprehensive care plan dated 5/31/23 for Resident #26 indicated that he exhibited behavioral symptoms as evidenced by eloping. Interventions were to praise appropriate behavior and maintain a calm environment. Record review of a facility progress note dated 5/28/23 at 7:51 am for Resident #26 indicated that he somehow exited the secure unit with all his clothing. Skilled nursing staff attempted to redirect him, and he became combative. He insisted that staff let him go home. No documentation of how staff was able to get resident back on unit. During an attempted telephone interview on 10/18/23 at 9:09 with CNA AA who was working the night of Resident #20's elopement from facility there was no answer and no option to leave a voicemail. During a telephone interview on 10/18/23 at 10:03 am LVN AB said that Resident #20 got out the end emergency door. She said when she entered the unit the alarm was sounding on the unit, but she could not hear the alarm at the nurse's station. She said that she did not recall seeing any other staff on the unit, but they may have been in a room. She said that this resident had been trying to get out for some time. She did not remember any interventions that were put into place. She said that she has not worked here in about 2 months and does not remember any other residents being able to get off unit while she was there. She said that this was the only time that a resident had gotten outside facility while she was there. She cannot remember if she was the nurse assigned to the unit that night, or if she just happened to be the one to notice the other resident gesturing for help. During an interview with DON on 10/18/23 at 10:20 am, she said she had been employed since July 11, 2023, as the DON. She said that she cannot comment on any specifics in this incident since it was before her employment, but she did say that she only considers it an elopement if the resident gets outside of the facility. She was not here when the elopement occurred. She said that he was not a resident at the time that she started as he was out to a behavioral hospital at that time. She said that normal procedures for an elopement would be that they would call the code, start searching, maintenance would usually go out and sweep the premises, including cars and parking lot, and if unable to find the missing resident, they would widen the search area. Once they found the resident, they would notify physician, responsible party, and DON, then do a reportable for state. They would check to make sure all systems were in place and functioning properly. During an observation and interview on 10/18/23 at 11:00 am the male secure unit end door revealed that it did not open with a 15 second delayed egress. The door did not alarm as it was pushed on. The DON had to go find the code to open the door, it took her about 5 minutes to go and find the code and come back to open the door. She did not know the code previously. She said that it had recently been changed and she did not know it. When she entered the code, the door unlocked and when opened, there was only a single door chime, like a doorbell chime, that could only be heard on C hall, not in entire facility. CNA Y on male unit also did not know the code to open the door. Patio door inside C hall dining room for male secured unit also did not open with a 15 second egress and had to have code entered, DON entered code. During an interview on 10/18/23 at 12:20 pm Administrator said that she did not remember exactly how Resident #20 got out but does remember it being reported to her that he got out of the facility. During a telephone interview on 10/18/23 at 12:40 pm, Maintenance Director said that he had been employed for a little over a year. He said that he checked the doors once a week. He said after the elopement, he came to look at the door and it had already been re-magnetized or reset and was locked. He said that he just changed the code at that time and made sure that the door was locked and shut completely. He said that the C hall emergency door does not have a delayed egress. He was unsure how Resident #20 got out of that door unless a staff member had used it and not ensure that it had been completely closed back and shut properly. During an interview on 10/18/23 at 1:00 pm, Administrator said that after the elopement incident, Resident #20 was referred to psych services (which he had already been receiving) and they had discontinued his Buspar and Effexor. She said that she was unsure of how he got out of the end door and assumed maybe a staff member had used it and not closed it completely, but there was no investigation afterward to find out how he eloped out of that doorway. She did not verbalize any risks to residents who were able to elope. Record review of facility policy titled Wandering and Elopements dated 9/1/23 read .The facility will ensure that resident who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care . and defines elopement as .when a resident leaves the premises or safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so . and .adequate supervision will be provided to help prevent accidents or elopements . The facility Administrator was notified on 10/18/23 at 7:11 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 10/19/23 at 4:41 PM and included: Resident #3 no longer resides at [name] Healthcare Center (discharged : 9/3/23) and will not return. Resident #20 is on 1:1 observation (initiated on 9/5/23, prior to surveyor entry) Resident #26 no longer resides at [name] Healthcare Center (discharged : 6/30/23). Action: -Educated all staff on Elopement Policy: **Key takeaway procedures to follow in the event of an elopement. Search for resident, call code pink, notify and administrator and police department in the event we cannot find the resident as soon as possible but within 30 minutes if the search of the home and grounds are unsuccessful. -Educated all staff on residents that reside on the secured unit should remain on the secured unit at all times (with an exception of appointments, out on pass with family, hospital visits, or other emergencies requiring such). Meals, activities, and smoking should occur in the resident's unit. -Educated all staff on ensuring residents do not come out of the unit when entering or exiting the unit. All staff shall be educated prior to working their next scheduled shift. All temporary and new staff will be educated prior to working their first/next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 10/19/2023 by 10AM Action: Placed signs on the inside and outside of the secured unit doors letting staff and visitors know to ensure residents do not leave the unit while they are entering and exiting. Person(s) Responsible: Administrator Date: 10/18/2023 by 10AM Action: Placed a lock on the outside of the unit dining room/common area. This still allows for entrance and exit through the hallway doors and is not impeding an emergency exit/altering the required egress. Person(s) Responsible: Administrator Date: 10/18/2023 by 2PM Action: Emergency Exit Only sign placed at the end of the secured unit doors leading outside. Continuous alarm has been activated and will sound when the emergency exit door, leading to an unenclosed outside area, is opened alerting staff that the door is ajar. Person(s) Responsible: Maintenance Director Date: 10/19/2023 by 4:25PM Action: Ad Hoc QAPI performed with Medical Director to notify him/her of the IJ Template and to share the Plan of Removal. MD has no additional steps to perform at this time. Person(s) Responsible: Administrator, Director of Nursing, and Medical Director Date: 10/19/2023 by 11:30AM On 10/19/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: 1. Educated all staff on Elopement Policy. Inservice dated 10/18/23 with 37 signatures. 2. Educated all staff on residents that reside on the secured unit should remain on the secured unit at all times. Inservice dated 10/18/23 with 37 signatures. 3. Educated all staff on ensuring residents do not come out of the unit when entering or exiting the unit. Inservice dated 10/19/23 with 25 signatures. 4. Placed signs on the inside and outside of the secured unit doors letting staff and visitors know to ensure residents do not leave the unit while they are entering and exiting. Observed signs on the glass entering the secured unit on 10/19/23 at 4:00pm 5. Placed a lock on the outside of the unit dining room/common area. Observation of door on 10/19/23 at 4:00pm, door handle has been removed and door has been permanently locked. 6. Emergency Exit Only sign placed at the end of the secured unit doors leading outside. Continuous alarm has been activated and will sound when the emergency exit door, leading to an unenclosed outside area, is opened alerting staff that the door is ajar. Observed 10/19/23 at 4:47pm door alarming when opened. 7. Ad Hoc QAPI. Verified with ad hoc qapi dated 10/19/23 at 11:30am with Administrator, DON and Medical director. Staff Interviews: During interviews on 10/19/23 between 4:50 pm and 5:15 pm, the following staff were able to appropriately verbalize understanding of education received during in-services. Nurses- 2-LVNS, 2-RN's (4:50pm DON, 5:01pm LVN S, 5:04pm ADON, 5:09pm RN L); CNA's- 5 CNA's (5:08pm CNA T, 5:12pm CNA O, 5:19pm CNA U, 5:06pm CNA P, 5:28pm CNA E); MA's- 1-MA's (4:57pm MA Q); and Other- 9 (4:53pm HSK SUP, 4:55pm COTA V, 4:59pm activity director, 5:00pm BOM/HR, 5:03pm HSK W, 5:08pm Maintenance Man, 5:11pm ST X, 5:13pm Administrator, and 5:15pm Dietary Supervisor). The Administrator was informed that the Immediate Jeopardy was removed on 10/19/23 at 5:31 pm; however, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #3) of 9 residents reviewed for assistive devices. The facility failed to promptly identify and intervene when Resident #3 had thick hardened secretions in his tracheostomy. Resident #3 was transported to the hospital in cardiac arrest and later died. An Immediate Jeopardy was identified on [DATE] at 7:11 p.m. While the Immediate Jeopardy was removed on [DATE] at 5:31 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate threat due to the facility's need to evaulate the effectiveness of the corrective systems. This failure could affect residents by placing them at risk for a delay in medical treatment, worsening in condition, and ultimately death. Findings included: Record review of Resident #3's face sheet undated revealed Resident #3 was a [AGE] year-old male that originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #3's diagnosis included malignant neoplasm of the oropharynx (throat cancer), major depressive disorder, tracheostomy (tube to keep airway open). Record review of Resident #3's quarterly MDS dated [DATE] indicated Resident #3 resident is rarely/never understood and a BIMS summary score was not obtained. Section O of the MDS revealed Resident #3 had received trach care within the last 14 days while a resident at the facility. Record review of Resident #3's care plan dated [DATE] indicated tracheostomy supplies are to be kept at resident's bedside for immediate access in locked cart. The goal was to maintain airway patency. The approach was medication cart to consist of trach tube (one size smaller), one set of trach ties, ambu bag, suctioning kit, sterile yankers. Record review of Resident #3's medication administration record for [DATE] through [DATE], revealed Resident #3 had a physician's order for Ipratropium Albuterol sol solution; 1.5-2.5mg/ml via inhalation to be given as needed every 4 hours. On [DATE] the medication record indicated the medication had not been given. Record review of nurse progress note dated [DATE] at 10:51 PM written by LVN C revealed Resident #3 allowed nurse to suction trach and was very hard to insert the suction tube, the nurse educated Resident #3 that he had to take the breathing treatments and allow other nurses to do trach care so the trach will not be clogged up. LVN C indicated that the DON was updated on the matter. Record review of nurse progress note dated [DATE] at 6:21 PM written by RN D: Resident was lying on the floor on the unit. The aid on the unit stated that he purposely laid down. Observed stridor in resident. Attempted to clear mucus plug from resident's trach without success. Resident became unconscious and CPR was started while another nurse called 911. 1st responders arrived in minutes and assisted with CPR while the ambulance was in route. CPR was continued and resident was sent to the hospital at 7:25 PM. Contacted resident EC and left message to call the facility. Also contacted NP, DON, Administrator. Resident's EC returned call and was notified of resident's event and that he is in route to the hospital. Record review of hospital records dated [DATE] at 1:04 PM, written by Hospital MD revealed Resident #3 admitted with out-of-hospital arrest, asystolic arrest, and etiology is likely hypoxic arrest. Resident #3 was noted with mucous plug, which has previously been prone to mucous plug noted in 2022. This would have resulted in hypoxic arrest which usually presents as PEA arrest, but after prolonged hypoxia/anoxia, would result in asystolic arrest. True downtime is unclear at this time. Record review of nurse progress note dated [DATE] at 8:10 AM, indicated the case manager at the hospital called and spoke with nurse with disposition on resident. Family had a meeting with physician and decided to stop all life sustaining measures on [DATE]. Case Manager went on to state, Resident with no brain activity @ 1340, and at 1710 was pronounced with no cardiac activity. During an interview on [DATE] at 9:15 AM the RP said she had received a call from the facility stating that Resident #3 had a mucus plug in his tracheostomy that the nurse was unable to remove. She said Resident #3 was very good at taking care of his tracheostomy himself and would suction himself. She said Resident #3 would let you know when he needed to by suctioned and tracheostomy care was needed. During an interview on [DATE] at 2:03 PM, LVN C said she worked with Resident #3, 2-3 nights a week. She said Resident #3 was hard to suction on [DATE] due to hard mucus in his trach. She said Resident #3 had a lot of buildup due to Resident #3 not allowing anyone to suction his trach. LVN C said she had to use a new suction tip each time she suctioned him due to the amount of buildup of mucus in his trach. She said she used 2 suction tips and then Resident #3 did not want her to suction him anymore. LVN C said she did not administer any as needed breathing treatments. She said she did notify the DON that Resident #3 was harder to suction but that she did not notify anyone else, and said she just charted it. LVN C said Resident #3 would let you know if he felt like he couldn't breathe. During an interview on [DATE] at 2:22 PM, RN AC said on [DATE] she was not the nurse taking care of Resident #3, she said it was an agency nurse and it was her first time at the facility, so she was helping her out by doing the nursing progress note for the incident. RN AC said she walked into the secured unit and observed Resident #3 lying on the floor and Resident #3 was in stridor (high-pitched respiratory sound). She said they got Resident #3 back to his room and she attempted to suction his trach and Resident #3 passed out. RN AC said Resident #3's secretions were very hard, and she was not able to clear them. She said they began CPR on Resident #3 while another nurse called 911. During an interview on [DATE] at 4:10 PM, the NP said she remembered Resident #3 and that Resident #3 refused care frequently. She said she could not recall if the nurse had called and notified her of being unable to clear thick hardened secretions from Resident #3's trach on [DATE]. Said if she had been notified, she would have given an order for a nebulizer treatment to attempt to loosen secretions and attempt 1 more suction pass to clear secretions and if unsuccessful then she would have given an order to send to the emergency room. She said she was unsure if it would have made a difference in resulting in Resident #'s death. She said that Resident #3 had significantly declined over the previous 6 months with his cancer and felt like resident would have died soon. She said she was aware that resident frequently refused care and was not complainant with his diet and peg tube. During an interview on [DATE] at 4:48 PM, the Medical Director said he did not recall being called on [DATE] and notified regarding the thick hardened secretions of Resident #3's trach. He said if he would have been notified, he would have given an order for Resident #3 to be sent out to the emergency room. He said that he was aware that Resident #3 had refused care in the past. He said he could not say if being sent out to the emergency room would have made a difference in the ultimate demise of Resident #3. During an interview on [DATE] at 8:35 AM, the DON said she had worked at the facility since [DATE]. She said she was not in the facility when Resident #3 went out to the hospital. She said the only notification that she received was that Resident #3 had refused to let the nurse suction him. She said that he would refuse trach care and suctioning from time to time but would later let the nurse clean and suction his trach. She said the NP was aware that Resident #3 refused care at times. She said that Resident #3 never suctioned himself or cleaned his trach himself, and said it was always a nurse. The DON said she was not notified of resident's secretions being hard to suction or that there was anything wrong with his trach. Record review of facility policy dated [DATE] titled Change in a Resident's Condition or Status revealed Our facility promptly notifies the resident, his or her attending physician, health care provider and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights etc.). The nurse will notify the resident's attending physician, health care provider or physician on call when there has been a (an): D. significant change in the resident's physical/emotional/mental condition; E. need to alter the resident's medical treatment significantly; F. refusal of treatment or medications G. need to transfer the resident to a hospital/treatment center;. 