**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 8 (Resident #1) residents reviewed for abuse. 1.The facility failed to prevent MA A from physically abusing Resident #1 on 5/23/25 witnessed by Resident #2's family member. 2. The facility failed to protect other residents in the building from potential abuse when on 05/23/2025 the facility did not suspend MA A for 1 month after the incident leading to MA A's termination on 06/27/2025. The noncompliance was identified as PNC. The IJ began on 5/23/25 and ended on 6/30/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings included: 1. Record review of the face sheet dated 7/1/25 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, psychosis, restlessness and agitation, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident # 1 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #1 had a BIMS of 00 and was severely cognitively impaired. The MDS indicated during the 7-day look back period, Resident #1 did not have any physical or verbal behaviors towards others. Record review of the care plan last updated 3/12/25 indicated Resident #1 had a diagnosis of anxiety and exhibited signs and symptoms of anxiety/behaviors of pacing and aggression. Record review of the PIR dated 6/23/25 indicated Resident #2's (another resident residing in the secured unit) family member reported to the DON that they witnessed MA A punch Resident #1 in the chest after Resident #1 kicked MA A on 5/23/25. The PIR indicated Resident #2's family member reported the incident to the former ADON on 5/27/25. The PIR indicated Resident #2's family member said the former ADON told them he had removed MA A from the secured unit, and that MA A would no longer be assigned to cover the secured unit. The PIR indicated Resident #2's family member said the reason they were disclosing this information now was because MA A had been assigned to an overnight shift on the unit on 6/20/25. The PIR indicated a skin assessment was performed on 6/23/25 on Resident #1, MA A was suspended and later terminated, safe surveys were completed, notifications were made to the NP and Resident #1's family, staff were in-serviced regarding abuse/neglect, mandatory notifications, and behavior management and de-escalation, and the former ADON was given a one-to-one in-service regarding abuse/neglect and mandatory notifications. During an interview on 7/1/25 at 11:28 a.m. the former ADON said he remembered on 5/23/25 he walked on to the secured unit and heard staff talking about something (He was not sure what was being discussed). He said he gathered it had something to do with MA A. The former ADON said he left the secured unit, and no one reported anything to him while he was on the unit. The former ADON said about 30 minutes later MA A was walking past his office and he asked her to come in and talk to him. The former ADON said he asked MA A what was going on. The former ADON said MA A told him she almost lost it on Resident #1 after he (Resident #1) kicked her, but she did not lose it and that the former ADON should be proud of her. The former ADON said MA A said Resident #2's family member had witnessed the incident. The former ADON said later (date not given) Resident #2's family member told him she had seen Resident #1 trip MA A. The former ADON said Resident #2's family member said it could have been bad and they did not know what would have happened if they had not witnessed the incident. The former ADON said Resident #2's family member had told him they did not feel MA A should be working on the secured unit. The former ADON said he changed MA A's work assignment and took her off the secured unit. The former ADON said he informed Resident #2's family member of who the abuse coordinator was, and they said they did not want to report anything. The former ADON said he did not report the incident to the Administrator due to nothing being specifically reported to him regarding abuse. The former ADON said he resigned from his ADON position, but had chose to remain at the facility as a charge nurse. During an interview on 7/1/25 at 11:38 a.m. MA A said on 5/23/25 she was walking around a table to sit down when Resident #1 tripped/kicked her, and she fell into the table. MA A said she pushed Resident #1 in the shoulder and told him no we don't do that. MA A said staff should never lay hands on a resident because it was considered abuse. MA A said she had just reacted that day and did not think anything of it because it was more of a push than a hit. During an interview on 7/1/25 at 1:05 p.m. Resident #2's family member said they witnessed the incident between MA A and Resident #1. Resident #2's family member said MA A was walking past Resident #1 when he kicked her in the butt. Resident #2's family member said MA A stumbled and almost fell. Resident #2's family member said when MA A regained her balance, she doubled up her fist and hit Resident #1 in the chest. Resident #2's family member said they reported the incident to the former ADON 4 days later and they did not know what came of it. Resident #2's family member said they had recently reported the incident to the Administrator because MA A was working on the secured unit again and they were afraid of what might happen if MA A was on the unit at night by herself with no witness. During an interview on 7/3/25 at 2:25 p.m. the Administrator said she expected staff to act professional and not hit the residents. The Administrator said all residents had the right to be safe from abuse. Record review of the facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy last revised April 2021 indicated Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents' symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: a. facility staff.5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems.10. Protect residents from any further harm during investigations. The Administrator was notified on 7/1/25 at 4:45 p.m. that a Past Non-Compliance Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 7/1/25 at 4:52 p.m. The facility had corrected the noncompliance prior to surveyor entrance by the following: Suspending and Terminating MA A In-servicing staff regarding abuse and neglect, mandatory notifications, and behavior management and de-escalation. The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: Suspending and Terminating MA A In-servicing staff regarding abuse and neglect, mandatory notifications, and behavior management and de-escalation.The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: Record review of Record of Employee Counseling dated 6/27/25 indicated on 6/23/25 an allegation of abuse was made against MA A. The Record of Employee Counseling indicated MA A was immediately suspended on 6/23/25 pending investigation. The Record of Employee Counseling indicated the outcome of the investigation was that MA A, by her own statement, did place her hands on Resident #1's chest and push him. The Record of Employee Counseling indicated MA A was terminated on 6/27/25. Record review of Record of Employee Counseling dated 6/26/25 indicated the former ADON received written counseling regarding failing to notify the Administrator, abuse coordinator, of an allegation of abuse. The Record of Employee Counseling indicated the former ADON would immediately report any knowledge of allegations of abuse/neglect to the Administrator. Record review of in-services dated 6/23/25 indicated all staff were in-serviced regarding abuse and neglect and immediate notifications required to be made to the Administrator and DON Record review of in-services dated 6/30/25 indicated all staff were in-serviced regarding dementia, aggressive behaviors, and de-escalation of a situation.Staff interviewed (CNA B, LVN C, LVN D, CNA E, CNA F, CNA G, LVN H, Housekeeper J, CNA K, and the Director of Housekeeping) on 7/1/25 between 2:00 p.m. and 2:20 p.m. were able to name all types of abuse, what to do in the event of witnessed or reported abuse, and who the Abuse Coordinator was.Record review of the Skin assessment dated [DATE] indicated Resident #1 did not have any skin issuesRecord review of the Safe 'Surveys conduct on 6/23/25 indicated residents interviewed did not have any concerns or complaints, felt staff treated them with dignity and respect, felt safe and comfortable at the facility, had not witnessed or heard anyone be mistreated, and was not afraid of any resident or visitor.Observations made between 7/1/25 and 7/3/25 indicated staff treated resident with dignity and respect.Residents interviewed (Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) on 7/1/25 and 7/2/25 between 9:20 a.m. and 3:15 p.m. said they were treated well at the facility, were not scared of anyone in the facility, and no one in the facility had ever abused them physically or verbally. The noncompliance was identified as PNC. The IJ began on 05/23/2025 and ended on 06/23/2025. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but , but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 8 (Resident #1) residents reviewed for abuse and neglect. The facility failed to ensure an allegation of abuse on 05/23/2025 was reported within 2 hours to the abuse coordinator on 5/27/25 when Resident #2's family member reported the abuse of Resident #1 to the former ADON. This failure to report resulted in MA A continuing to work with residents and being assigned to Resident #1's unit again on 06/20/2025. MA A continued to work until the family member reported the incident to the Administrator on 06/23/2025. The facility failed to report the allegation of abuse within 24 hours on 05/23/2025 when MA hit Resident #1. The facility failed to suspend MA A for 1 month after the incident. The noncompliance was identified as PNC. The IJ began on 5/23/25 and ended on 6/30/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings included: Record review of the face sheet dated 7/1/25 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, psychosis, restlessness and agitation, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident # 1 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #1 had a BIMS of 00 and was severely cognitively impaired. The MDS indicated during the 7-day look back period Resident #1 did not have any physical or verbal behaviors towards others. Record review of the care plan last updated 3/12/25 indicated Resident #1 had a diagnosis of anxiety and exhibited signs and symptoms 0f anxiety/behaviors of pacing and aggression. Record review in TULIP on 7/1/25 indicated the incident of alleged abuse by MA A to Resident #1 that occurred on 5/23/25 was not reported to the state agency until 6/23/25. Record review of the PIR dated 6/23/25 indicated Resident #2’s family member reported to the DON that they witnessed MA A punch Resident #1 in the chest after Resident #1 kicked MA on 5/23/25. The PIR indicated Resident #2’s family member reported the incident to the former ADON on 5/27/25. The PIR indicated Resident #2’s family member said the former ADON told them he had removed MA A from the secured unit, and that MA A would no longer be assigned to cover the secured unit. The PIR indicated Resident #2’s family member said the reason they were disclosing this information now was because MA A had been assigned to an overnight shift on the unit on 6/20/25. The PIR indicated a skin assessment was performed on Resident #1, MA A was suspended and later terminated, safe surveys were completed, notifications were made to the NP and Resident #1’s family, staff were in-serviced regarding abuse/neglect, mandatory notifications, and behavior management and de-escalation, and the former ADON was given a one-to-one in-service regarding abuse/neglect and mandatory notifications. During an interview on 7/1/25 at 11:28 a.m. the former ADON said he remember on 5/23/25 he walked on to the secured unit and heard staff talking about something (He was not sure what was being discussed). He said he gathered it had something to do with MA A. The former ADON said he left the secured unit, and no one reported anything to him while he was on the unit. The former ADON said about 30 minutes later MA A was walking past his office and he asked her to come in and talk to him. The former ADON said he asked MA A what was going on. The former ADON said MA A told him she almost lost it on Resident #1 after he (Resident #1) kicked her, but she did not lose it and that the former ADON should be proud of her. The former ADON said MA A said Resident #2’s family member had witnessed the incident. The former ADON said later (date not given) Resident #2’s family member told him she had seen Resident #1 trip MA A. The former ADON said Resident #2’s family member said it could have been bad and they did not know what would have happened if they had not witnessed the incident. The former ADON said Resident #2’s family member had told him they did not feel MA A should be working on the secured unit. The former ADON said he changed MA A’s work assignment and took her off the secured unit. The former ADON said he informed Resident #2’s family member of who the abuse coordinator was, and they said they did not want to report anything. The former ADON said he did not report the incident to the Administrator due to nothing being specifically reported to him regarding abuse. The former ADON said he resigned from his ADON position but had chosen to remain at the facility as a charge nurse. l During an interview on 7/1/25 at 1:05 p.m. Resident #2’s family member said they witnessed the incident between MA A and Resident #1. Resident #2’s family member said MA A was walking past Resident #1 when he kicked her in the butt. Resident #2’s family member said MA A stumbled and almost fell. Resident #2’s family member said when MA A regained her balance, she doubled up her fist and hit Resident #1 in the chest. Resident #2’s family member said they reported the incident to the former ADON 4 days later and they did not know what came of it. Resident #2’s family member said they had recently reported the incident to the Administrator because MA A was working on the secured unit again and they were afraid of what might happen if MA A was on the unit at night by herself with no witness. During an interview on 7/3/25 at 2:25 p.m. the Administrator said she expected staff to act professional and not hit the residents. The Administrator said all residents had the right to be safe from abuse. The Administrator said she reported the incident of alleged abuse on 5/23/25 as soon as she found out about the incident on 6/23/25. The Administrator said she expected staff to immediately report any incidents of alleged or suspected abuse to her immediately. The Administrator said the importance of reporting abuse to the state agency in a timely manner was to aide in preventing further abuse and to protect the residents from abuse. Record review of the facility’s Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy last revised September 2022 indicated, “All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management….Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines…3. “Immediately” is defined as: a. withing two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in bodily injury…12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete…” The Administrator was notified on 7/1/25 at 4:45 p.m. that a Past Non-Compliance Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 7/1/25 at 4:52 p.m. The facility had corrected the noncompliance prior to surveyor entrance by the following: • Suspending and Terminating MA A• In-servicing staff regarding abuse and neglect, mandatory notifications, and behavior management and de-escalation. The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: • Record review of Record of Employee Counseling dated 6/27/25 indicated on 6/23/25 an allegation of abuse was made against MA A. The Record of Employee Counseling indicated MA A was immediately suspended on 6/23/25 pending investigation. The Record of Employee Counseling indicated the outcome of the investigation was that MA A, by her own statement, did place her hands on Resident #1’s chest and push him. The Record of Employee Counseling indicated MA A was terminated on 6/27/25.• Record review of Record of Employee Counseling dated 6/26/25 indicated the former ADON received written counseling regarding failing to notify the Administrator, abuse coordinator, of an allegation of abuse. The Record of Employee Counseling indicated the former ADON would immediately report any knowledge of allegations of abuse/neglect to the Administrator .