2. A significant change of condition is major decline or improvement in the resident's status that: A. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). Record review of the facility policy dated [DATE] titled Tracheostomy Care The purpose of this procedure is to guide tracheostomy care and the cleaning of reusable tracheostomy cannulas. General Guidelines 4. Tracheostomy tubes should be changed as ordered and as needed (at least monthly). 5. Tracheostomy care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies. 7. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. An Immediate Jeopardy was identified on [DATE] at 7:11 PM. The Administrator and the DON were notified of the Immediate Jeopardy on [DATE] at 7:11 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on [DATE] at 2:34 PM and reflected the following: Resident #3 no longer resides at [NAME] Healthcare Center (discharged : [DATE]) and will not return. Action: No residents residing at [NAME] Healthcare Center have a Tracheostomy. Person(s) Responsible: Director of Nursing Date: [DATE] Action: Nurses have been educated over the Tracheostomy Policy and suctioning/techniques. *Key Takeaways: Nurses will understand the need to promptly identify and intervene for thick hardened secretions, if suctioning is unsuccessful, notify the MD immediately/as soon as possible, and follow orders given. All Nurses will be educated prior to working their next shift. All new and temporary nurses will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: [DATE] by 10AM Action: Any future admissions with tracheostomies will be reviewed prior to admission to ensure proper equipment is present and proper training has been completed with staff. Orders will be reviewed and put in place to ensure proper care is given to ensure residents receive treatment and care in accordance with professional standards of practice. Care plans will be person centered and reflect residents' choices/preferences. In future situations nurses will be trained prior to working with a tracheostomy resident. Person(s) Responsible: Director of Nursing and/or Assistant Director of Nursing Date: [DATE] by 11:30AM Action: Ad Hoc QAPI performed with Medical Director to notify him/her of the IJ Template and to share the Plan of Removal. MD has no additional steps to perform at this time. Person(s) Responsible: Administrator, Director of Nursing, and Medical Director Date: [DATE] by 11:30AM On [DATE] between 2:34 PM and 5:31 PM, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Record review of in-service dated [DATE] titled Oxygen Administration, Tracheostomy, Nebulizer, Inhaler revealed 7 nurse signatures. Record review of Ad Hoc QAPI completed on [DATE] at 10:30 AM with 8 signatures including the Medical Director. During interviews on [DATE] between 2:34 PM and 5:31 PM the following nurses were able to verbalize understanding of Oxygen Administration, tracheostomy care, Nebulizers, and Inhalers: DON, ADON, LVN S, and RN L. On [DATE] at 5:31 pm, the facility was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate threat due to the facility's need to evaulate 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 residents were free from abuse for 5 of 6 residents (Resident #3, Resident #20, Resident #21, Resident #23, and Resident #24) reviewed for Resident Abuse. 1. The facility failed to protect Resident #3 from abuse by Resident #20. On [DATE] Resident #20 tried to choke Resident #3. 2. The facility failed to protect Resident #21 from abuse by Resident #20. On [DATE] Resident #20 attempted to strike Resident #21 and both fell to floor. 3. The facility failed to protect Resident #3 from abuse by Resident #20. On [DATE] Resident #20 bit Resident #3 on the thumb causing a skin tear, leading to an infection requiring treatment. 4. The facility failed to protect Resident #20 from abuse by Resident #23. On [DATE] Resident #20 was involved in an altercation with Resident #23 and Resident #23 hit Resident #20 causing him to fall. 5. The facility failed to protect Resident #20 from abuse by Resident #25. On [DATE] Resident #20 wandered into Resident #25's room and Resident #25 hit Resident #20 on the head. 6. The facility failed to protect Resident #24 from abuse by Resident #20. On [DATE] Resident #20 wandered into Resident # 24's room on the male secured unit of the facility and hit him in the face. An IJ (immediate jeopardy) was identified on [DATE] at 5:52 pm. While the IJ was removed on [DATE] at 2:45 pm, 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's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. These failures placed all residents at risk of physical harm, mental anguish, emotional distress, or death. Findings included: 1. Record review of facility face sheet dated [DATE] indicated Resident #3 was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with a primary diagnosis of malignant neoplasm of oropharynx (type of cancer that affects the tonsils, back of the throat, tongue, or roof of the mouth), hypertension (high blood pressure), and tracheostomy status (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs). Record review of a quarterly MDS dated [DATE] indicated Resident #3 was unable to complete interview for BIMS status due to rarely/never being understood. Section C for cognition indicated Resident #3 had inattention and disorganized thinking. Section E for behaviors indicated Resident #3 had no verbal or physical behaviors directed toward others. Record review of care plan dated [DATE] indicated Resident #3 required psychotropic medications for diagnosis of mood disorder and anxiety. Resident #3 had impaired cognitive function and dementia and required the secured unit due to wandering and poor safety awareness. Record review of facility incident report dated [DATE] revealed a resident-to-resident altercation that occurred between Resident #3 and Resident #20. Resident #3 was observed pushing and hitting Resident #20. Resident #3 was redirected by staff. Resident #3 then demonstrated to charge nurse that Resident #20 had tried to choke him by putting his hands around his throat. Record review of a witness statement, undated, signed by ADON J for incident on [DATE] read I, [name], entered into men's secure unit. Staff immediately stated that she had observed the two residents having an altercation. Resident [name Resident #3] began demonstrating that the other resident attempted to choke him. The other resident began calling him [Resident #3] a terrorist. Record review of a witness statement dated [DATE], signed by CNA H read I, [name], CNA was coming down the hall, saw resident going into another resident room. Staff observed Resident [name - Resident #20] guarding self from other resident. Resident [name - Resident #3] was striking the head, body blows. I separated them and redirected Resident [name - Resident #3] to room and I then pressed call light and ADON entered the unit and spoke with resident in room. Record review of a facility progress note dated [DATE] at 4:46 pm SW stated Resident #20 initiated incident and referral to Behavioral Hospital was pending. Record review of a facility progress note dated [DATE] at 3:36 am indicated that Resident #3 was bitten on the thumb by another resident when the other resident tried to enter his room and Resident #3 held up his hand to stop the other resident. The bite caused a skin tear, and the area was cleansed with wound cleanser, patted dry and bandage was applied. Record review of a facility progress note dated [DATE] at 11:48 am indicated that Resident #3's thumb was swollen, warm to touch. New order was received for Levaquin 750mg by mouth daily for 7 days. Record review of a facility progress note dated [DATE] at 4:03 pm indicated that nurse practitioner changed the order from Levaquin to Bactrim DS one tab by mouth twice daily for 7 days. Responsible party was notified. Record review of a facility progress note dated [DATE] at 9:00 pm indicated that initial dose of Bactrim DS was given at this time. Record review of a facility progress note dated [DATE] at 2:48 pm indicated that Resident #3 had completed antibiotic treatment for infection in skin/soft tissue. 2. Record review of facility face sheet dated [DATE] indicated Resident #20 was a [AGE] year-old male admitted to the facility [DATE] with the diagnosis of Alzheimer's disease. Record review of quarterly MDS dated [DATE] indicated Resident #20 had a BIMS of 9 indicating Resident #20 had moderate cognitive impairment. Section E for behaviors indicated Resident #20 wandered 1 to 3 days of previous 7 days and that he exhibited physical behaviors directed toward others 4 to 6 days but less than daily. Record review of comprehensive care plan dated [DATE] indicated that Resident #20 had physically abusive behavioral symptoms evidenced by him becoming agitated and hitting others. Also indicated that resident was not easily re-directed related to dementia/bipolar disorder. Care plan interventions included increased supervision for safety of self and others if needed. Record review of a facility incident report dated [DATE] read .The resident across the hall from [name - Resident #25] continuously goes into his room and [name - Resident #25] him [name - Resident #20] on the side of his head. [Name - Resident #25] also was screaming and cussing at the resident. Two CNAs and a nurse had to intervene . Record review of a facility progress note dated [DATE] at 10:19 pm stated .Resident across the hall wandered into another [name - Resident #25]'s room, and [name - Resident #25] got very upset and was screaming and cussing and hit the other resident (Resident #20) upside the head. When I got to the room the other resident (Resident #20) was sitting on the floor and was attempting to defend himself but did not make contact. No injuries . signed by LVN G. 3.Record review of facility face sheet dated [DATE] indicated Resident #21 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of dementia. Record review of a comprehensive MDS dated [DATE] indicated Resident #21 had a BIMS of 3 indicating Resident #21 had severe cognitive impairment. Section E for behaviors indicated no behaviors directed towards others during previous 7 days. Record review of comprehensive care plan dated [DATE] indicated Resident #21 had a potential to demonstrate physical behaviors such as increased agitation and hitting/pushing others. Record review of a facility incident report dated [DATE] for Resident #21 indicated that Resident #21 attempted to block his roommate (Resident #20) from getting into their room. Resident #20 continued to try to enter room and Resident #21 attempted to forcefully move Resident #20 out from path of door. This caused both resident to exchange punches and Resident #21 fell on top of Resident #20. Record review of a facility progress note dated [DATE] at 9:30 pm indicated that Resident #20 was involved in an altercation with his roommate where he pushed his roommate (Resident #21) away from the door and Resident #21 then struck Resident #20. Both sat in the floor and Resident #20 was noted to have a 6cm (centimeter) discolored area to right elbow and a small, opened area to right wrist. 4. Record review of facility face sheet dated [DATE] indicated Resident #23 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS dated [DATE] indicated Resident #23 had a BIMS of 3 indicating severe cognitive deficit. Section E for behaviors indicated no physical behavioral symptoms directed towards others during the previous 7 days. Record review of comprehensive care plan dated [DATE] indicated Resident #23 required secured unit and was an elopement risk for wandering. Record review of a facility incident report dated [DATE] for Resident #23 indicated that resident became angry at another resident and hit him in his left side. Record review of a facility progress note dated [DATE] at 1:48 pm for Resident #20 indicated that Resident #20 was on the secured unit when he was hit in his left side by another resident (Resident #23). Record review of a witness statement dated [DATE] and signed by CNA F read .I, [name], CNA, was working C hall today and I was making Mr. [name - Resident #23]'s bed. And as I was making Mr. [name - Resident #20] came to talk to me. He didn't come in the room. He was just standing outside the door. Mr. [name - Resident #23] came up to Mr. [name - Resident #20] and cold cock him in the side and knock him to his knees. And then started to grab his arm and tried to drag him. I to Mr. [name - Resident #23] to stop and went and got the nurse from the nursing station. Ms. [name] the nurse came and got Mr. [name - Resident #20] and brung (brought) him to the nursing station. Everything I stated is true to my knowledge . 5. Record review of facility face sheet dated [DATE] indicated Resident #25 was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS dated [DATE] indicated Resident #25 had a BIMS score of 3, indicating severe cognitive impairment. Section E for behaviors indicated no physical or verbal behaviors directed at others in the previous 7 days. Record review of comprehensive care plan dated [DATE] and edited on [DATE] indicated Resident #25 had a diagnosis of schizophrenia and it could possibly alter his mood, resulting in violent behaviors towards himself, peers, or others. Care plan also indicated that Resident #25 had a history of hitting another resident for repeatedly coming in and out of his room and he was easily agitated. Record review of a facility incident report dated [DATE] for Resident #25 indicated that the resident across the hall from Resident #25 continuously went into his room and Resident #25 hit him (Resident #20) on the side of his head. Resident #25 also was screaming and cussing at the resident. Two CNAs and a nurse had to intervene. During an observation on [DATE] at 12:00 pm of male secured unit, multiple residents were gathered in common area of unit. No altercations or behaviors seen at this time. During an observation on [DATE] at 11:00 am Resident #20 was sitting in a wheelchair at nurses' station, 1:1 sitter observed standing next to him. No aggressive behaviors observed at this time. Resident remains on 1:1 supervision due to agitation, aggressive behaviors and exit-seeking. During an observation on [DATE] at 10:20 am Resident #25 was observed lying in bed watching TV. He said that he was treated well and said that no one had ever been mean to him. During an observation on [DATE] at 10:25 am Resident #21 was observed ambulating in men's secure unit. He said that he was treated well. Denied anyone having ever been mean to him and did not remember any incidents. During an observation on [DATE] at 10:35 am Resident #23 was observed lying in bed, pleasantly confused. He said that he was treated well. He said that no one had ever been mean to him. He said that he had been here for years, and he cannot remember how long. During an observation on [DATE] at 10:42 am, Resident #24 was observed lying in bed. He denied that he was Resident #24. Staff (CNA E) confirmed that he was indeed Resident #24. He was unable to answer questions appropriately. Resident #3 was not observed during investigation due to being discharged from the facility on [DATE] and expired in the hospital due to an unrelated condition. During an interview with DON on [DATE] at 02:00 pm she stated that she had been employed as the DON since [DATE], and could not comment on any altercations that had occurred before that date. She said that Resident #20 now had an around the clock 1 on 1 sitter with him to prevent his wandering and any resident-to-resident altercations. 1 on 1 monitoring began on [DATE] during the day shift and on [DATE] was increased to round the clock. During an interview with Administrator on [DATE] at 1:15 pm she said that their plan now if the sitter needs to take a break was for the sitter to call the nurses station using a phone or the call light and another staff member must come to sit with resident until sitter can return. She said that Resident #20 had been put on 1:1 on day shift on [DATE] and it was increased to 24 hours a day on [DATE]. Attempted a telephone interview with CNA D on [DATE] at 3:07 pm, who was the 1:1 sitter who was on duty [DATE], the night of the altercation between Resident #20 and Resident #24. Received a message saying that the mailbox was full and was unable to leave a voicemail. A text message was sent asking for a return phone call to surveyor's state phone number. No return call was received before exiting the facility on [DATE]. During a telephone interview on [DATE] at 3:10 pm, CNA A said that on [DATE] she had just finished a round in the male secure unit, and when she came out into the hall, she heard a clapping noise and when she went into Resident #24's room, she saw Resident #20 standing over him, hitting him in the face and upper body area. She said that she was not told that Resident #20 required 1:1 monitoring until after the incident occurred. Record review of a facility policy titled Wandering and Elopements dated [DATE] read .The facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care . Record review of a facility policy titled Abuse Prevention Program revised on [DATE] read .