• Record review of in-services dated 6/23/25 indicated all staff were in-serviced regarding abuse and neglect and immediate notifications required to be made to the Administrator and DON• Record review of in-services dated 6/30/25 indicated all staff were in-serviced regarding dementia, aggressive behaviors, and de-escalation of a situation.Staff interviewed (CNA B, LVN C, LVN D, CNA E, CNA F, CNA G, LVN H, Housekeeper J, CNA K, and the Director of Housekeeping) on 7/1/25 between 2:00 p.m. and 2:20 p.m. were able to name all types of abuse, what to do in the event of witnessed or reported abuse, and who the Abuse Coordinator was. Record review of the Skin assessment dated [DATE] indicated Resident #1 did not have any skin issues Record review of the Safe 'Surveys conduct on 6/23/25 indicated residents interviewed did not have any concerns or complaints, felt staff treated them with dignity and respect, felt safe and comfortable at the facility, had not witnessed or heard anyone be mistreated, and was not afraid of any resident or visitor. Observations made between 7/1/25 and 7/3/25 indicated staff treated resident with dignity and respect. Residents interviewed (Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) on 7/1/25 and 7/2/25 between 9:20 a.m. and 3:15 p.m. said they were treated well at the facility, were not scared of anyone in the facility, and no one in the facility had ever abused them physically or verbally. The noncompliance was identified as PNC. The IJ began on 05/23/2025 and ended on 06/23/2025. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress from 1 of 11 staff members (MA A) and 1 of 8 residents (Resident #1) reviewed for abuse.The facility failed to protect residents from potential abuse when MA A was not suspended after an allegation of physical abuse was reported to the former ADON on 05/27/25. This failure to report resulted in MA A continuing to work with residents and being assigned to Resident #1's unit again on 06/20/2025. MA A continued to work until the family member reported the incident to the Administrator on 06/23/2025. The noncompliance was identified as PNC. The IJ began on 5/27/25 and ended on 6/30/25. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk for further abuse from a staff member. Findings included: Record review of the face sheet dated 7/1/25 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, psychosis, restlessness and agitation, and anxiety disorder. Record review of the MDS dated [DATE] indicated Resident # 1 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #1 had a BIMS of 00 and was severely cognitively impaired. The MDS indicated during the 7-day look back period Resident #1 did not have any physical or verbal behaviors towards others. Record review of the care plan last updated 3/12/25 indicated Resident #1 had a diagnosis of anxiety and exhibited signs and symptoms 0f anxiety/behaviors of pacing and aggression. Record review of the PIR dated 6/23/25 indicated Resident #2’s family member reported to the DON that they witnessed MA A punch Resident #1 in the chest after Resident #1 kicked MA on 5/23/25. The PIR indicated Resident #2’s family member reported the incident to the former ADON on 5/27/25. The PIR indicated Resident #2’s family member said the former ADON told them he had removed MA A from the secured unit, and that MA A would no longer be assigned to cover the secured unit. The PIR indicated Resident #2’s family member said the reason they were disclosing this information now was because MA A had been assigned to an overnight shift on the unit on 6/20/25. The PIR indicated a skin assessment was performed on Resident #1, MA A was suspended and later terminated, safe surveys were completed, notifications were made to the NP and Resident #1’s family, staff were in-serviced regarding abuse/neglect, mandatory notifications, and behavior management and de-escalation, and the former ADON was given a one-to-one in-service regarding abuse/neglect and mandatory notifications. Record review of MA A’s daily timecard dated 5/23/25 through 6/23/25 indicated MA A worked on the following days:5/23/25-8.07 hours5/24/25-8.43 hours5/26/25-7.82 hours5/27/25-8.15 hours5/28/25-8.03 hours5/29/24-7.87 hours5/30/25-7.48 hours5/31/25-8.32 hours6/2/25-8.00 hours6/3/25-5.82 hours6/4/25-7.87 hours6/5/25-7.98 hours6/6/25-8.05 hours6/9/25-8.07 hours6/10/25-13.20 hours6/11/25-0.43 hours6/12/25-8.13 hours6/13/25-8.32 hours6/16/25-7.10 hours6/17/25-7.13 hours6/18/25-8.00 hours6/19/25-7.97 hours6/20/25-14.70 hours6/23/25-2.85 hoursThe daily timecard did not indicate where in the facility MA A had worked on these days. During an interview on 7/1/25 at 11:28 a.m. the former ADON said on 5/23/25 he walked on to the secured unit and heard staff talking about something. He said he gathered it had something to do with MA A. The former ADON said he left the secured unit and no one reported anything to him while he was on the unit. The former ADON said about 30 minutes later MA A was walking past his office and he asked her to come in and talk to him. The former ADON said he asked MA A what was going on. The former ADON said MA A told him she almost lost it on Resident #1 after he kicked her but she did not and that the former ADON should be proud of her. The former ADON said MA A said Resident #2’s family member had witnessed the incident. The former ADON said later (date not given) Resident #2’s family member told him she had seen Resident #1 trip MA A. The former ADON said Resident #2’s family member said it could have been bad and they did not know what would have happened if they had not witnessed the incident. The former ADON said Resident #2’s family member had told him they did not feel MA A should be working on the secured unit. The former ADON said he changed MA A’s work assignment and took her off the secured unit. The former ADON said informed Resident #2’s family member of who the abuse coordinator was and they said they did not want to report anything. The former ADON said he did not report the incident to the Administrator due to nothing being specifically reported to him regarding abuse. During an interview on 7/1/25 at 1:05 p.m. Resident #2’s family member said they witnessed the incident between MA A and Resident #1. Resident #2’s family member said MA A was walking past Resident #1 when he kicked her in the butt. Resident #2’s family member said MA A stumbled and almost fell. Resident #2’s family member said when MA A regained her balance, she doubled up her fist and hit Resident #1 in the chest. Resident #2’s family member said they reported the incident to the former ADON 4 days later and they did not know what came of it. Resident #2’s family member said they had recently reported the incident to the Administrator because MA A was working on the secured unit again and they were afraid of what might happen if MA A was on the unit at night by herself with no witness. During an interview on 7/3/25 at 2:25 p.m. the Administrator said she expected staff to act professional and not hit the residents. The Administrator said all residents had the right to be safe from abuse. The Administrator said she reported the incident of alleged abuse on 5/23/25 as soon as she found out about the incident on 6/23/25. The Administrator said she expected staff to immediately report any incidents of alleged or suspected abuse to her immediately The Administrator said the former ADON should have reported the alleged abuse to her immediately and that MA A should have been suspended on 5/27/25. The Administrator said the importance of reporting abuse to the state agency in a timely manner was to aide in preventing further abuse and to protect the residents from abuse. Record review of the facility’s Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy last revised April 2021 indicated “Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents’ symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: a. facility staff…5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems…10. Protect residents from any further harm during investigations…” Record review of the facility’s Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy last revised September 2022 indicated, “All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management….Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines…3. “Immediately” is defined as: a. withing two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does no involve abuse or result in bodily injury…12. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete…”Record review of the Long-Term Care Regulatory Provider Letter issued 7/10/19 indicated, “…The facility becomes aware of, or receives, an allegation of suspected abuse, neglect, exploitation, or another reportable incident….Report the incident within 24 hours of within 2 hours depending on the incident. Complete an internal investigation of the incident, Take appropriate corrective action. Report the investigation findings within 5 working days from the initial report to HHSC on form 3613-A. Maintain evidence demonstrating results of all incidents for no less than three years after the reported allegation.” The Administrator was notified on 7/1/25 at 4:45 p.m. that a Past Non-Compliance Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 7/1/25 at 4:52 p.m. The facility had corrected the noncompliance prior to surveyor entrance by the following: • Suspending and Terminating MA A• In-servicing staff regarding abuse and neglect, mandatory notifications, and behavior management and de-escalation. The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: • Record review of Record of Employee Counseling dated 6/27/25 indicated on 6/23/25 an allegation of abuse was made against MA A. The Record of Employee Counseling indicated MA A was immediately suspended on 6/23/25 pending investigation. The Record of Employee Counseling indicated the outcome of the investigation was that MA A, by her own statement, did place her hands on Resident #1’s chest and push him. The Record of Employee Counseling indicated MA A was terminated on 6/27/25.• Record review of Record of Employee Counseling dated 6/26/25 indicated the former ADON received written counseling regarding failing to notify the Administrator, abuse coordinator, of an allegation of abuse. The Record of Employee Counseling indicated the former ADON would immediately report any knowledge of allegations of abuse/neglect to the Administrator .• Record review of in-services dated 6/23/25 indicated all staff were in-serviced regarding abuse and neglect and immediate notifications required to be made to the Administrator and DON• Record review of in-services dated 6/30/25 indicated all staff were in-serviced regarding dementia, aggressive behaviors, and de-escalation of a situation.Staff interviewed (CNA B, LVN C, LVN D, CNA E, CNA F, CNA G, LVN H, Housekeeper J, CNA K, and the Director of Housekeeping) on 7/1/25 between 2:00 p.m. and 2:20 p.m. were able to name all types of abuse, what to do in the event of witnessed or reported abuse, and who the Abuse Coordinator was. Record review of the Skin assessment dated [DATE] indicated Resident #1 did not have any skin issues Record review of the Safe 'Surveys conduct on 6/23/25 indicated residents interviewed did not have any concerns or complaints, felt staff treated them with dignity and respect, felt safe and comfortable at the facility, had not witnessed or heard anyone be mistreated, and was not afraid of any resident or visitor. Observations made between 7/1/25 and 7/3/25 indicated staff treated resident with dignity and respect. Residents interviewed (Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) on 7/1/25 and 7/2/25 between 9:20 a.m. and 3:15 p.m. said they were treated well at the facility, were not scared of anyone in the facility, and no one in the facility had ever abused them physically or verbally. The noncompliance was identified as PNC. The IJ began on 05/23/2025 and ended on 06/30/2025. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for seven of seven residents (Resident #1, #3, #4, #5, #6, #7, and #8) reviewed for accidents and hazards in that: 1. The facility failed to ensure the gate in the courtyard was locked and the alarm was functioning after Resident #1 eloped. 2. The facility failed to follow their policy and monitor the alarms daily. 3. The facility failed to secure the side door on Hall 500 and there was no alarm on it. Resident #3, #4, #5, #6, #7, and #8 were in the facility at this time and were at risk of elopement. 4. The facility failed to monitor and supervise residents in the courtyard who were an elopement risk. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 08/23/23 at 03:52 PM. While the IJ was removed on 08/24/23 at 11:10 AM, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place the residents at risk for serious harm, serious injury, or death. Findings included: 1. Record review of Resident #1's face sheet, dated 08/22/23, indicated she was an [AGE] year-old female, admitted on [DATE]. Her diagnoses included dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), diabetes mellitus type 2 (a long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels), heart failure (a condition that occurs when the heart muscle doesn't pump blood as well as it should), and repeated falls. Record review of Resident #1's annual MDS assessment, dated 07/13/23, indicated she had a BIMS score of 04, which indicated severe cognitive impairment. The MDS indicated she exhibited behaviors of wandering at least 1-3 of 7 days of the assessment. Resident #1 required limited assistance with bed mobility, transfers, walking in room and the corridor, locomotion on and off unit, and eating. She required extensive assistance with dressing, toileting, and personal hygiene. She normally used a wheelchair as a mobility device. She required insulin injections and diuretic medications 7 of 7 days of the assessment. She used a wander/elopement alarm daily. Record review of Resident #1's physician's orders, dated 08/22/23, indicated she had this order: *May have Wanderguard bracelet. Verify placement each shift. Special instructions: left lower leg. Every Shift. The start date was 09/15/22. Record review of Resident #1's care plan, last edited 08/07/23, indicated a problem of resident is at risk for wandering around facility with/without purpose. Interventions included: *observe resident when out of room for wandering in/out of other rooms, wandering to unauthorized areas and provide redirection when needed. *wanderguard to ankle for safety *If wandering increases and places resident at risk for injury, or leaving facility, notify MD, RP, ADMIN, DON and assess, discuss possible need for secure unit/proper placement. *Maintenance to check all alarm functions Further record review of Resident #1's care plan, edited on 07/24/23, indicated a problem of potential for elopement resident verbalizing she needs to get out of building. She often believes she needs to leave to her her children to/from school. Interventions included: *Assess resident for use of wanderguard system, Wanderguard placed to left ankle. *Attempt to make resident feel secure/safe within facility *Re-direct if resident attempts to elope Record review of Resident #1's elopement risk assessment, completed on 07/11/23, indicated Resident #1 was at risk for elopement. The assessment indicated Resident #1 had a history of wandering. Record review of Resident #1's provider investigation report for her elopement incident indicated she told the staff after her elopement I am trying to get out of here to leave. Further review indicated Resident #1 was located at 1830 (6:30 pm) on 08/06/23, 15 minutes after RN A last saw her inside the building. 2. Record review of Resident #3's facesheet, dated 08/22/23, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included acute respiratory disease (a serious lung condition that causes low blood oxygen), delusional disorders (a type of mental health condition in which a person can't tell what's real from what's imagined), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Record review of Resident #3's annual MDS assessment, dated 05/18/23, indicated she had a BIMS score of 06, which indicated severe cognitive impairment. The MDS indicated she exhibited behaviors of wandering at least 4-6 of 7 days of the assessment. The MDS indicated her wandering put her at significant risk of getting to a potentially dangerous place. She required supervision assistance with bed mobility, transfers, walking in room and the corridor, and locomotion on and off unit. She required limited assistance with dressing, toileting, and personal hygiene. She did not use a mobility device such as a walker or wheelchair. She used a wander/elopement alarm daily. Record review of Resident #3's physician's orders, dated 08/23/23, indicated she had this order: *May have Wanderguard bracelet. Verify placement each shift. Special instructions: left lower leg. Every Shift. The start date was 05/09/23. Record review of resident #3's care plan, last edited on 08/18/23, indicated a problem of resident is at risk for wandering and elopement with/without purpose. Interventions included: *place in wandering book at each nurse's station, as well as in wanderguard bracelet for resident's own safety. *if resident is noted attempting to wander away from facility, attempt to redirect back to facility. Offer distraction for example food, activity, call family, and if they become agitated and continue to wander, seek assistance and continue to observe for safety until resident is back in building. * If wandering increases and places resident at risk for injury, or leaving facility, notify MD, RP, ADMIN, DON and assess, discuss possible need for secure unit/proper placement. Record review of resident #3's elopement risk assessment, dated 08/14/23, indicated Resident #3 was at risk for elopement. She exhibit behaviors of making statements she was leaving, and displayed behavior(s) that may indicate an attempt to leave. 3. Record review of Resident #4's face sheet, dated 08/23/23, indicated he was a [AGE] year-old male, admitted on [DATE]. His diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and anxiety (persistent and excessive worry that interferes with daily activities). Record review of Resident #4's quarterly MDS assessment, dated 08/07/23, indicated he had a BIMS score of 0, which indicated severe cognitive impairment. The MDS indicated he exhibited behaviors of wandering at least 1-3 of 7 days of the assessment. Resident #4 required limited assistance with bed mobility, transfers, walking in room and corridor, locomotion on and off unit, dressing and eating. He required extensive assistance with toileting and personal hygiene. He did not use a mobility device such as a walker or wheelchair. He required antipsychotic and diuretic medications 7 out of 7 days of the assessment. He used a wander/elopement alarm daily. Record review of Resident #4's physician's orders, dated 08/23/23, indicated he had this order: *May have wanderguard bracelet to right ankle, verify placement every shift. The start date was 02/01/23. Record review of Resident #4's care plan, last edited on 08/02/23, indicated a problem of potential for elopement, attempted to open door. Interventions included: *continue wanderguard to ankle *assess resident for use of wanderguard system, wanderguard placed to left ankle *Re-direct if resident attempts to elope Record review of Resident #4's elopement risk assessment, dated 08/05/23, indicated he was at risk for elopement. He exhibited behaviors of history of wandering into unsafe areas, making statements he was leaving, and displaying behaviors that may indicate an attempt to leave. 4. Record review of Resident #5's face sheet, dated 08/23/23, indicated she was a [AGE] year-old female, admitted on [DATE]. Her diagnoses included insomnia (common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep), schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), and Alzheimer's disease with late onset (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Record review of Resident #5's quarterly MDS, dated [DATE], indicated she did not have a BIMS score assessment because she was rarely/never understood. She exhibited behaviors of wandering at least 1-3 of 7 days of the assessment. She required supervision assistance with walking in room and corridor, locomotion on and off unit, and eating. She required limited assistance with bed mobility and transfers. She required extensive assistance with dressing, toileting, and personal hygiene. She did not use a mobility device such as a walker or wheelchair. The MDS indicated she did not use a wander/elopement alarm. Record review of Resident #5's physician's orders, dated 08/23/23, indicated she had this order: *May have wanderguard bracelet to right ankle, verify placement every shift. The start date was 11/18/22. Record review of Resident #5's care plan, edited on 06/13/23, indicated she had a problem of potential for elopement. Interventions included: *Attempt to make resident fell secure/safe within facility *Encourage resident to verbalize feelings *re-direct if resident attempts to elope *Wanderguard system placed to right ankle Record review of Resident #5's elopement risk assessment, completed on 07/14/23, indicated she was at risk for elopement. She displayed behaviors that may indicate an attempt to leave. 5. Record review of Resident #6's face sheet, dated 08/24/23, indicated she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), psychotic disorder with delusions (a disorder in which people who have it cannot tell what is real from what is imagined), anxiety disorder (persistent and excessive worry that interferes with daily activities), insomnia (common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep), and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs and lows). Her assigned room was on the 500 hall. Record review of Resident #6's annual MDS assessment, dated 07/11/23, indicated she had a BIMS score of 15, which indicated intact cognition. She exhibited behaviors of wandering at least 1-3 of 7 days of the assessment. She required limited assistance with all activities of daily living. She normally used a walker as a mobility device. The MDS indicated she did not use a wander/elopement alarm. Record review of Resident #6's physician's orders, dated 08/24/23, indicated she had this order: *Wanderguard bracelet. Check placement every shift. Special instructions: Rolling walker. The start date was 08/24/22. Record review of Resident #6's care plan, edited 07/17/23, indicated a problem of [Resident #6] is at risk for wandering around facility with/without purpose. Looking for her dog. Has history of leaving prior facility. Packs her belongings and makes statements about going to Tennessee. Wanderguard placed to rolling walker due to resident not keeping bracelet on wrist. Interventions included: *Observe resident when out of room for wandering in/out of other rooms, wandering to unauthorized areas and provide redirection as needed. *Wanderguard to bottom of walker for safety. Takes walker with her about facility. If wandering increases and resident is placed at risk for injury, or leaving facility, notify MD, RP, Admin, DON and assess, discuss possible need for secure unit/proper placement. *If resident is noted attempting to wander away from facility, attempt to redirect back to facility. Record review of Resident #6's elopement risk assessment, dated 07/31/23, indicated she was at risk for elopement. She exhibited behaviors of history of wandering. 6. Record review of Resident #7's face sheet, dated 08/23/23, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #7's significant change in status MDS assessment, dated 08/09/23, indicated she had a BIMS score of 0, which indicated severe cognitive impairment. The assessment indicated she exhibited behaviors of wandering daily. She required supervision assistance with walking in her room, locomotion on and off unit, and eating. She required limited assistance with bed mobility, transfers, walking in corridor, dressing, toileting, and personal hygiene. She normally used a walker as a mobility device. She received an anticoagulant medication 7 of 7 days of the assessment. She used a wander/elopement alarm daily. Record review of Resident #7's physician's orders, dated 08/23/23, indicated she had this order: *May have wanderguard bracelet. Verify placement every shift to L ankle. The start date was 04/26/23. Record review of Resident #7's care plan, edited 08/11/23, indicated she had a problem of Resident #7 is at risk for wandering around the facility with/without purpose, and requires use of a wanderguard. The interventions included: *Observe resident when out of room for wandering in/out of other rooms, wandering to unauthorized areas, and provide redirection as needed. *Wander guard for safety *If resident is noted attempting to wander away from facility, attempt to redirect back to facility. Further record review of Resident #7's care plan, edited 08/11/23, indicated a problem of potential for elopement. Interventions included: *Assess resident for use of wanderguard system. Wander guard bracelet on the left ankle. *Attempt to make resident feel secure/safe within facility. *re-direct if resident attempts to elope Record review of Resident #7's elopement risk assessment, dated 08/07/23, indicated she was at risk for elopement. She exhibited behaviors of making statements that she was leaving. 