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . Record review of a facility policy titled Resident Rights dated 2001 and revised February 2021 read .Federal and state laws guarantee certain basic right to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect. misappropriation of property, and exploitation . The facility Administrator was notified on [DATE] at 5:52 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on [DATE] at 10:54 AM and included: (Immediate) Action: Resident #20 has been put on continuous 1:1 on [DATE] and has remained on 1:1, without fail, since the [DATE] incident. Resident #3 no longer resides at [name] Healthcare Center. Residents #21, #24, and #25 have received a safe survey or skin assessment (if unable to verbalize concerns). The sitter that brought Resident #20 to the secured unit on the night of [DATE] was a temporary staff member (agency) and have been placed on the do not return list and has not worked since [DATE]. The facility is actively seeking alternate placement for Resident #20. Resident #20 will remain on 1:1 until deemed appropriate/safe by the IDT (at minimum Administrator, Director of Nursing, and/or Social Services Director), and/or Medical Director, and/or psych services, and/or evaluation, treatment, and discharged from a psychiatric facility. The discontinuation of the 1:1 will be documented in the resident's medical record. (See below action item) Person(s) Responsible: Administrator and Director of Nursing Date: [DATE]; [DATE] by 5:00PM (Identification) Action: Cognitive residents have received a safe survey to include: 1. Do you enjoy living at [name] Healthcare? 2. Do you feel safe at [name] Healthcare? 3. Are you afraid of any residents or staff? 4. Have you ever been hit, slapped, kicked, pinched, etc. by anyone at [name] Healthcare? If so, who and how long ago? Resident Education: Your abuse coordinator is your administrator; you should report any abuse or neglect immediately to your Abuse Coordinator. Her phone number is posted if she is not present. You can also report any abuse or wrong treatment to any staff, and they will let the Abuse Coordinator immediately know. Any residents unable to answer due to level of cognition received head-to-toe skin assessments (no concerns identified) Person(s) Responsible: Social Services, Director of Nursing, and/or Designee Date: Started/Finished [DATE] by 5PM-[DATE] by 3:15PM (Prevention) Action: All staff educated over the following: Following a Resident-to-Resident Altercation the aggressor will immediately be placed on 1:1. When you are assigned to 1:1 you will remain with the resident 1:1 until you are relieved, and someone takes over for you. You cannot leave a resident requiring 1:1 alone, no exceptions. If you require a break, you must find someone to 1:1 the resident until you return. 1:1 can be defined as within arm's length from the resident when residents are in common areas and within eyesight when residents are in their rooms. 1:1 is in place to ensure overall safety for the resident and other residents residing in [name] Healthcare Center. At no time is it appropriate to place a resident on the secured unit that has not been deemed appropriate by the IDT. Resident can only come off 1:1 when deemed appropriate/safe by the IDT (at minimum Administrator, Director of Nursing, and/or Social Services Director), and/or Medical Director, and/or psych services, and/or evaluation, treatment, and discharged from a psychiatric facility. Key Takeaway: Employees will understand 1:1, what it entails, and the expectations of 1:1 observation/intervention. Abuse & Neglect Key Takeaway: Employees will understand resident to resident altercations can be considered abuse and must be reported to the abuse coordinator immediately to ensure timely response to the allegation. Resident to Resident Altercations Key Takeaway: Employees will understand the steps to follow as a result of a resident-to-resident altercation (immediately separate, ensure resident safety, notify the abuse coordinator, Charge Nurse- notify the MD or MD extender-follow orders given, put interventions in place/ensure they are care planned). All staff shall be educated prior to working their next scheduled shift. All temporary and new staff will be educated prior to working their first/next shift. Person(s) Responsible: Director of Nursing, Administrator, and/or Designee Date: Started [DATE]-Completed [DATE] @ 5PM (Monitoring) Action: Clinical Meeting to include Event Report Review x5 days, Monday-Friday, Monday to encompass Friday-Sunday events. Date: Event Reports Review: Any Resident-to-Resident Altercations? Any other reportable events? **Has this been reported to HHSC & an investigation initiated?** 1.MD Notified? 2. RP Notified? 3. Documentation/Follow-Up? 1. What interventions have been initiated? 2. Care Plan updated? 3. Assessments Completed? This action will ensure that events are investigated, reported (if applicable), prevented (to the best of our abilities), and corrected. Person(s) Responsible: Director of Nursing and/or Designee Date/Time: Initiated [DATE] by 10AM and will continue to be documented x4 weeks Action: The facility has established a 1:1 policy following each resident to resident altercation in which can only be discontinued by 1 of the following options: Resident can only come off 1:1 when deemed appropriate/safe by the IDT (at minimum Administrator, Director of Nursing, and/or Social Services Director), and/or Medical Director, and/or psych services, and/or evaluation, treatment, and discharged from a psychiatric facility. The discontinuation of the 1:1 will be documented in the resident's medical record. This action item has been discussed with the Medical Director and he is agreeable with the policy change. Person(s) Responsible: [NAME] President of Clinical Services and/or Administrator Date/Time: [DATE] @ 10PM Action: Ad Hoc QAPI performed with Medical Director to notify him/her of the IJ Template and to share the Plan of Removal. MD has no additional steps to perform at this time. Person(s) Responsible: Administrator, Director of Nursing, and Medical Director Date: [DATE] by 6:45PM On [DATE], the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: 1. Residents #21, #24, and #25 have received a safe survey or skin assessment (if unable to verbalize concerns). - 2 safe and 1 skin assessment reviewed on [DATE]. 2. The facility was actively seeking alternate placement for Resident #20. - SW notes reviewed on [DATE]. 3. Resident #20 will remain on 1:1 until deemed appropriate/safe by the IDT (at minimum Administrator, Director of Nursing, and/or Social Services Director), and/or Medical Director, and/or psych services, and/or evaluation, treatment, and discharged from a psychiatric facility. - Attestation reviewed on [DATE]. 4. Cognitive residents have received a safe survey. - X38 safe surveys or skin assessments reviewed on [DATE] 5. Staff In-services: a. Following a Resident-to-Resident Altercation the aggressor will immediately be placed on 1:1. - x43 signatures reviewed on [DATE]. b. When you are assigned to 1:1 you will remain with the resident 1:1 until you are relieved, and someone takes over for you. - X44 signatures reviewed on [DATE]. c. You cannot leave a resident requiring 1:1 alone, no exceptions. - X44 signatures on [DATE]. d. If you require a break, you must find someone to 1:1 the resident until you return. - X44 signatures reviewed on [DATE]. e. 1:1 can be defined as within arm's length from the resident when residents are in common areas and within eyesight when residents are in their rooms. - X44 signatures reviewed on [DATE]. f. 1:1 is in place to ensure overall safety for the resident and other residents residing in [name] Healthcare Center. - X44 signatures reviewed on [DATE]. g. At no time is it appropriate to place a resident on the secured unit that has not been deemed appropriate by the IDT. - X44 signatures reviewed on [DATE]. h. Resident can only come off 1:1 when deemed appropriate/safe by the IDT (at minimum Administrator, Director of Nursing, and/or Social Services Director), and/or Medical Director, and/or psych services, and/or evaluation, treatment, and discharged from a psychiatric facility. - x43 signatures reviewed on [DATE]. 6. Clinical Meeting to include Event Report Review x5 days, Monday-Friday, Monday to encompass Friday-Sunday events. - Monitoring tool reviewed on [DATE]. 7. The facility has established a 1:1 policy following each resident to resident altercation in which can only be discontinued by 1 of the following options: Resident can only come off 1:1 when deemed appropriate/safe by the IDT (at minimum Administrator, Director of Nursing, and/or Social Services Director), and/or Medical Director, and/or psych services, and/or evaluation, treatment, and discharged from a psychiatric facility. Resident to resident altercation policy revised [DATE] reviewed on [DATE]. 8. Ad Hoc QAPI performed with Medical Director to notify him/her of the IJ Template and to share the Plan of Removal. [DATE] at 6:33pm including medical director; reviewed on [DATE]. During interviews on [DATE] between the times of 1:00 pm and 2:30 pm, the following staff were able to appropriately voice understanding resident to resident altercations, when to report, and 1:1 monitoring. Nurses- 4-LVN's and 2-RN's (LVN B, LVN K, RN L, LVN M, ADON, and DON); CNA's- 4-CNA's (CNA E, CNA N, CNA O, and CNA P); MA's - 1 MA (MA Q); and Other- 3 (DA R, Activity Director, and BOM/HR). The Administrator was informed that the Immediate Jeopardy was removed on [DATE] at 2:45 pm.; however, the facility remained out of compliance at a severity level of actual harm that is not an immediate jeopardy and scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to implement written policies and procedures that prohibit abuse/neglect for 5 of 6 residents (Resident #3, Resident #20, Resident #21, Resident #23, and Resident #24) reviewed for incidents. The facility failed to implement their abuse policy and program to prevent abuse when: 1. On 6/5/23 Resident #20 tried to choke Resident #3. 2 On 6/14/23 Resident #20 attempted to strike Resident #21 and both fell to floor. 3.On 6/14/23 Resident #20 bit Resident #3 on the thumb causing a skin tear, leading to an infection requiring treatment. This incident was not investigated or reported. 4.On 6/20/23 Resident #20 was involved in an altercation with Resident #23 and Resident #23 hit Resident #20 causing him to fall. 5. On 8/21/23 Resident #20 wandered into Resident #25's room and Resident #25 hit Resident #20 on the head. 6. On 9/18/23 Resident #20 wandered into Resident # 24's room on the male secured unit of the facility and hit him in the face. An IJ (immediate jeopardy) was identified on 10/24/2023 at 5:52 pm. While the IJ was removed on 10/25/2023 at 2:45 pm, 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's need to monitor and evaluate the effectiveness of their plan of removal and corrective actions. These deficient practices affected all residents and contributed to further abuse. Findings included: 1. Record review of facility face sheet dated 10/20/23 indicated Resident #3 was a [AGE] year-old male originally admitted to the facility on [DATE] and subsequently readmitted on [DATE] with a primary diagnosis of malignant neoplasm of oropharynx (type of cancer that affects the tonsils, back of the throat, tongue, or roof of the mouth), hypertension (high blood pressure), and tracheostomy status (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs). Record review of a quarterly MDS dated [DATE] indicated Resident #3 was unable to complete interview for BIMS status due to rarely/never being understood. Section C for cognition indicated Resident #3 had inattention and disorganized thinking. Section E for behaviors indicated Resident #3 had no verbal or physical behaviors directed toward others. Record review of care plan dated 05/10/2023 indicated Resident #3 required psychotropic medications for diagnosis of mood disorder and anxiety. Resident #3 had impaired cognitive function and dementia and required the secured unit due to wandering and poor safety awareness. Record review of facility incident report dated 06/05/2023 revealed a resident-to-resident altercation that occurred between Resident #3 and Resident #20. Resident #3 was observed pushing and hitting Resident #20. Resident #3 was redirected by staff. Resident #3 then demonstrated to charge nurse that Resident #20 had tried to choke him by putting his hands around his throat. Record review of a witness statement, undated, signed by ADON J for incident on 6/5/23 read I, [name], entered into men's secure unit. Staff immediately stated that she had observed the two residents having an altercation. Resident [name Resident #3] began demonstrating that the other resident attempted to choke him. The other resident began calling him [Resident #3] a terrorist. Record review of a witness statement dated 6/5/23, signed by CNA H read I, [name], CNA was coming down the hall, saw resident going into another resident room. Staff observed Resident [name - Resident #20] guarding self from other resident. Resident [name - Resident #3] was striking the head, body blows. I separated them and redirected Resident [name - Resident #3] to room and I then pressed call light and ADON entered the unit and spoke with resident in room. Record review of a facility progress note dated 6/5/23 at 4:46 pm SW stated Resident #20 initiated incident and referral to Behavioral Hospital was pending. Record review of a facility progress note dated 6/15/23 at 3:36 am indicated that Resident #3 was bitten on the thumb by another resident when the other resident tried to enter his room and Resident #3 held up his hand to stop the other resident. The bite caused a skin tear, and the area was cleansed with wound cleanser, patted dry and bandage was applied. Record review of a facility progress note dated 6/18/23 at 11:48 am indicated that Resident #3's thumb was swollen, warm to touch. New order was received for Levaquin 750mg by mouth daily for 7 days. Record review of a facility progress note dated 6/18/23 at 4:03 pm indicated that nurse practitioner changed the order from Levaquin to Bactrim DS one tab by mouth twice daily for 7 days. Responsible party was notified. Record review of a facility progress note dated 6/18/23 at 9:00 pm indicated that initial dose of Bactrim DS was given at this time. Record review of a facility progress note dated 6/25/23 at 2:48 pm indicated that Resident #3 had completed antibiotic treatment for infection in skin/soft tissue. 2. Record review of facility face sheet dated 7/11/2023 indicated Resident #20 was a [AGE] year-old male admitted to the facility 05/24/23 with the diagnosis of Alzheimer's disease. Record review of quarterly MDS dated [DATE] indicated Resident #20 had a BIMS of 9 indicating Resident #20 had moderate cognitive impairment. Section E for behaviors indicated Resident #20 wandered 1 to 3 days of previous 7 days and that he exhibited physical behaviors directed toward others 4 to 6 days but less than daily. Record review of comprehensive care plan dated 10/17/2023 indicated that Resident #20 had physically abusive behavioral symptoms evidenced by him becoming agitated and hitting others. Also indicated that resident was not easily re-directed related to dementia/bipolar disorder. Care plan interventions included increased supervision for safety of self and others if needed. Record review of a facility incident report dated 8/21/23 read .The resident across the hall from [name - Resident #25] continuously goes into his room and [name - Resident #25] him [name - Resident #20] on the side of his head. [Name - Resident #25] also was screaming and cussing at the resident. Two CNAs and a nurse had to intervene . Record review of a facility progress note dated 8/21/23 at 10:19 pm stated .Resident across the hall wandered into another [name - Resident #25]'s room, and [name - Resident #25] got very upset and was screaming and cussing and hit the other resident (Resident #20) upside the head. When I got to the room the other resident (Resident #20) was sitting on the floor and was attempting to defend himself but did not make contact. No injuries . signed by LVN G. 3.Record review of facility face sheet dated 10/25/2023 indicated Resident #21 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of dementia. Record review of a comprehensive MDS dated [DATE] indicated Resident #21 had a BIMS of 3 indicating Resident #21 had severe cognitive impairment. Section E for behaviors indicated no behaviors directed towards others during previous 7 days. Record review of comprehensive care plan dated 10/24/2023 indicated Resident #21 had a potential to demonstrate physical behaviors such as increased agitation and hitting/pushing others. Record review of a facility incident report dated 6/14/23 for Resident #21 indicated that Resident #21 attempted to block his roommate (Resident #20) from getting into their room. Resident #20 continued to try to enter room and Resident #21 attempted to forcefully move Resident #20 out from path of door. This caused both resident to exchange punches and Resident #21 fell on top of Resident #20. Record review of a facility progress note dated 6/14/23 at 9:30 pm indicated that Resident #20 was involved in an altercation with his roommate where he pushed his roommate (Resident #21) away from the door and Resident #21 then struck Resident #20. Both sat in the floor and Resident #20 was noted to have a 6cm (centimeter) discolored area to right elbow and a small, opened area to right wrist. 