7. Record review of Resident #8's face sheet, dated 08/24/23, indicated she was an [AGE] year-old female, admitted to the facility 02/03/20. Her diagnoses included cerebral infarction (a pathologic process that results in an area of necrotic tissue in the brain, typically caused by disrupted blood supply to the brain), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and heatstroke (a condition caused by your body overheating, usually as a result of prolonged exposure to or physical exertion in high temperatures). Her assigned room was on the 500 hall. Record review of Resident #8's quarterly MDS assessment, dated 08/08/23, indicated she had a BIMS score of 0, which indicated severe cognitive impairment. The MDS indicated she exhibited behaviors of wandering 1-3 of 7 days of the assessment. She required limited assistance with locomotion off unit and eating. She required extensive assistance with bed mobility, transfers, locomotion on unit, dressing, toileting, and personal hygiene. She normally used a wheelchair as a mobility device. She used a wander/elopement alarm daily. Record review of Resident #8's physician orders, dated 08/24/23, indicated she had this order: *Wanderguard to left ankle. Verify placement every shift. The start date was 07/15/22. Record review of Resident #8's care plan, edited 08/10/23, indicated she had a problem of potential for elopement. Interventions included: *Attempt to make resident feel secure/safe within facility *Offer diversional activities such as snacks, fluids, or bingo during wandering episodes. *Re-direct if resident attempts to elope *wanderguard system applied to left ankle Record review of Resident #8's elopement risk assessment, dated 08/04/23, indicated she was at risk for elopement. She exhibited behaviors of history of wandering. During an interview on 08/23/23 at 12:08PM, RN A said she was the front station charge nurse on the day Resident #1 eloped. She said she was not assigned to Resident #1. She said a resident at the front door signaled to her that Resident #1 was outside in the parking lot propelling herself in her wheelchair. She said she went outside and was able to redirect Resident #1 back inside. She said she assessed her and she did not see any negative findings. She said she notified the DON of the elopement and put Resident #1 on 15 minute checks. She placed a CNA 1 to 1 with her for 45 minutes. She said she notified the MD and family. She said Resident #1 did not have other events after this for the rest of her shift. Before the elopement she had seen the resident moving around all over the building about 15 minutes before the elopement. She said after this she checked all the exterior door locks and alarms. She said the gate in the courtyard was open and the alarm was not making any noise. She said she closed and secured the gate. During an interview on 08/23/23 at 12:45PM, the Administrator said the gate was not locked before the elopement. He said it was latched the same way it was then. There was a latch in the ground and a latch across the gate. He said they did it this way to allow egress in case of a fire. During an interview on 08/23/23 at 12:50PM, RN A said when she was checking the gate in the smoking area on the day of Resident #1's elopement the gate in the smoking area was open and the alarm was broken and nonfunctional. She said she did not notify the Administrator or DON that the alarm was broken. She said she did not assign someone to the gate even though she knew the alarm was nonfunctional. She did not say why she did not notify administration or assign someone to the gate when asked by this surveyor. During an observation on 08/23/23 at 12:52PM, the Director of Clinical Services said they do not check on residents in the courtyard anymore. She said they used to check on them every hour as part of an old plan of corrections, but the QAPI team had decided it was no longer needed sometime before August 2023. During an interview on 08/23/23 at 12:55PM, the [NAME] President of Operations said he checked the courtyard gate and the alarm on 08/07/23. He said at that time the alarm was functional. He said the gate had two latches, one in the ground and one across the center of the gate. He said there was no lock on the gate. During an interview on 08/23/23 at 1:20PM, the DON said the gate and exterior doors were supposed to be locked. She said the maintenance man checked the gate and that the exterior doors were locked once a week. She said no one else checked the doors or gate more often than that. She said that the charge nurses were responsible for checking on any residents in the courtyard. She said there was no set frequency that they should check the courtyard for residents. She said they only had a wander guard alarm on the front door and the back door. She said there was no wanderguard on the other emergency exits at the end of the halls, or the courtyard gate. During an observation on 08/23/23 at 1:35PM, the gate to the smoker's courtyard was closed and latched. There were two latches on the gate. There was a lower latch that attached to the right side of the gate into the ground. There was another latch that attached the two sides of the gate that was a slide bolt style of latch. The gate was not locked. There was an alarm attached to the gate that sounded inside the courtyard door in the dining room of the facility. There was no wanderguard alarm. During an observation on 08/23/23 at 1:39PM, an exterior door on the 500 hall that was accessible to residents was unlocked and not alarmed. This surveyor was able to open the door and walk outside to the side of the building. There was no gate or fence outside. During an interview on 08/23/23 at 2:18PM, the Administrator said he had taken over the gate and door lock checks because the maintenance person was busy with the renovations in the facility. He said he checked the emergency exits and the courtyard gate every week on Monday. He said he checked that 500 hall side door every week on Monday as part of his gate and door lock checks. During an observation on 08/23/23 at 4:25PM, an extra wanderguard was brought near the front door. The wanderguard alarm did not sound when the wanderguard was brought near it. The front door alarm only sounded when the door was pushed on. The door was locked and required a code to exit. During an interview on 08/23/23 at 4:30PM, the Director of Clinical Services said the front door was locked because the wanderguard alarm was not functioning. She said someone was working on it today and was unable to fix it. During an interview on 08/24/23 at 8:20AM, the Director of Clinical Services said the front door wanderguard was not working on 08/23/23 because they had an outside company come in to upgrade it. She said it was not as loud as they would like so they decided to upgrade it. They had to take the board with them on 08/23/23 to make some repairs. She said they should be back on 08/24/24 to put the board back in and it should be fully repaired. She said in the meantime the door was locked and the residents cannot get out of it. During an interview on 08/24/23 at 11:26 AM, ADON B said the potential for the unlocked 500 hall side door being open was that a resident could walk out if they were not supervised. She said there was a risk of serious injury, serious harm, or death if they got out and were not found. During an interview on 08/24/23 at 11:31AM, ADON B said the potential for the unlocked 500 hall side door being open was that a resident could have eloped, and they could have gotten hurt. She said there was a potential for serious harm or serious injury. During an interview on 08/24/23 at 11:36AM, the DON said on 08/06/23 a resident notified RN A that Resident #1 was outside propelling herself in the parking lot. RN A redirected her inside and an assessment was performed. Resident #1 did not have any negative effects from being outside. Resident #1 had no complaints. RN A had no negative findings on assessment. RN A did a perimeter check on the building and increased supervision for Resident #1. She said the potential harm to a resident related to the 500 hall side door being open was death, especially with the heat. She said there was a driveway around the facility and residents could have been run over. She said a resident could fall or get lost. She said there was potential for serious harm, or serious injury. She said if RN A noticed the alarm was broken on the courtyard gate she would have expected her to notify the DON. She said she expected the nurse to assign someone to remain at the door to ensure a resident did not leave out of it while the alarm was broken. During an interview on 08/24/23 at 11:54AM, the Administrator said if a resident got out of the 500 hall side door there was potential for sunburn, heat stroke, heat exhaustion, falls, or death. He said there was potential for serious harm or serious injury. He said he expected the nurse to notify the administration if the alarm was broken. He expected her to assign someone to watch the gate if the alarm was broken. Record review of the facility's Door Weekly Testing sheet indicated the hall doors and the Smoker's courtyard gate was checked on 8/21/23. Record review of the facility's policy, signal device (wanderguard) and door alarm monitoring, dated February 2020, stated: Policy: At times, the facility admits and retains residents that are confused and have the tendency to wander about the facility. If the facility is equipped with a secured unit, these residents will normally be secured on this unit. However, some facilities do not have secured units and it becomes very important to identify residents who walk or wheel themselves unrestricted and become a threat to leave the facility unattended due to their confusion. The facility must ensure the resident's safety while utilizing the least restrictive means available. To meet this need the facility will obtain information during pre-admission or admission conferences with the resident and family regarding any history of wandering or the potential for wandering. All instances of wandering or attempted elopement will be recorded in the medical record. A plan of care will be developed and implemented with specific approaches and goals for the wanderer. The resident's name, picture, and physical description are placed in the wander book located at the nurses' station. All staff are responsible for knowing whose name is in on the list and be able to recognize the resident and be able to intervene as necessary. Every new employee will be informed of the wandering policy at orientation. A monitoring device will placed on the resident according to the manufacturer's directions. Practice Guidelines: 1. Signal device testing: The signaling device (Wanderguard) will be tested daily . .2. Door Testing: Each monitored door should be inspected once each week by the Maintenance Supervisor and recorded on the test form. In most facilities, the monitored doors will sound several times per day. This in itself provides daily testing. a. A daily inspection should be made of the monitor to ensure that the indicator light is on and that the electrical connections are secure. Any door alarms that are not routinely operated at least once per shift should be activated at least once a day as a test . Record review of the facility's policy, safety and supervision of residents, dated June 2020, stated: .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . .Facility-Oriented approach to safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI review of safety and incident/accident reports; and a facility-wide commitment to safety at all levels of the organization . .Systems approach to safety 1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, the adjusts interventions accordingly. 2. Resident supervision is a core component is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's addressed needs and identified hazards in the environment. 3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is change in the resident's condition . The Administrator was notified of an IJ on 08/23/23 at 3:52PM and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 08/24/23 at 9:15 AM and included the following: Plan of Removal Issues: 1. The facility failed to: * The facility failed to ensure the gate in the courtyard was locked and the alarm was functioning. * The facility failed to follow their policy and monitor the alarms daily. * The facility failed to secure and lock the side door on Hall 500 and there was no alarm on it. Two residents who are at risk of elopement reside on Hall 500. * The facility failed to monitor and supervise residents in the courtyard who were an elopement risk. Plan of Removal 1. Immediate actions * The gate and the alarm in the courtyard were checked and functioned on 8/23/2023 at 4pm by the administrator. * All the alarms were checked to ensure proper functionality on 8/23/2023 at 4pm by the administrator. * The side door on Hall 500 was secured with an alarm on 8/23/2023 at 4pm by the administrator. * Policy was revised for Wander Guard daily checks and exit doors weekly. * Residents at risk for elopement will be monitored every hour to ensure not in courtyard unsupervised starting 8/23/2023 at 6pm. Staff will check functionality of the alarm on the gate every shift for three days, every day for 3 days, and return to weekly checks by the Administrator on 8/23/23. 2. Education (provided by DON, RNC, ADON) * The Administrator and Maintenance Director were in-serviced on monitoring door alarms and the Wander Guard system on 8/23/2023. The Wander Guard system is monitored daily, and the exit doors are monitored weekly by the Maintenance Director. This is documented on separate daily and weekly check-off systems and sheets. * All nurses were educated on monitoring and supervising residents in the courtyard who are an elopement risk every hour on 8/23/2023. All Nurses will be in-serviced prior to next working shift. 3. Medical Director - The Medical Director has been notified of the Immediate Jeopardy at 4pm. 4. QAPI Committee Review - An interim QAPI committee meeting was completed on 8/23/2023. 5. Plan of removal date: 8/23/2023 The surveyor verification of the Plan of Removal from 08/24/23 was as follows: During an observation on 08/24/23 at 9:27AM, this surveyor opened the gate in the smoker's courtyard and heard the alarm sound in the dining room. The administrator silenced the

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) 1 of 3 (Resident #1) residents reviewed for notification of change. The facility did not notify the physician of Resident #1's decreased fluid intake, decreased urine output, increased confusion, or urinary analysis not being obtained which resulted in Resident #1 being admitted to the hospital with diagnoses of acute metabolic encephalopathy (a problem in the brain that encompasses delirium and the acute confusional state with causes including dehydration, malnutrition, and metabolic imbalances), dehydration, fluid depletion, and acute kidney injury (a condition in which kidneys suddenly cannot filter waste from the blood with causes including severe dehydration, low blood volume after bleeding, and excessive vomiting or diarrhea). This failure resulted in an identification of an Immediate Jeopardy (IJ) at 11:00 a.m. on 1/19/23. While the IJ was removed on 1/20/23, the facility remained out of compliance at actual 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. This failure could place residents at risk for not receiving care and services to meet resident needs. Findings include: 1. Record review of the consolidated physician orders dated 1/20/23 indicated Resident #1 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses including diabetes, cognitive communication disorder, urinary tract infection, hypokalemia, and paranoid schizophrenia. The physician orders indicated Resident #1 had an order to document fluid intake every shift starting 5/31/21 and was discontinued on 1/19/23. The physician orders indicated Resident #1 had an order to document urine output every shift starting 5/31/21 and was discontinued on 1/19/23. Record review of the comprehensive MDS dated [DATE] indicated Resident #1 usually understood others and usually made herself understood. The MDS indicated Resident #1 had a BIMS score of 13 and was cognitively intact. The MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required supervision with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The MDS indicated Resident #1 was occasionally incontinent. Record review of the care plan revised on 12/27/22 indicated Resident #1 had a potential fluid deficit related to diuretic use with intervention including obtain and monitor lab/diagnostic work as ordered, observe and document intake and output as per facility policy, monitor/document/report to the physician signs and symptoms of fluid deficits including but not limited to: decreased or no urine output, cracked lips, new onset of confusion, and fatigue/weakness. Record review of a dietician progress note dated 1/17/22 indicated Resident #1's estimated daily fluid needs were 2682 milliliters. The dietician progress note indicated Resident #1 had good intake. Record review of Resident #1's intake and output record indicated her average fluid intake for 12/31/22 through 1/06/23 was 487 milliliters and her averaged urine output was 216 milliners. The intake and output record indicated her average fluid intake for 1/07/23 through 1/13/23 was 297 milliliters and her average urine output was 1 milliliter. Record review of the nursing progress note dated 1/05/23 at 3:03 p.m. indicated Resident #1 received a new order for a UA. Record review of the nursing progress note dated 1/06/23 at 3:03 p.m. indicated Resident #1 was hard to arouse. The progress note indicated Resident #1 required spoon feeding by the nurse and only drank a small amount of water. Record review of the nursing progress note dated 1/09/23 at 1:13 p.m. indicated Resident #1 refused breakfast and lunch. The nursing progress note indicated Resident #1 drank 8 ounces of water. The nursing progress note indicated Resident #1 voided a small amount of urine. The nursing progress note indicated mouth care was performed on Resident #1. Record review of the nursing progress note dated 1/09/23 at 6:55 p.m. indicated Resident #1 refused her supper tray and consumed 4 ounces of water per nurse. The nursing progress note indicated Resident #1 had an incontinent episode and peri-care was performed. Record review of the nursing progress note dated 1/10/23 at 6:33 a.m. indicated Resident #1 did not void on the 10:00 p.m.