4. Record review of facility face sheet dated 10/25/2023 indicated Resident #23 was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS dated [DATE] indicated Resident #23 had a BIMS of 3 indicating severe cognitive deficit. Section E for behaviors indicated no physical behavioral symptoms directed towards others during the previous 7 days. Record review of comprehensive care plan dated 10/18/2023 indicated Resident #23 required secured unit and was an elopement risk for wandering. Record review of a facility incident report dated 6/20/23 for Resident #23 indicated that resident became angry at another resident and hit him in the left side. Record review of a facility progress note dated 6/20/23 at 1:48 pm for Resident #20 indicated that Resident #20 was on the secured unit when he was hit in his left side by another resident (Resident #23). Record review of a witness statement dated 6/20/23 and signed by CNA F read .I, [name], CNA, was working C hall today and I was making Mr. [name - Resident #23]'s bed. And as I was making Mr. [name - Resident #20] came to talk to me. He didn't come in the room. He was just standing outside the door. Mr. [name - Resident #23] came up to Mr. [name - Resident #20] and cold cock him in the side and knock him to his knees. And then started to grab his arm and tried to drag him. I to Mr. [name - Resident #23] to stop and went and got the nurse from the nursing station. Ms. [name] the nurse came and got Mr. [name - Resident #20] and brung (brought) him to the nursing station. Everything I stated is true to my knowledge . 5. Record review of facility face sheet dated 10/25/2023 indicated Resident #25 was an [AGE] year-old male admitted to the facility on [DATE] with diagnosis of dementia. Record review of a quarterly MDS dated [DATE] indicated Resident #25 had a BIMS score of 3, indicating severe cognitive impairment. Section E for behaviors indicated no physical or verbal behaviors directed at others in the previous 7 days. Record review of comprehensive care plan dated 8/23/23 and edited on 10/24/2023 indicated Resident #25 had a diagnosis of schizophrenia and it could possibly alter his mood, resulting in violent behaviors towards himself, peers, or others. Care plan also indicated that Resident #25 had a history of hitting another resident for repeatedly coming in and out of his room and he was easily agitated. Record review of a facility incident report dated 8/21/23 for Resident #25 indicated that the resident across the hall from Resident #25 continuously went into his room and Resident #25 hit him (Resident #20) on the side of his head. Resident #25 also was screaming and cussing at the resident. Two CNAs and a nurse had to intervene. Record review of Resident #20's electronic medical record revealed that he was not transferred to a behavioral hospital until 7/5/23. Resident #20 was not put on 1 on 1 monitoring until 9/8/23 on a 24-hour continuous basis. During an observation on 10/17/23 at 12:00 pm of male secured unit, multiple residents were gathered in common area of unit. No altercations or behaviors seen at this time. During an observation on 10/17/23 at 11:00 am Resident #20 was sitting in a wheelchair at nurses' station, 1:1 sitter observed standing next to him. No aggressive behaviors observed at this time. Resident remains on 1:1 supervision due to agitation, aggressive behaviors and exit-seeking. During an observation on 10/26/23 at 10:20 am Resident #25 was observed lying in bed watching TV. He said that he was treated well and said that no one had ever been mean to him. During an observation on 10/26/23 at 10:25 am Resident #21 was observed ambulating in men's secure unit. He said that he was treated well. Denied anyone having ever been mean to him and did not remember any incidents. During an observation on 10/26/23 at 10:35 am Resident #23 was observed lying in bed, pleasantly confused. He said that he was treated well. He said that no one had ever been mean to him. He said that he had been here for years, and he cannot remember how long. During an observation on 10/26/23 at 10:42 am, Resident #24 was observed lying in bed. He denied that he was Resident #24. Staff (CNA E) confirmed that he was indeed Resident #24. He was unable to answer questions appropriately. Resident #3 was not observed during investigation due to being discharged from the facility on 9/2/23 and expiring in the hospital. During an interview with DON on 10/18/23 at 02:00 pm she stated that she had been employed as the DON since July 11, 2023, and could not comment on any altercations that had occurred before that date. She said that Resident #20 now had an around the clock 1 on 1 sitter with him to prevent his wandering and any resident-to-resident altercations. Resident had 1 on 1 monitoring initiated on 9/7/23 during the day shift and 1 on 1 monitoring was increased to 24 hours on 9/8/23. During an interview with Administrator on 10/24/23 at 1:15 pm she said that their plan now if the sitter needs to take a break was for the sitter to call the nurses station using a phone or the call light and another staff member must come to sit with resident until sitter can return. She said that Resident #20 had been put on 1:1 on day shift on 9/7/23 and on 9/8/23 it was increased to 24 hours a day. She said regarding the biting incident with Resident #20 and Resident #3, that it had not been reported to her until the next day in stand-up meeting at approximately 9am. The incident had happened at 1:50 am on 6/15/23. She said that she thought she had reported the incident but apparently had only reported another incident that occurred that same day. She said that she had now reported the incident and would do an investigation. She said that risks to residents could include that they may need to go out or get first aid if incidents are not reported. She verbalized no other possible risks regarding failure to report abuse timely or do an investigation. Attempted a telephone interview with CNA D on 10/24/23 at 3:07 pm, who was the 1:1 sitter who was on duty 9/18/21, the night of the altercation between Resident #20 and Resident #24. Received a message saying that the mailbox was full and was unable to leave a voicemail. A text message was sent asking for a return phone call to surveyor's state phone number. No return call was received before exiting the facility on 10/26/2023. During a telephone interview on 10/24/2023 at 3:10 pm, CNA A said that on 9/18/2023 she had just finished a round in the male secure unit, and when she came out into the hall, she heard a clapping noise and when she went into Resident #24's room, she saw Resident #20 standing over him, hitting him in the face and upper body area. She said that she was not told that Resident #20 required 1:1 monitoring until after the incident occurred. Record review of a facility policy titled Wandering and Elopements dated 9/1/23 read .The facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care . Record review of a facility policy titled Abuse Prevention Program revised on 1/9/23 read .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . and .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and /or injuries of unknown origin source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by Center management. Findings of abuse will also be reported . and .the administration will: 6. Investigate and report any allegations of abuse within timeframes as required by federal requirements . Record review of a facility policy titled Resident Rights dated 2001 and revised February 2021 read .Federal and state laws guarantee certain basic right to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect. misappropriation of property, and exploitation . The facility Administrator was notified on 10/24/23 at 5:52 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 10/25/23 at 10:54 AM and included: 1. (Immediate) Action: The facility initiated a self-report and investigation for a resident-to-resident incident of abuse that occurred on 6/15/2023 for Resident #20 biting Resident #3's thumb. Intake has been received and worked. 2. Review all Resident-to-Resident incidents that have occurred in the previous 90-days to ensure the MD and RP were notified, that interventions were placed in the care plan, that the documentation shows the interventions that have been put into place are effective, and that the incidents were reported to HHSC/investigated. Any concerns noted will be updated, added, and/or notified immediately. 3. Educate Administrator and Director of Nursing: Self Reports will be submitted per the Provider Letter 19-17 & SOM Appendix PP 5 Day Investigations will be thorough & all supporting documentation will be documented/submitted Review all incidents daily x5 days (Monday-Friday) Everything is completed and documented that facility said would be completed. 4. Educated IDT regarding: (Department Heads) Appropriate interventions following events Care Plan Updates Notification of MD, RP, and psych services (if applicable) Documentation Review- Event Report Review, Progress Note Review, CP, and Additional Documentation (i.e.- increased supervision). 5. Educated all nurses regarding: Aggressive behaviors initiated or Received Contact the DON (Director of Nursing) if you are unsure an event needs to be completed If you complete an event or document a problem, you must complete the notification of the RP and the physician. Notify the DON to ensure the event is not reportable. If you document a problem or behavior, you must document an intervention. If you are unsure of what intervention, you must contact the DON (Director of Nursing). Ad Hoc QAPI with the Medical Director performed to inform him/her of the IJ template and our plan of action to remove the immediacy and correct the deficient practice. On 10/25/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: 1. (Immediate) Action: The facility initiated a self report and investigation for a resident-to-resident incident of abuse that occurred on 6/15/2023 for Resident #20 biting Resident #3's thumb. Intake has been received and worked. 2. Review all Resident-to-Resident incidents that have occurred in the previous 90-days to ensure the MD and RP were notified, that interventions were placed in the care plan, that the documentation shows the interventions that have been put into place are effective, and that the incidents were reported to HHSC/investigated. Any concerns noted will be updated, added, and/or notified immediately. Incidents reviewed from 7/23/-10/24/23. 3. Educate Administrator and Director of Nursing: Self Reports will be submitted per the Provider Letter 19-17 & SOM Appendix PP 5 Day Investigations will be thorough & all supporting documentation will be documented/submitted Review all incidents daily x5 days (Monday-Friday) Everything is completed and documented the facility said would be completed. Reviewed in-service signed by admin and DON. 4. Educated IDT regarding: (Department Heads) Appropriate interventions following events Care Plan Updates Notification of MD, RP, and psych services (if applicable) Documentation Review- Event Report Review, Progress Note Review, CP, and Additional Documentation (ie- increased supervision). X11 signatures 5. Educated all nurses regarding: Aggressive behaviors initiated or Received Contact the DON (Director of Nursing) if you are unsure an event needs to be completed If you complete an event or document a problem, you must complete the notification of the RP and the physician. Notify the DON to ensure the event is not a reportable. If you document a problem or behavior, you must document an intervention. If you are unsure of what intervention, you must contact the DON (Director of Nursing). X13 signatures 6. Ad Hoc QAPI with the Medical Director performed to inform him/her of the IJ template and our plan of action to remove the immediacy and correct the deficient practice. 10/24/23 at 6:33pm including medical director. During interviews on 10/25/23 during the times of 1:00 pm to 2:30 pm, the following staff were able to appropriately voice understanding resident to resident altercations, when to report, and 1:1 monitoring. Nurses- 4-LVN's and 2-RN's (LVN B, LVN K, RN L, LVN M, ADON, and DON); CNA's- 4-CNA's (CNA E, CNA N, CNA O, and CNA P); MA's - 1 MA (MA Q); and Other- 3 (DA R, Activity Director, and BOM/HR). The Administrator was informed that the Immediate Jeopardy was removed on 10/25/23 at 2:45 pm; however, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and scope of pattern 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 Quality Assurance and Performance Improvement committee (QAPI) failed to develop and implement appropriate plans of action to correct and identify quality deficiencies for 1 of 1 facility. The facility QAPI failed to identify and implement an action plan to address multiple, resident to resident altercations, that occurred on 6/5/23, 6/14/23, 6/20/23, 8/21/23 and 9/18/23. The facility QAPI failed to identify and implement an action plan to address an elopement that occurred on 6/6/23. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 10/25/23 at 3:49 PM. While the IJ was removed on 10/26/23 at 11:45 AM, the facility remained out of compliance at a severity level of the potential for more than minimal harm with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for physical, mental, and psychosocial harm and at risk for not receiving appropriate care and services to prevent harm. Findings include: 1.Record review of Resident #20's face sheet undated revealed Resident #20 was a [AGE] year-old male that originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #20's diagnoses included Alzheimer's disease (progressive disease that destroys memory), bipolar disorder (mood swings and depression), and metabolic encephalopathy (a problem in the brain). Record review of Resident #20's care plan dated 10/17/23 indicated Resident #20 had behavioral symptoms and interventions included were assess whether the behavior endangers the resident and or others, when resident becomes physically abusive keep distance between resident and others. Resident #20 is at risk for elopement with interventions were to equip resident with a device that alarms when resident wanders. 2.Record review of Resident #3's face sheet undated revealed Resident #3 was a [AGE] year-old male that originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #3's diagnoses included malignant neoplasm of the oropharynx (throat cancer), major depressive disorder, tracheostomy (tube to keep airway open). Record review of Resident #3's care plan dated 1/6/23 indicated Resident #3 had behavioral symptoms and interventions included assess whether the behavior endangers the resident and or others, remove resident from other residents' rooms and unsafe situations. 3.Record review of Resident #25's face sheet undated revealed Resident #25 was an [AGE] year-old male that admitted to the facility on [DATE]. Resident #25's diagnoses included dementia with behaviors (problem with thinking), cerebral infarction (stroke), and bipolar disorder (mood swings and depression). Record review of Resident #25's care plan dated 8/23/23 revealed Resident #25 had a problem with mood and interventions included staff will monitor Resident #25's mood and interactions with peers and others to intervene when indicated and notify psych services for med reviews to assist in managing his mood and behaviors. 4. Record review of Resident #24's face sheet undated revealed Resident #24 was a [AGE] year-old male that originally admitted to the facility on [DATE] with the most recent readmission on [DATE]. Resident #24's diagnoses included Schizophrenia (affects a person's ability to think, feel, and behave clearly), dementia with behaviors (problem with thinking). Record review of Resident #24's care plan dated 5/21/23 revealed Resident #24 had behavioral symptoms and interventions included assess whether the behavior endangers the resident and or others. Intervene if necessary. 5. Record review of Resident #21's face sheet undated revealed Resident #21 was a [AGE] year-old male that admitted to the facility on [DATE]. Resident #21's diagnoses included dementia with behaviors (problem with thinking), impulse disorder, and anxiety. Record review of Resident #21's care plan dated 5/21/23 revealed Resident #24 had behavioral symptoms and interventions included staff will monitor me and report changes in exit seeking behaviors to the facility Administrator, Director of Nursing, Physician, and responsible party. Record review of event report dated 6/5/23 indicated Resident #20 attempted to choke Resident #3. Record review of event report dated 6/6/23 indicated Resident #20 eloped from the male secured unit. Record review of event report dated 6/14/23 indicated Resident #20 attempted to strike Resident #21 and both fell to the floor. Record review of event report dated 6/14/23 indicated Resident #20 bit Resident #3 on the thumb. Record review of event report dated 6/20/23 indicated Resident #21 hit Resident #20 causing him to fall. Record review of event report dated 8/21/23 indicated Resident #25 hit Resident #20. Record review of event report dated 9/18/23 indicated Resident #20 hit Resident #24. Review of the monthly QAPI meeting minutes provided by the facility indicated a QAPI meeting was held on 7/3/23 which covered the month of June 2023. Further review of the QAPI minutes revealed no issues or care area concerns were identified related to resident elopement. Two self-reports for resident-to-resident abuse were identified with no plan of action to address resident to resident altercations. Review of the monthly QAPI meeting minutes provided by the facility indicated a QAPI meeting was held on 9/1/23 which covered the month of August 2023. Further review of the QAPI minutes revealed no issues or care area concerns were identified related to resident elopement. No issues or care area concerns were identified related to resident-to-resident abuse, and no plan of action to address resident to resident altercations. Review of the monthly QAPI meeting minutes provided by the facility indicated a QAPI meeting was held on 10/3/23 which covered the month of September 2023. Further review of the QAPI minutes revealed no issues or care area concerns were identified related to resident elopement. No issues or care area concerns were identified related to resident-to-resident abuse, and no plan of action to address resident to resident altercations. Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program, revised February 2023, indicated, The facility shall develop, implement, and maintain an ongoing, facility-wide, data driven QAPI Program that is focused on indicators of the outcomes of care and quality of life for our residents .The objectives of the QAPI Program are to: Provide a means to measure current and potential indicators for outcomes of care and quality of life .Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators .establish systems through which to monitor and evaluate corrective actions. Implementation: The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process included A. Tracking and measuring performance. B. Establishing goals and thresholds for performance measurement. C. Identifying and prioritizing quality deficiencies. D. Systematically analyzing underlying causes of systemic quality deficiencies. E. Developing and implementing corrective action or performance improvement activities. F. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. During an interview on 10/24/23 at 10:54 AM, the DON said she had worked at the facility since July 2023, and said she is part of the QAPI process. She said the QAPI meeting is held monthly and as needed. The DON said they have discussed resident to resident altercations in QAPI meetings. She said Resident #20 had been a topic and discussed alternated placement for him. She said since she has worked at the facility Resident #20 had been the only resident to resident altercation that had been discussed. The DON said they had not discussed elopement since she has worked at the facility. She said she was not aware of any performance improvement plans but if there were any the Administrator would have them in her office. During an interview on 10/24/23 at 11:15 AM, the Administrator said during QAPI meetings each department head brought up topics they felt needed to be addressed. This was the facility's process for identifying areas of concern. She said if any new issues or concerns were identified they come up with a performance improvement plan. She said they discuss any resident-to-resident altercations if there are any reports. She said they discussed finding alternate placement for Resident #20, and Resident #3. The Administrator said they had not discussed any elopements in the QAPI meetings. She said they had not done any performance improvement plans on resident-to-resident altercations or elopement. The facility Administrator was notified on 10/25/23 at 3:49 PM, that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 10/26/23 at 10:29 AM and included: 1. Resident #20 has been put on continuous 1:1 on 9/18/2023 and has remained on 1:1, without fail, since the 9/18/2023 incident. Resident #3 no longer resides at [NAME] Healthcare Center. Residents #21, #24, and #25 have received a safe survey or skin assessment (if unable to verbalize concerns). The sitter that brought resident #20 was a temporary staff member (agency) and have been placed on the do not return list and has not worked since 9/18/2023. The facility is actively seeking alternate placement for Resident #20. Resident #20 will remain on 1:1 until deemed appropriate/safe by the IDT (at minimum Administrator, Director of Nursing, and/or Social Services Director), and/or Medical Director, and/or psych services, and/or evaluation, treatment, and discharged from a psychiatric facility. The discontinuation of the 1:1 will be documented in the resident's medical record. (See below action item) 2. Administrator and Director of Nurses provided a copy of the State Operations Manual, Appendix PP for 867 lining out the regulations, expectations, and elements of non-compliance. 3. The Interdisciplinary Committee IDT, including the Administrator, Director of Nursing, Assistant Director of Nursing, Social Services, Human Resources, Maintenance Director, Dietary Manager, Director of Rehab, and Activity Director, educated regarding the Quality Assurance Performance Improvement QAPI Policy. The IDT should understand that issues, concerns, problems, patterns, and non-compliance identified throughout their departments, and the entirety of the nursing home, should be brought to the QAPI meeting, at minimum monthly. At this time, the IDT as a whole will develop an action plan to correct the issue, concern, problem, patterns, and non-compliance. 4. At minimum, the Director of Nursing and/or Administrator, will identify issues such as resident to resident altercations and elopements through the daily meeting process/clinical meeting and will implement interventions/ensure interventions are implemented, to assist in the reduction or elimination of these incidents occurring/reoccurring. These interventions will be documented in the resident's medical record. Clinical Meeting to include Event Report Review x5 days, Monday-Friday, Monday to encompass Friday-Sunday events. Event Reports Review: Any Resident-to-Resident Altercations? Any other reportable events? **Has this been reported to HHSC & an investigation initiated? ** 1.MD Notified? 2. RP Notified? 3. Documentation/Follow-Up? 1.What interventions have been initiated? 2. Care Plan updated? 3. Assessments Completed? This action will ensure that events are investigated, reported (if applicable), prevented (to the best of our abilities), and corrected. Person(s) Responsible: Director of Nursing and/or Designee Date/Time: Initiated 10/23/2023 by 10AM and will continue to be documented x4 weeks. 5. Ad Hoc QAPI meeting performed with Medical Director regarding the template and plan of removal for the immediate jeopardy called for F-867: QAPI/QAA Improvement Activities. On 10/26/23 between 10:29 AM and 11:45 AM, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Record review of in-service dated 10/25/23 titled I have received a copy of the SOM appendix PP for 867 lining out the regulations/key elements for noncompliance signed by the Administrator and DON. Record review of in-service dated 10/25/23 titled QAPI: it is the IDT's responsibility to identify and provide interventions with incidents and deficient practices signed by the Administrator, DON, HR, Maintenance Director, Social Worker, ADON, DOR, Housekeeping Supervisor, Dietary Manager, and Activity Director. Record review of daily monitoring tool titled Event Report Review to be used in the daily clinical meeting 5 days a week. Record review of Ad Hoc QAPI meeting performed 10/25/23 with the following attendees: Administrator, Social Worker, DON, Medical Director, Housekeeping Supervisor, Dietary Manager, and ADON. During interviews on 10/26/23 between 10:29 AM and 11:45 AM the following members of the IDT were able to appropriately verbalize understanding of the QAPI process: Administrator, DON, ADON, Social Worker, Dietary Manager, HR, Maintenance Director, Housekeeping Supervisor, and DOR. On 10/26/23 at 11:45 AM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of the potential for more than minimal harm with a scope identified as pattern 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 the resident had the right to be free form neglect for 1 (Resident #1) of 5 residents reviewed for neglect. The facility failed to ensure Resident #1's care plan was followed, and interventions were in place. The facility failed to ensure Resident #1 received weekly skin assessments The facility failed to ensure the system they had in place with the podiatrist was in functional in providing Resident #1 with the care needed. The facility failed to ensure aides were assessing skin, and feet when providing care. The facility failed to document and assess Resident #1 when concerns were reported from therapy of Residents #1 being in pain and his feet were bleeding. The failures caused Resident #1 to have part of his foot/toes amputated. An Immediate Jeopardy (IJ) situation was identified 08/15/23 at 3:42 p.m. While the IJ was removed on 08/16/23 at 4:09 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Record review of Resident #1's undated face sheet indicted his current admission date was 5/25/23. He was a [AGE] year-old male with diagnoses of vascular dementia, with behavioral disturbances, diabetes mellitus, muscle wasting to the right and left lower leg, lack of coordination, and muscle weakness. Record review of Resident #1's admission MDS dated [DATE] indicated he was severely cognitively impaired. He had inattention and disorganized thinking behaviors present that came and went and changed in severity. The MDS indicated Resident # 1 required extensive assist of two people for bed mobility and transfers. He required extensive assist with dressing, toilet use, and personal hygiene of one person. He used a wheelchair for mobility. Resident #1 was totally dependent for putting on or taking off footwear. He was at risk for developing pressure ulcers but did not have any wounds listed. Record review of Resident #1's care plan with a start date of 10/20/21 and last updated 7/27/23 indicated a problem of at risk for diabetic complications, frequent infections, pressure/venous/status ulcers, vision impairment, hyper/hypoglycemia, kidney failure, cognitive/physical impairment. Skin desensitized to pain or pressure related to diabetes mellitus. Some of the approaches were to assist with repositioning routinely and as needed with pillows for comfort, support and to keep feet elevated of the bed as the resident will allow, and weekly skin assessments. Resident #1 was at risk for skin break down related to impaired mobility, diabetes mellitus, and incontinence. One of the approaches was weekly skin assessments. Resident #1 had self-care deficits due to impaired cognition, impaired memories, impaired daily decision making, occasional refusal of care and impaired mobility. Some of the approaches were bathing, personally hygiene, transfers required one to 2 people assist, if he refused, reapproach, notify the nurse. The resident required 1 to 2 people assist with bed mobility, use of pillows for comfort and support. And to keep the feet elevated off the bed. He required 1 to 2 people assist with dressing, offer clothing choices and encourage the resident to participate. Record review of Resident #1's computerized physician's orders indicated an order dated 5/27/23 for Tylenol Extra Strength 500 mg, 2 tablets, every 6 hours as needed for pain. An order dated 4/9/23 reflected to admit to the secure unit due to exit seeking secondary to dementia. An order dated 3/13/23 for a podiatry consult as needed. An order dated 10/2/21 indicated to assess for pain every shift. Record review of Resident #1's social services note dated 6/13/23 indicated his family member expressed several requests that she would like Resident #1 to be seen by a podiatrist due to his toes needing attention and he was a diabetic. Record review of Resident #1's nursing notes dated 6/14/23 indicated the podiatrist to see Resident #1 and they would be at the facility on 6/29/23. Written by LVN D. Record review of Resident #1's Braden scale for predicting pressure sore risk dated 6/15/23 indicated the resident had very limited responses to a sensory perception, his skin was moist constantly, he was chair fast with his ability to was walk severely limited or nonexistence. The resident's ability to change or control body position was very limited but made occasional slight changes. The resident's nutrition was he ate most of his meals every day. Friction and shear were a problem due to the resident required moderate to maximum assist with moving his. The Braden scale score was listed as a 12 which indicated high risk for pressure sores. There were no interventions checked as for preventive measures listed on the form. Record Review of Resident #1's Physical Therapy notes indicated the resident received therapy between 6/15/23 and 6/26/23. Therapy notes dates 6/19/23 indicated Resident #1 complained of not feeling well and said his foot hurt bad on this day. The LVN was notified. The resident was unwilling to participate secondary to pain. Therapy notes dated 6/22/23 indicated observation of blood to the right great toe through his sock. The nursing staff were made aware of observation and complaints of pain on this day. Therapy notes dated 6/26/23 indicated Resident #1 had difficulty with shifting onto his right lower extremity secondary to pain. All notes written by PTA. During an interview on 8/16/23 at 11:18 p.m. the PTA said she had voiced her concerns she had written in her therapy notes to the nursing staff about Resident #1. She said she was not sure exactly who she talked to, but they were made aware of Resident #1' complaints of pain and the blood on his sock for at least two occasions. Record review of Resident #1's Podiatry report dated 6/29/23 indicated. [The patient was unable to answer questions appropriately and was confined to a wheelchair. The chief complaint was diabetes, lesions at risk for poor circulation, and diseased toenails. The impression was cutaneous abscess (localized collection of pus in the skin and may occur on any skin surface. Symptoms and signs are pain and tender, firm or swelling.) to the right foot, cellulitis (bacterial skin infection) of right toe, onychogryphosis (nail disorder resulting from slow nail plate growth. Yellow brown thickening of the nail plate.), and peripheral vascular disease. The plan was due to the patient's pain tolerance. The medial right first nail border and all loose nail distally was freed from its soft tissue attachments and avulsed the offending border with nail nippers, care being taken to remove and excise all nonviable (dead) tissue. All corners were inspected for spicules (hard tissue) as best as possible. The abscess was drained from the nail bed noting malodorous (unpleasant smelling) red, brow, rust colored moderate amount of drainage approximately 1cc in total. All noted drainage and dicrotic tissue was removed with manual pressure to right toe and mechanical debridement (removal of damaged tissue from a wound) and nail nippers revealing clean, moist nail bed. The nail margins and nail bed were cleansed with Techni care and treated with triple antibiotic and dressed with a 2x2 and paper tape. Discussed with nurse the patient's right hallux(big toe) nail. Verbally recommended continued wound care consisting of daily cleaning and application of betadine and bandage until dry. Discussed possible by mouth antibiotic for the patient, nurse said she would confirm with attending NP for antibiotic. If deterioration of nail bed or eschar( dry, dark scab) on right hallux please bring patient to clinic. As soon as possible or if the patient develops systemic signs of infection including fever, chills, increased warmth to right toe/foot.] Record review of the facility 24-hour report dated 6/29/23 to 6/30/23 did not indicate any mention of Resident #1. During a telephone interview on 8/10/23 at 4:12 p.m. the Podiatrist said she remembered Resident #1. She said on 6/29/22 she had debrided his toe, bandaged his toe with triple antibiotic ointment, gauze and paper tape. The Podiatrist said when she was ready to leave there were several people at the nurse's station. She said she talked to a nurse and did not get a name or remember who she was. The Podiatrist said she asked for an order form to write her order for treatment of Resident #1's toe down but was told by the nurse she could give a verbal order. The Podiatrist said had given her verbal order to cleanse Resident #1's toe and apply betadine daily until healed. The unknown nurse said she would relay the information to the NP. She said Resident #1's wound did not appear to be tunneling and she felt if they had kept it cleaned and changed the bandage daily it would have healed in about two weeks. The Podiatrist said they did not need to wait until she came to the facility for Resident #1 to be seen, they could have brought him to her office. The Podiatrist said the only person she remembered at the nurse's station was the BOM. During an interview on 8/10/23 at 4:16 p.m. the BOM said she saw the Podiatrist at the nurse's station on 6/29/23 during her last visit. The BOM said she was talking to someone. However, she did not remember who she was talking to or hear what was said. Record review of Resident #1's nursing notes from 6/14/23 to 8/7/32 revealed no documented evidence of the Podiatrist recommendations, foot, pain, bleeding, bandage, or toe. Record review of Resident #1's weekly skin assessments indicated: On 5/29/23 no skin problems- completed by LVN J On 6/5/23- no skin problems On 6/12/23- no assessment was found On 6/19/23 - no skin problems-completed by RN K On 6/26/23 - no skin problems On 7/3/23- no assessment found On 7/10/23- no skin problems-LVN L On 7/17/23 no assessment found On 7/24/23 no assessment found On 7/31/23 - no skin problems On 8/7/23 - no skin problems (the day before hospitalization) Record review of Resident #1's June 2023, July 2023 and August 2023 MARs and TARs indicated he did not receive any thing for pain and his pain assessment indicated no pain for those months. There was not documented evidence of treatments provided to his foot or toe. Record review of Resident #1's nutritional assessment dated [DATE] indicated the resident required supervision and oversite, encouragement or cueing for eating. He did not have any skin conditions or no recent labs. Record review of Resident #1's Physician's Progress note dated 7/5/23 indicated the resident was seen face to face with the nurse at bedside. There were no new complaints or concerns reported at the time. Review of systems indicated a general review. The resident was an unreliable historian, and the information was provided by staff. There were no changes in skin reported. Record review of Resident #1's ADL sheets for August 3023 indicated the resident was given a shower or bed bath each day from 8/2/23 through 8/7/23. Record review of Resident #1's nursing note dated 8/8/23 at 3:45 p.m. indicated Resident #1's family member came to the nurse's station asking to have the bandage on the resident's foot changed. The nurse went to do an assessment and changed the bandage. It was noted the entire right great toe was dark in color and dry. The DON and the NP were notified. New orders were received to send the resident to the ER for possible osteomyelitis (inflammation of the bone cause by infection). Record review of a Wound Information sheet dated 8/8/23 and created on 8/9/23 at 10:34 a.m. indicated Resident #1 had a wound type other, entire right great toe, not present on admission, the length was 4 cm and the with 3 cm and it was declining. The entire right great toe was dark in color and dry to touch. Record review of Resident #1's hospital History and Physical dated 8/9/23 at 2:29 a.m. indicated the Resident#1 received services on 8/8/23 at 7:43 p.m. Records indicated Resident #1 was assessed and determined to have chronic, worsening dry gangrene likely due to severe PVD. The right foot x ray showed gas within the soft tissue of the first digit of the right foot. Consult podiatry for possible amputation of the first digit. The radial pulses were 2+ on the right side and 2+ on the left side (blood flow was normal). The dorsalis pedis pulse was 0 on the right side (foot indicated vascular disease) and detected without doppler( Used to evaluate blood flow through the major arteries and veins of the feet.) on the left side. Posterior tibial pulses was detected without doppler on the right and left side. The skin integrity was positive for ulcer great, black discoloration of first digit, with skin breakdown, callus and dry. Ulcer located dorsal aspect of foot. Record review of Resident #1's Internal Medicine daily progress note dated 8/17/2023 at 8:42 a.m. indicated Resident #1 presented to the hospital on 8/8/23 from the nursing home with the chief complaint of right big toe pain with a chronic wound present. Resident #1 was at baseline with orientation to self only and used the wheelchair for mobility. The family member was at bedside and unsure how long the wound had been present but said at least a few months. An x-ray of the right foot indicated gas was shown within the soft tissue of the 1st digit with signs of arterial atherosclerosis (thickening or hardening of the arteries caused by buildup of plaque in the inner lining of the artery) and osteopenia (loss of bone mass and bone gets weaker), concerning for gas gangrene (dead tissue caused by and infection or loss of blood flow.). Podiatry preformed a right trans metatarsal amputation (surgery to remove part of the foot, one or more toes) and medial planner artery( supplies muscles of the big toe) based rotation flap 5cm (provides similar tissue with sensation and reaches the posterior most part of the weightbearing surface of the heal with ease.) on 8/12/23. Recommended daily bandage changes to the right foot. Due to poor healing. Cardiology recommended possible physical therapy involvement with wound care. A bone cultures preliminary results showed gram positive coli impairs and a few gram-positive rods. There was a recommendation was for a continued intravenous vancomycin( medication used to treat infections caused by bacteria) and cefepime ( medication antibiotic to treat bacterial infection) . The bone margarine biopsy was negative. Dry gangrene resolved as of 8/16/2023. Chronic worsening likely due to severe PVD. Podiatry performed the right trans metatarsal amputation and a medial plantar artery-based rotation flap 5 centimeters on 8/12/23 physical deconditioning chronic. The nursing home indicated the resident was totally dependent for care, bed bound, and needed assistance to wheelchair and to be pushed. During an interview on 8/10/23 at 11:37 a.m. said Resident #1's family member said Resident #1 was still in the hospital due to poor circulation in his foot and gangrene. The family member said they had not seen him for two weeks. The family member said when they arrived on 8/8/23 Resident #1 was complaining of foot pain. When the family member took off his sock, it was obvious the sock had been on a while. The sock was filled with dried dead skin and dust. The family member said they had asked the ADON to come and look at his foot. The family member said there was gauze wrapped around Resident #1's big toe. The bandage was dirty and looked like it had been on Resident #1's foot for a while. The family member said they knew the Podiatrist had put a bandage on the foot. The way the bandage looked it could have been the same one. The family member said they could not be sure, but it was obvious it was not changed daily, if at all. The family member said the whole top of the right foot was black, the big toe was black. During an interview on 8/10/23 at 2:18 p.m. the DON said the NP gave an order on 8/8/23 to send Resident #1 to the ER for possible osteomyelitis to the great toe. The DON said the ADON had called her to the room to look at Resident #1's foot. It was dark in color and there was no drainage, no smell. The Administrator called in the incident into the State. She said Resident #1 was not on the wound care log, they had no records of him was receiving treatments. She said they checked, and he did not have a physician's order for wound care. The DON said they also checked the shower sheets and the assessments and there was no indication of a wound on Resident #1's foot. The DON said she began work at the facility in the middle of July and was not present when the Podiatrist had visited. She said she had checked the assessments, the TARS, physician orders, and shower sheets because she expected those things to give some indication of what was going on with Resident #1's foot. However, those records did not reveal anything. During an interview on 8/10/23 at 3:05 p.m. the Administrator said she learned about Resident #1's right foot from the DON. She said a family member came and asked to put another bandage on his foot. The DON went down on to look at his foot and called her to look as well. The Administrator said the big toe on his right was dark in color. She said the NP was notified and said to send Resident #1 out due to possible osteomyelitis. The Administrator said she reported the incident to the state because assessments, and treatments had not been done to the wound. She said as best their investigation could determine no one was aware he had any issues with his foot. She said she called the allegation in due to possible neglect in providing care to Resident #1. During an interview on 8/10/23 at 3:15 p.m. the ADON said she was called to Resident #1's room by a family member. She said she observed a bandage on Resident #1's toe, the bandage may have been on Resident #1's foot for a few days, it did not look new. The bandage had no date, and no initials on it. She said the bandage was tan in color. The ADON said Resident #1's foot was dark and dry, no drainage, and no smell. LVN D told the doctor, and she said send to the hospital to rule out osteomyelitis. The ADON said Resident #1 did not complain of pain. Record review of the facility Provider Investigation Report dated 8/9/23 at 5:00 p.m. indicated they had first learned of the incident on 8/9/23 at 2:30 p.m. The narrative indicated Resident #1 had poor circulation to his bilateral feet and experienced pain. The family member asked the nurse to remove his bandage on Resident #1's foot. The ADON removed the bandage and noted the entire right toe was dark in color and dry. She then notified the DON. The DON notified the NP and received orders to transfer the Resident #1 to the ER for possible osteomyelitis. The nursing staff was educated starting with the facility policy and procedures for reporting skin issues, making weekly rounds, and abuse and neglect. The allegation was Resident Neglect. During an interview on 8/10/23 at 1:00 p.m. CNA A said sometime in June 2023 Resident #1 had an area on his foot, and she notified LVN D. She said Resident #1 had something on the top of his big toe, and she showed LVN D. She said LVN D cleaned Resident #1's foot and the Podiatrist was contracted. CNA A said she was off for a couple of days, but she gave the resident a bed bath on 8/7/23. She said had not seen his foot; the foot had a dressing on the toe. CNA A said Resident #1 got baths MWF and she could not say the last time she had seen his foot even though she said he received his bath regularly and did not refuse. CNA A was asked several different times and several different ways when the last time she saw Resident #1's foot. She could not say the last time she had seen Resident #1's foot. She would refer to the day she showed the area to the LVN D and when the Podiatrist came on 6/29/23. During an interview on 8/10/23 at 1:30 p.m. LVN D said Resident #1 came back from another facility and the aide showed her his nails were long and needed attention. She said she thought it was 6/14/23 that she observed the resident's feet. His right foot looked like it had athlete's feet. His skin was flakey, he was diabetic, and his toes were long and thick. She notified the NP and did a referral for the Podiatrist. She said she had never conducted a treatment on Resident #1. She said that he did not have any orders so there was no need to provide wound care. She said she had not seen his foot since the day she did the podiatry referral. She had not conducted a skin assessment. She said she as a floor nurse and had worked at the facility for about 3 months. During a telephone interview on at 8/10/23 at 3:32 p.m. RN E said she did not provide any treatments to Resident #1. RN E said she had never seen his feet and did not know anything about a podiatrist visit. Record review of a nursing note dated 6/29/23 at 9:12 a.m. indicated Resident #1 was up in his chair with no problems during a day 3 of 3 post fall assessments. His vital signs were within normal limits, and he had no pain reported. Signed by RN E During a telephone interview on at 3:34 p.m. RN F said she has never been in the building when Podiatry was there. She said no one had given her a verbal order. RN F said that she was not aware of any wound on Resident #1's toe. She said she had never put a bandage on foot or seen his feet. During a telephone interview on at 3:43 p.m. RN G said she did not remember Resident #1 but if he had a treatment order, she would have provided treatment as needed. During an interview on 8/10/23 at 4:26 p.m. the DON said she started working at the facility on Monday, 7/10/23 She said when first started working she asked for wound report and Resident #1 had never been on any wound reports. The DON said it looked like nurses or aide had not assessed Resident #1's skin. The DON said she could not find any treatment orders or treatments for Resident #1. During an interview on 8/10/3 at 5:34 p.m. LVN H said she had never completed a skin assessment on Resident #1 or provided any treatment. During a telephone interview on 8/10/23 at 5:55 p.m. CNA A said she was there when the Podiatrist treated Resident #1's foot. She said Resident #1 was sitting in the chair and Resident#1 kept saying oh, oh, oh and the Podiatrist kept on doing what she was doing telling him it was ok. CNA A said the Podiatrist used clippers and a grinder. She did not see her put a bandage on Resident #1's toe; she left before the Podiatrist finished the process. She said she had not seen Resident #1's foot lately because he had a bandage on his toe, and they were not to take off bandages. She said she was aware of what abuse was, who to report abuse to. She said neglect was failure to provide goods and services to a resident. During an interview on 8/10/23 at 6:00 p.m. LVN D said she cleaned Resident #1' right foot on 6/14/23 and alerted therapy that his foot was tender. She said the aides put socks on Resident #1's feet. She said he did complain of a little pain when she cleaned his foot. However, after podiatry came Resident #1 had no more complaints of pain. During an interview on 8/10/23 at 6:09 p.m. CNA B said she gave Resident #1 a bath and she had cleaned him up because he had a BM but never saw his foot. She said she did not remember ever seeing his feet. She said she was aware of what abuse was, who to report abuse to. She said neglect was failure to provide goods and services to a resident. During an interview and observation on 8/14/23 at 3:15 p.m. Resident #1 was observed in the hospital bed. He was sitting up and alert but confused. He said he had sprained his ankle and that was what was wrong with is foot. He said he had never been to the nursing facility. He said the hospital had cut off his foot. Observation of his right foot revealed it was heavily bandaged, but it was still there. During an interview on 8/15/23 at 8:12 a.m. the Administrator said they had QA meetings on the first Monday of the month. She said they had not taken the incident with Resident #1 to QA yet, she was waiting to finish her investigation into the incident and the 3615(Provider Investigation Report to the State) was not due until tomorrow. She said after that was completed; they would conduct an impromptu QA meeting. She said they had finished some of the in-services on skin assessments, documentation, and shower sheets being completed correctly Sunday, 8/13/23, and they had conducted skin assessments on all residents and finished on 8/11/23 During a telephone interview on 8/15/23 at 8:20 a.m. the NP said Resident #1 had been in the hospital before and had diagnoses of stoke and high blood. She was not aware he had a diagnosis of PVD. The NP said she knew he was referred to podiatry but had not received any recommendations from podiatry. She was not made aware of any orders from the podiatrist. The NP said on 8/8/23 the nursed called her to discuss Resident #1's foot. They compared it to another resident she had looked at the day before and it was worse than that resident. She said the staff told her Resident #1's foot was black and there was a question of circulation. She said they said it was dry and they could not tell how deep the injury was. She told the staff to send the resident to the hospital for possible osteomyelitis. The NP said she had never saw Resident #1's feet. She was not aware of any issues with Resident #1's feet. During an interview on 8/15/23 at 9:12 a.m. LVN I said she worked at the facility for 4.5 years. She said she completed skin assessments when they populated in the computer. Resident #1 was readmitted to the facility on [DATE] by LVN J who was out on leave. LVN I said she never provided any care to Resident #1. She said she had gone to Resident #1's room on 8/8/23 with the ADON. She had seen the bandage and it was beige in color. During an interview on 8/15/23 at 10:16 a.m. the Corporate Nurse and DON said they had a system with the Podiatrist. The procedure was the podiatrists leave a census sheet and if there were any orders associated with the visit they would be noted on that sheet. The Corporate Nurse said in most facilities the Podiatrist asked for who they could see and who they could not related to payor source. The DON said the Podiatrist had not been to the facility since she had been working there. They did not have a DON during the last Podiatrist visit. The Corporate Nurse said the Podiatrist was to meet with the DON or the Administrator prior to exit. They said there was a failure of the Podiatrist to communicate the order or write the order down. The Corporate Nurse said she did not know why a nurse would have told her not to write the order down. There were plenty of physician order forms at the nurses station. The DON said they could not determine who the order was given to or why the order did not get transcribed. The Corporate Nurse said they were going to have some communication with the Podiatrist. During a record review and interview on 8/15/23 at 11:00 a.m. the Corporate Nurse said they had an issue with the Podiatrist. Review of the Podiatrist's notes indicated all residents had the same diagnoses of poor circulation, diseased toenails, on left and right feet like she copied and pasted, the only difference were the medications. Review of records revealed Resident#1 was the only resident on 6/29/23 with an order. Review of the note's indicated the residents were educated even the confused ones, and all had debridement. Review of the notes for 36 residents indicated they all reflected similar information. There was one code used on all the records code 11721- debridement of nails. Review of the 2/3/23 podiatrist consult notes indicated the same code and the same similarities in the records. The Corporate Nurse said perhaps the 11721 was a pay code they used to bill for services. The Corporate Nurse said they had a computer system Plan of Care (POC) that triggered when to do the skin assessments. She was checking that system to determine why assessments were not completed as they should have been. She could not tell if the system did not trigger the need to do the assessments or if staff had just no completed them as required. During an interview on 8/15/23 at 12:40 p.m. the DON said she could not determine who put the bandage on Resident #1's foot that was discovered on 8/8/23. During an interview on 8/15/23 at 2:00 p.m. with RN K and the Corporate Nurse, RN K said she saw Resident #1's foot but it had been a while, about 6 weeks. She said she had not seen a bandage on his foot and did not remember what the foot looked like. Corporate Nurse said RN K completed a skin assessment on Resident #1 on 6/19/23 (the day the PTA said Resident #1 was complaining of foot pain) RN K said she could not remember what the foot looked like. She said all diabetic residents had the thick toenails with fungus. She did not remember anything different about Resident #1's feet. During an interview on 8/16/23 at 3:38 p.m. LVN L said she never saw Resident #1's foot. (She completed Resident #1's a skin assessment on 7/10/23.) Record review of the facility's skin management documentation workflow dated 5/23/22 indicated to complete skin assessments on admission observation. Document all skin alterations to include abrasions, bruises, burn, dermatitis, laceration, rash, skin graft, skin tear, surgical incision, and ostomies and other areas. Complete a weekly Braden Scale observation each week post admission for three weeks. Complete weekly head to toe skin inspections. These are to be competed and documented in the POC computer system as they are scheduled. Record review of an in-service dated 8/10/23 indicated Nursing Care of the Older Adult with Diabetes indicated Skin and Foot Care: Skin should be kept as dry and clean as possible apply lotion to dry skin as needed unless contraindicated. Use antiseptic technique in caring for any lacerations, abrasions of or breaks in skin integrity, and report the condition immediately to your supervisor. Bathe the feet in warm hot water as necessary to keep clean. Keep the feet dry, especially between the toes. Encourage the use of non-constricting, well-fitting shoes, slippers, and hose. Keep the feet warm without the use of external heat sources Record review of the facility's in-service conducted on 8/10/23 the in-service indicated CNAs reporting and documenting skin injuries on weekly shower sheets and PRN notifications. The in-service indicated CNAs should report all skin injuries, discoloration, skin tears, lacerations, blisters, pressure injuries, open areas, to the charge nurse immediately. The area should be indicated on the CNA shower sheets when turned into the nurse, after notification to the charge nurse. Resident skin should be checked during showers/ bed baths, turning and repositioning, dressing, and toileting. CNAs should be moisturizing resident skin daily, and using moisture barrier to resident buttocks, peri-area, and groins after performing incontinent care. If there was a dressing without nursing initials or dates are found to be in place, notify the charge nurse immediately. If dressings become dislodged, or solided, notify the charge nurse so that the dressing can be changed. Check for breaks and skin and pressure ulcers to the external portions of the ear. When giving bed baths remove residence clothing, undergarments and socks, and check between toes. Inspects ankles and heels for pressure areas, blisters, or non-blanchable redness. Is very important to dry our diabetic residents' feet and between their toes well. Wash residents' hands with soap and water and moisturize their hands, especially those with contractures be gentle and respect the decreased range of motion strengthening the digits that are severely contracted. Keep residents covered during bed baths to keep them warm as possible and to preserve their dignity. Record review of the facility's undated contract with [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident received proper treatment and care to maintain good foot health for 1 of 5 residents reviewed for foot care. (Resident #1) The facility failed to ensure Resident #1 who had diagnosis of diabetes and was at risk for issues with his feet, received assessments, and treatments. The facility failed to ensure accurate, timely skin assessments. Resident #1 had 7 weekly skin assessments from 5/29/23 through 8/7/23 by 7 different nurses and none of those assessments revealed any foot issues. The facility failed to ensure assessments of Resident #1's feet were completed during baths. Resident #1 had bed baths from 8/4/23 through 8/7/23 from 2 different aides. Those aides did not assess his feet during care. The resident was seen by the Podiatrist on 6/29/23, his toenails were cut, and his right big toe was debrided. A bandage was placed on his toe. The facility failed to ensure podiatry recommendations were followed for Resident #1. The facility failed to ensure Resident #1 received wound care, cleaning of the wound, treatment, and possible antibiotics for the wound on the toe. On 8/8/23 Resident #1 was found with a discolored bandage on his right big toe. He was sent to the hospital with a diagnosis of PVD, gangrene, and had to have surgery to remove part of the foot, one or more toes. An Immediate Jeopardy (IJ) situation was identified 08/15/23 at 3:42 p.m. While the IJ was removed on 08/16/23 at 4:09 p.m., the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Record review of Resident #1's undated face sheet indicted his current admission date was 5/25/23. He was a [AGE] year-old male with diagnoses of vascular dementia, with behavioral disturbances, diabetes mellitus, muscle wasting to the right and left lower leg, lack of coordination, and muscle weakness. Record review of Resident #1's admission MDS dated [DATE] indicated he was severely cognitively impaired. He had inattention and disorganized thinking behaviors present that came and went and changed in severity. The MDS indicated Resident # 1 required extensive assist of two people for bed mobility and transfers. He required extensive assist with dressing, toilet use, and personal hygiene of one person. He used a wheelchair for mobility. Resident #1 was totally dependent for putting on or taking off footwear. He was at risk for developing pressure ulcers but did not have any wounds listed. Record review of Resident #1's care plan with a start date of 10/20/21 and last updated 7/27/23 indicated a problem of at risk for diabetic complications, frequent infections, pressure/venous/status ulcers, vision impairment, hyper/hypoglycemia, kidney failure, cognitive/physical impairment. Skin desensitized to pain or pressure related to diabetes mellitus. Some of the approaches were to assist with repositioning routinely and as needed with pillows for comfort, support and to keep feet elevated of the bed as the resident will allow, and weekly skin assessments. Resident #1 was at risk for skin break down related to impaired mobility, diabetes mellitus, and incontinence. One of the approaches was weekly skin assessments. Resident #1 had self-care deficits due to impaired cognition, impaired memories, impaired daily decision making, occasional refusal of care and impaired mobility. Some of the approaches were bathing, personally hygiene, transfers required one to 2 people assist, if he refused, reapproach, notify the nurse. The resident required 1 to 2 people assist with bed mobility, use of pillows for comfort and support. And to keep the feet elevated off the bed. He required 1 to 2 people assist with dressing, offer clothing choices, and encourage the resident to participate. Record review of Resident #1's computerized physician's orders indicated an order dated 5/27/23 for Tylenol Extra Strength 500 mg, 2 tablets, every 6 hours as needed for pain. An order dated 4/9/23 reflected to admit to the secure unit due to exit seeking secondary to dementia. An order dated 3/13/23 for a podiatry consult as needed. An order dated 10/2/21 indicated to assess for pain every shift. Record review of Resident #1's social services note dated 6/13/23 indicated his family member expressed several requests that she would like Resident #1 to be seen by a podiatrist due to his toes needing attention and he was a diabetic. Record review of Resident #1's nursing notes dated 6/14/23 indicated the podiatrist to see Resident #1 and they would be at the facility on 6/29/23. Written by LVN D. Record review of Resident #1's Braden scale for predicting pressure sore risk dated 6/15/23 indicated the resident had very limited responses to a sensory perception, his skin was moist constantly, he was chair fast with his ability to was walk severely limited or nonexistence. The resident's ability to change or control body position was very limited but made occasional slight changes. The resident's nutrition was he ate most of his meals every day. Friction and shear were a problem due to the resident required moderate to maximum assist with moving his. The Braden scale score was listed as a 12 which indicated high risk for pressure sores. There were no interventions checked as for preventive measures listed on the form. Record Review of Resident #1's Physical Therapy notes indicated the resident received therapy between 6/15/23 and 6/26/23. Therapy notes dates 6/19/23 indicated Resident #1 complained of not feeling well and said his foot hurt bad on this day. The LVN was notified. The resident was unwilling to participate secondary to pain. Therapy notes dated 6/22/23 indicated observation of blood to the right great toe through his sock. The nursing staff were made aware of observation and complaints of pain on this day. Therapy notes dated 6/26/23 indicated Resident #1 had difficulty with shifting onto his right lower extremity secondary to pain. All notes written by PTA. During an interview on 8/16/23 at 11:18 p.m. the PTA said she had voiced her concerns she had written in her therapy notes to the nursing staff about Resident #1. She said she was not sure exactly who she talked to, but they were made aware of Resident #1' complaints of pain and the blood on his sock for at least two occasions. Record review of Resident #1's Podiatry report dated 6/29/23 indicated. [The patient was unable to answer questions appropriately and was confined to a wheelchair. The chief complaint was diabetes, lesions at risk for poor circulation, and diseased toenails. The impression was cutaneous abscess (localized collection of pus in the skin and may occur on any skin surface. Symptoms and signs are pain and tender, firm or swelling.) to the right foot, cellulitis (bacterial skin infection) of right toe, onychogryphosis (nail disorder resulting from slow nail plate growth. Yellow brown thickening of the nail plate.), and peripheral vascular disease. The plan was due to the patient's pain tolerance. The medial right first nail border and all loose nail distally was freed from its soft tissue attachments and avulsed the offending border with nail nippers, care being taken to remove and excise all nonviable (dead) tissue. All corners were inspected for spicules (hard tissue) as best as possible. The abscess was drained from the nail bed noting malodorous (unpleasant smelling) red, brow, rust colored moderate amount of drainage approximately 1cc in total. All noted drainage and dicrotic tissue was removed with manual pressure to right toe and mechanical debridement (removal of damaged tissue from a wound) and nail nippers revealing clean, moist nail bed. The nail margins and nail bed were cleansed with Techni care and treated with triple antibiotic and dressed with a 2x2 and paper tape. Discussed with nurse the patient's right hallux(big toe) nail. Verbally recommended continued wound care consisting of daily cleaning and application of betadine and bandage until dry. Discussed possible by mouth antibiotic for the patient, nurse said she would confirm with attending NP for antibiotic. If deterioration of nail bed or eschar( dry, dark scab) on right hallux please bring patient to clinic. As soon as possible or if the patient develops systemic signs of infection including fever, chills, increased warmth to right toe/foot.] Record review of the facility 24-hour report dated 6/29/23 to 6/30/23 did not indicate any mention of Resident #1. During a telephone interview on 8/10/23 at 4:12 p.m. the Podiatrist said she remembered Resident #1. She said on 6/29/22 she had debrided his toe, bandaged his toe with triple antibiotic ointment, gauze and paper tape. The Podiatrist said when she was ready to leave there were several people at the nurse's station. She said she talked to a nurse and did not get a name or remember who she was. The Podiatrist said she asked for an order form to write her order for treatment of Resident #1's toe down but was told by the nurse she could give a verbal order. The Podiatrist said had given her verbal order to cleanse Resident #1's toe and apply betadine daily until healed. The unknown nurse said she would relay the information to the NP. She said Resident #1's wound did not appear to be tunneling and she felt if they had kept it cleaned and changed the bandage daily it would have healed in about two weeks. The Podiatrist said they did not need to wait until she came to the facility for Resident #1 to be seen, they could have brought him to her office. The Podiatrist said the only person she remembered at the nurse's station was the BOM. During an interview on 8/10/23 at 4:16 p.m. the BOM said she saw the Podiatrist at the nurse's station on 6/29/23 during her last visit. The BOM said she was talking to someone. However, she did not remember who she was talking to or hear what was said. Record review of Resident #1's nursing notes from 6/14/23 to 8/7/32 revealed no documented evidence of the Podiatrist recommendations, foot, pain, bleeding, bandage, or toe. Record review of Resident #1's weekly skin assessments indicated: On 5/29/23 no skin problems- completed by LVN J On 6/5/23- no skin problems On 6/12/23- no assessment was found On 6/19/23 - no skin problems-completed by RN K On 6/26/23 - no skin problems On 7/3/23- no assessment found On 7/10/23- no skin problems-LVN L On 7/17/23 no assessment found On 7/24/23 no assessment found On 7/31/23 - no skin problems On 8/7/23 - no skin problems (the day before hospitalization) Record review of Resident #1's June 2023, July 2023 and August 2023 MARs and TARs indicated he did not receive any thing for pain and his pain assessment indicated no pain for those months. There was not documented evidence of treatments provided to his foot or toe. Record review of Resident #1's nutritional assessment dated [DATE] indicated the resident required supervision and oversite, encouragement or cueing for eating. He did not have any skin conditions or no recent labs. Record review of Resident #1's Physician's Progress note dated 7/5/23 indicated the resident was seen face to face with the nurse at bedside. There were no new complaints or concerns reported at the time. Review of systems indicated a general review. The resident was an unreliable historian, and the information was provided by staff. There were no changes in skin reported. Record review of Resident #1's ADL sheets for August 3023 indicated the resident was given a shower or bed bath each day from 8/2/23 through 8/7/23. Record review of Resident #1's nursing note dated 8/8/23 at 3:45 p.m. indicated Resident #1's family member came to the nurse's station asking to have the bandage on the resident's foot changed. The nurse went to do an assessment and changed the bandage. It was noted the entire right great toe was dark in color and dry. The DON and the NP were notified. New orders were received to send the resident to the ER for possible osteomyelitis (inflammation of the bone cause by infection). Record review of a Wound Information sheet dated 8/8/23 and created on 8/9/23 at 10:34 a.m. indicated Resident #1 had a wound type other, entire right great toe, not present on admission, the length was 4 cm and the with 3 cm and it was declining. The entire right great toe was dark in color and dry to touch. Record review of Resident #1's hospital History and Physical dated 8/9/23 at 2:29 a.m. indicated the Resident#1 received services on 8/8/23 at 7:43 p.m. Records indicated Resident #1 was assessed and determined to have chronic, worsening dry gangrene likely due to severe PVD. The right foot x ray showed gas within the soft tissue of the first digit of the right foot. Consult podiatry for possible amputation of the first digit. The radial pulses were 2+ on the right side and 2+ on the left side (blood flow was normal). The dorsalis pedis pulse was 0 on the right side (foot indicated vascular disease) and detected without doppler(Used to evaluate blood flow through the major arteries and veins of the feet.) on the left side. Posterior tibial pulses was detected without doppler on the right and left side. The skin integrity was positive for ulcer great, black discoloration of first digit, with skin breakdown, callus and dry. Ulcer located dorsal aspect of foot. Record review of Resident #1's Internal Medicine daily progress note dated 8/17/2023 at 8:42 a.m. indicated Resident #1 presented to the hospital on 8/8/23 from the nursing home with the chief complaint of right big toe pain with a chronic wound present. Resident #1 was at baseline with orientation to self only and used the wheelchair for mobility. The family member was at bedside and unsure how long the wound had been present but said at least a few months. An x-ray of the right foot indicated gas was shown within the soft tissue of the 1st digit with signs of arterial atherosclerosis (thickening or hardening of the arteries caused by buildup of plaque in the inner lining of the artery) and osteopenia (loss of bone mass and bone gets weaker), concerning for gas gangrene (dead tissue caused by and infection or loss of blood flow.). Podiatry preformed a right trans metatarsal amputation (surgery to remove part of the foot, one or more toes) and medial planner artery(supplies muscles of the big toe) based rotation flap 5cm (provides similar tissue with sensation and reaches the posterior most part of the weightbearing surface of the heal with ease.) on 8/12/23. Recommended daily bandage changes to the right foot. Due to poor healing. Cardiology recommended possible physical therapy involvement with wound care. A bone cultures preliminary results showed gram positive coli impairs and a few gram-positive rods. There was a recommendation was for a continued intravenous vancomycin(medication used to treat infections caused by bacteria) and cefepime ( medication antibiotic to treat bacterial infection) . The bone margarine biopsy was negative. Dry gangrene resolved as of 8/16/2023. Chronic worsening likely due to severe PVD. Podiatry performed the right trans metatarsal amputation and a medial plantar artery-based rotation flap 5 centimeters on 8/12/23 physical deconditioning chronic. The nursing home indicated the resident was totally dependent for care, bed bound, and needed assistance to wheelchair and to be pushed. During an interview on 8/10/23 at 11:37 a.m. said Resident #1's family member said Resident #1 was still in the hospital due to poor circulation in his foot and gangrene. The family member said they had not seen him for two weeks. The family member said when they arrived on 8/8/23 Resident #1 was complaining of foot pain. When the family member took off his sock, it was obvious the sock had been on a while. The sock was filled with dried dead skin and dust. The family member said they had asked the ADON to come and look at his foot. The family member said there was gauze wrapped around Resident #1's big toe. The bandage was dirty and looked like it had been on Resident #1's foot for a while. The family member said they knew the Podiatrist had put a bandage on the foot. The way the bandage looked it could have been the same one. The family member said they could not be sure, but it was obvious it was not changed daily, if at all. The family member said the whole top of the right foot was black, the big toe was black. During an interview on 8/10/23 at 2:18 p.m. the DON said the NP gave an order on 8/8/23 to send Resident #1 to the ER for possible osteomyelitis to the great toe. The DON said the ADON had called her to the room to look at Resident #1's foot. It was dark in color and there was no drainage, no smell. The Administrator called in the incident into the State. She said Resident #1 was not on the wound care log, they had no records of him was receiving treatments. She said they checked, and he did not have a physician's order for wound care. The DON said they also checked the shower sheets and the assessments and there was no indication of a wound on Resident #1's foot. The DON said she began work at the facility in the middle of July and was not present when the Podiatrist had visited. She said she had checked the assessments, the TARS, physician orders, and shower sheets because she expected those things to give some indication of what was going on with Resident #1's foot. However, those records did not reveal anything. During an interview on 8/10/23 at 3:05 p.m. the Administrator said she learned about Resident #1's right foot from the DON. She said a family member came and asked to put another bandage on his foot. The DON went down on to look at his foot and called her to look as well. The Administrator said the big toe on his right was dark in color. She said the NP was notified and said to send Resident #1 out due to possible osteomyelitis. The Administrator said she reported the incident to the state because assessments, and treatments had not been done to the wound. She said as best their investigation could determine no one was aware he had any issues with his foot. She said she called the allegation in due to possible neglect in providing care to Resident #1. During an interview on 8/10/23 at 3:15 p.m. the ADON said she was called to Resident #1's room by a family member. She said she observed a bandage on Resident #1's toe, the bandage may have been on Resident #1's foot for a few days, it did not look new. The bandage had no date, and no initials on it. She said the bandage was tan in color. The ADON said Resident #1's foot was dark and dry, no drainage, and no smell. LVN D told the doctor, and she said send to the hospital to rule out osteomyelitis. The ADON said Resident #1 did not complain of pain. Record review of the facility Provider Investigation Report dated 8/9/23 at 5:00 p.m. indicated they had first learned of the incident on 8/9/23 at 2:30 p.m. The narrative indicated Resident #1 had poor circulation to his bilateral feet and experienced pain. The family member asked the nurse to remove his bandage on Resident #1's foot. The ADON removed the bandage and noted the entire right toe was dark in color and dry. She then notified the DON. The DON notified the NP and received orders to transfer the Resident #1 to the ER for possible osteomyelitis. The nursing staff was educated starting with the facility policy and procedures for reporting skin issues, making weekly rounds, and abuse and neglect. The allegation was Resident Neglect. During an interview on 8/10/23 at 1:00 p.m. CNA A said sometime in June 2023 Resident #1 had an area on his foot, and she notified LVN D. She said Resident #1 had something on the top of his big toe, and she showed LVN D. She said LVN D cleaned Resident #1's foot and the Podiatrist was contracted. CNA A said she was off for a couple of days, but she gave the resident a bed bath on 8/7/23. She said had not seen his foot; the foot had a dressing on the toe. CNA A said Resident #1 got baths MWF and she could not say the last time she had seen his foot even though she said he received his bath regularly and did not refuse. CNA A was asked several different times and several different ways when the last time she saw Resident #1's foot. She could not say the last time she had seen Resident #1's foot. She would refer to the day she showed the area to the LVN D and when the Podiatrist came on 6/29/23. During an interview on 8/10/23 at 1:30 p.m. LVN D said Resident #1 came back from another facility and the aide showed her his nails were long and needed attention. She said she thought it was 6/14/23 that she observed the resident's feet. His right foot looked like it had athlete's feet. His skin was flakey, he was diabetic, and his toes were long and thick. She notified the NP and did a referral for the Podiatrist. She said she had never conducted a treatment on Resident #1. She said that he did not have any orders so there was no need to provide wound care. She said she had not seen his foot since the day she did the podiatry referral. She had not conducted a skin assessment. She said she as a floor nurse and had worked at the facility for about 3 months. During a telephone interview on at 8/10/23 at 3:32 p.m. RN E said she did not provide any treatments to Resident #1. RN E said she had never seen his feet and did not know anything about a podiatrist visit. Record review of a nursing note dated 6/29/23 at 9:12 a.m. indicated Resident #1 was up in his chair with no problems during a day 3 of 3 post fall assessments. His vital signs were within normal limits, and he had no pain reported. Signed by RN E During a telephone interview on at 3:34 p.m. RN F said she has never been in the building when Podiatry was there. She said no one had given her a verbal order. RN F said that she was not aware of any wound on Resident #1's toe. She said she had never put a bandage on foot or seen his feet. During a telephone interview on at 3:43 p.m. RN G said she did not remember Resident #1 but if he had a treatment order, she would have provided treatment as needed. During an interview on 8/10/23 at 4:26 p.m. the DON said she started working at the facility on Monday, 7/10/23 She said when first started working she asked for wound report and Resident #1 had never been on any wound reports. The DON said it looked like nurses or aide had not assessed Resident #1's skin. The DON said she could not find any treatment orders or treatments for Resident #1. During an interview on 8/10/3 at 5:34 p.m. LVN H said she had never completed a skin assessment on Resident #1 or provided any treatment. During a telephone interview on 8/10/23 at 5:55 p.m. CNA A said she was there when the Podiatrist treated Resident #1's foot. She said Resident #1 was sitting in the chair and Resident#1 kept saying oh, oh, oh and the Podiatrist kept on doing what she was doing telling him it was ok. CNA A said the Podiatrist used clippers and a grinder. She did not see her put a bandage on Resident #1's toe; she left before the Podiatrist finished the process. She said she had not seen Resident #1's foot lately because he had a bandage on his toe, and they were not to take off bandages. She said she was aware of what abuse was, who to report abuse to. She said neglect was failure to provide goods and services to a resident. During an interview on 8/10/23 at 6:00 p.m. LVN D said she cleaned Resident #1' right foot on 6/14/23 and alerted therapy that his foot was tender. She said the aides put socks on Resident #1's feet. She said he did complain of a little pain when she cleaned his foot. However, after podiatry came Resident #1 had no more complaints of pain. During an interview on 8/10/23 at 6:09 p.m. CNA B said she gave Resident #1 a bath and she had cleaned him up because he had a BM but never saw his foot. She said she did not remember ever seeing his feet. She said she was aware of what abuse was, who to report abuse to. She said neglect was failure to provide goods and services to a resident. During an interview and observation on 8/14/23 at 3:15 p.m. Resident #1 was observed in the hospital bed. He was sitting up and alert but confused. He said he had sprained his ankle and that was what was wrong with is foot. He said he had never been to the nursing facility. He said the hospital had cut off his foot. Observation of his right foot revealed it was heavily bandaged, but it was still there. During an interview on 8/15/23 at 8:12 a.m. the Administrator said they had QA meetings on the first Monday of the month. She said they had not taken the incident with Resident #1 to QA yet, she was waiting to finish her investigation into the incident and the 3615(Provider Investigation Report to the State) was not due until tomorrow. She said after that was completed; they would conduct an impromptu QA meeting. She said they had finished some of the in-services on skin assessments, documentation, and shower sheets being completed correctly Sunday, 8/13/23, and they had conducted skin assessments on all residents and finished on 8/11/23 During a telephone interview on 8/15/23 at 8:20 a.m. the NP said Resident #1 had been in the hospital before and had diagnoses of stoke and high blood. She was not aware he had a diagnosis of PVD. The NP said she knew he was referred to podiatry but had not received any recommendations from podiatry. She was not made aware of any orders from the podiatrist. The NP said on 8/8/23 the nursed called her to discuss Resident #1's foot. They compared it to another resident she had looked at the day before and it was worse than that resident. She said the staff told her Resident #1's foot was black and there was a question of circulation. She said they said it was dry and they could not tell how deep the injury was. She told the staff to send the resident to the hospital for possible osteomyelitis. The NP said she had never saw Resident #1's feet. She was not aware of any issues with Resident #1's feet. During an interview on 8/15/23 at 9:12 a.m. LVN I said she worked at the facility for 4.5 years. She said she completed skin assessments when they populated in the computer. Resident #1 was readmitted to the facility on [DATE] by LVN J who was out on leave. LVN I said she never provided any care to Resident #1. She said she had gone to Resident #1's room on 8/8/23 with the ADON. She had seen the bandage and it was beige in color. During an interview on 8/15/23 at 10:16 a.m. the Corporate Nurse and DON said they had a system with the Podiatrist. The procedure was the podiatrists was to leave a census sheet and if there were any orders associated with the visit they would be noted on that sheet. The Corporate Nurse said in most facilities the Podiatrist asked for who they could see and who they could not related to payor source. The DON said the Podiatrist had not been to the facility since she had been working there. They did not have a DON during the last Podiatrist visit. The Corporate Nurse said the Podiatrist was to meet with the DON or the Administrator prior to exit. They said there was a failure of the Podiatrist to communicate the order or write the order down. The Corporate Nurse said she did not know why a nurse would have told her not to write the order down. There were plenty of physician order forms at the nurse's station. The DON said they could not determine who the order was given to or why the order did not get transcribed. The Corporate Nurse said they were going to have some communication with the Podiatrist. During a record review and interview on 8/15/23 at 11:00 a.m. the Corporate Nurse said they had an issue with the Podiatrist. Review of the Podiatrist's notes indicated all residents had the same diagnoses of poor circulation, diseased toenails, on left and right feet like she copied and pasted, the only difference were the medications. Review of records revealed Resident#1 was the only resident on 6/29/23 with an order. Review of the note's indicated the residents were educated even the confused ones, and all had debridement. Review of the notes for 36 residents indicated they all reflected similar information. There was one code used on all the records code 11721- debridement of nails. Review of the 2/3/23 podiatrist consult notes indicated the same code and the same similarities in the records. The Corporate Nurse said perhaps the 11721 was a pay code they used to bill for services. The Corporate Nurse said they had a computer system Plan of Care (POC) that triggered when to do the skin assessments. She was checking that system to determine why assessments were not completed as they should have been. She could not tell if the system did not trigger the need to do the assessments or if staff had just no completed them as required. During an interview on 8/15/23 at 12:40 p.m. the DON said she could not determine who put the bandage on Resident #1's foot that was discovered on 8/8/23. During an interview on 8/15/23 at 2:00 p.m. with RN K and the Corporate Nurse, RN K said she saw Resident #1's foot but it had been a while, about 6 weeks. She said she had not seen a bandage on his foot and did not remember what the foot looked like. Corporate Nurse said RN K completed a skin assessment on Resident #1 on 6/19/23 (the day the PTA said Resident #1 was complaining of foot pain) RN K said she could not remember what the foot looked like. She said all diabetic residents had the thick toenails with fungus. She did not remember anything different about Resident #1's feet. During an interview on 8/16/23 at 3:38 p.m. LVN L said she never saw Resident #1's foot. (She completed Resident #1's a skin assessment on 7/10/23.) Record review of the facility's skin management documentation workflow dated 5/23/22 indicated to complete skin assessments on admission observation. Document all skin alterations to include abrasions, bruises, burn, dermatitis, laceration, rash, skin graft, skin tear, surgical incision, and ostomies and other areas. Complete a weekly Braden Scale observation each week post admission for three weeks. Complete weekly head to toe skin inspections. These are to be competed and documented in the POC computer system as they are scheduled. Record review of an in-service dated 8/10/23 indicated Nursing Care of the Older Adult with Diabetes indicated Skin and Foot Care: Skin should be kept as dry and clean as possible apply lotion to dry skin as needed unless contraindicated. Use antiseptic technique in caring for any lacerations, abrasions of or breaks in skin integrity, and report the condition immediately to your supervisor. Bathe the feet in warm hot water as necessary to keep clean. Keep the feet dry, especially between the toes. Encourage the use of non-constricting, well-fitting shoes, slippers, and hose. Keep the feet warm without the use of external heat sources Record review of the facility's in-service conducted on 8/10/23 the in-service indicated CNAs reporting and documenting skin injuries on weekly shower sheets and PRN notifications. The in-service indicated CNAs should report all skin injuries, discoloration, skin tears, lacerations, blisters, pressure injuries, open areas, to the charge nurse immediately. The area should be indicated on the CNA shower sheets when turned into the nurse, after notification to the charge nurse. Resident skin should be checked during showers/ bed baths, turning and repositioning, dressing, and toileting. CNAs should be moisturizing resident skin daily, and using moisture barrier to resident buttocks, peri-area, and groins after performing incontinent care. If there was a dressing without nursing initials or dates are found to be in place, notify the charge nurse immediately. If dressings become dislodged, or soiled, notify the charge nurse so that the dressing can be changed. Check for breaks and skin and pressure ulcers to the external portions of the ear. When giving bed baths remove residence clothing, undergar[TRUNCATED]