- 6:00 a.m. shift. The nursing progress note indicated the nurse got Resident #1 to drink 8 ounces of water. Record review of the nursing progress note date 1/10/23 at 9:38 a.m. indicated Resident #1 refused breakfast. Record review of the nursing progress note dated 1/10/23 at 12:38 p.m. indicated Resident #1 refused lunch. The nursing progress note indicated Resident #1 would not open her eyes to verbal stimuli. The nursing progress noted indicated Resident #1 was assessed by the Medical Director. The nursing progress noted indicated Resident #1 received an order to transfer her to the emergency department for evaluation and treatment. Record review of the nursing progress noted dated 1/10/23 at 12:50 p.m. indicated Resident #1 was transferred to the emergency department via ambulance. Record review of Resident #1's hospital records dated 1/10/23 indicated she was admitted to the hospital with diagnoses of acute metabolic encephalopathy (a problem in the brain that encompasses delirium and the acute confusional state with causes including dehydration, malnutrition, and metabolic imbalances), dehydration, fluid depletion, and acute kidney injury (a condition in which kidneys suddenly cannot filter waste from the blood with causes including severe dehydration, low blood volume after bleeding, and excessive vomiting or diarrhea). The hospital records indicated Resident #1's sodium level was elevated with a level of 155 milliequivalents/liter (normal sodium level is 135-145 milliequivalents/Liter). The hospital records indicated Resident #1 was suffering from urinary retention and altered mental status upon arrival at the hospital. The hospital records indicated the nursing home staff noted Resident #1 had altered level of consciousness since 1/03/23 and progressively getting worse. The hospital records indicated the nursing home staff noted Resident #1 was not eating, drinking, or urinating. During an interview on 1/18/23 at 12:40 p.m. CNA B said signs and symptoms of dehydration included dry mouth and lethargy. CNA B said Resident #1 had a dry mouth, decreased urine output, and was lethargic. CNA B said she reported Resident #1's dry mouth, decreased urine output, and lethargy to the charge nurse. CNA B said she noticed Resident #1's change in condition on 1/09/23. During an interview on 1/18/23 at 12:53 p.m. LVN C said when a lab order was received for a UA a lab requisition should be completed and nurses should obtain the UA. LVN C said if a resident refused a UA the nurse should document the refusal in the electronic medical records. LVN C said signs and symptoms of dehydration included headache, dizziness, poor skin turgor, decreased urine output, dark urine, and confusion. During an interview on 1/18/23 at 12:58 p.m. LVN D said signs and symptoms of dehydration included lethargy, swollen tongue, not communicating, and decreased urination. LVN D said Resident #1 had signs and symptoms of dehydration including swollen tongue, not waking up, and not voiding. LVN D said she was aware Resident #1 had an order for a UA. LVN D said the UA was not obtained. LVN D said the UA was not obtained because Resident #1 was incontinent. LVN D said an in and out catheter was not attempted on Resident #1. During an interview on 1/18/23 at 1:06 p.m. The Medical Director said when he assessed Resident #1 on 1/10/23 while making rounds she looked very dehydrated. The [NAME] Director said he gave the order for Resident #1 to be sent to the emergency department on 1/10/23. The Medical Director said he was not aware whether the facility had notified him or his nurse practitioner of Resident #1's change in condition prior to him making rounds on 1/10/23. During an interview on 1/18/23 at 1:29 p.m. CNA A said she had reported Resident #1's change in condition to the charge nurse on 1/09/23. During an interview on 1/18/23 at 1:32 p.m. LVN D said she notified the physician on 1/10/23 of Resident #1's signs and symptoms of dehydration while he was in the facility making rounds. LVN D said she did not notify the physician or nurse practitioner that the UA was not obtained on Resident #1. During an interview on 1/18/23 at 1:43 p.m. the Nurse Practitioner said she was vaguely familiar with Resident #1. The Nurse Practitioner said she was aware of the order for the UA on Resident #1. The Nurse Practitioner said the order for the UA was wrote by the Psychiatric Nurse Practitioner. The Nurse Practitioner said she had been notified by an evening nurse the facility was unable to obtain the UA on Resident #1. The Nurse Practitioner said she recommended the facility perform an in and out catheterization on Resident #1 to obtain the UA. The Nurse Practitioner said she was not informed the in and out catheter had not been performed. The Nurse Practitioner said she expected to be informed if the in and out catheter was unsuccessful or unable to be performed. The Nurse Practitioner said she had not been notified of Resident #1's dehydration or change in condition. During an interview on 1/19/23 at 8:17 a.m. the Psychiatric Nurse Practitioner said she had ordered the UA on Resident #1 on 1/05/23. The Psychiatric Nurse Practitioner said she had ordered the UA on Resident #1 due to the nursing facility reporting increased hallucinations and an increase in incontinent episodes for 2-3 days. The Psychiatric Nurse Practitioner said she was not notified of the UA not being obtained on Resident #1. During an interview on 1/19/23 at 8:27 a.m. CNA B said she first noticed the change in condition with Resident #1 on 1/09/23. During an interview on 1/19/23 at 8:31 a.m. CNA A said Resident #1 had tried to drink 4-6 ounces of water by assistance from the nurse. CNA A said Resident #1 would not arouse to eat on 1/09/23. CNA A said on 1/05/23 or 1/06/23 Resident #1 required assistance with eating and drinking. CNA A said Resident #1 did not usually require assistance with eating and drinking. CNA A said Resident #1 usually drank lots of fluids, fed herself, and carried a pitcher of water at all times. CNA A said on 1/05/23 or 1/06/23 Resident #1 was not getting up or carrying around her water pitcher. CNA A said she reported the changes in Resident #1 to the charge nurse. During an interview on 1/19/23 at 8:40 a.m. LVN D said on 1/09/23 she noticed Resident #1 was not eating or drinking. LVN D said on 1/09/23 Resident #1 drank some water in the morning but would not arouse for food or fluid the rest of the day. LVN D said Resident #1 had been incontinent of bladder on 1/09/23 which was outside of her baseline. LVN D said she did not report to the physician Resident #1's decrease in food intake, decrease in fluid intake, increased need for assistance, or incontinence on 1/09/23 when she noticed the change in condition. Record review of the facility's undated Notification to Physician, Family, and others policy indicated, The facility will remain compliant with reporting guidelines as outlined by state and federal regulations. The facility will inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative and document in the residents' medical record where applicable, when there is: .A significant change in the resident's physical, mental, or psychosocial status .Notifications of non-life threatening issues will be considered timely if made within the context of the respective staff members regularly scheduled shift and as early as practicable. The closes time to the event is considered ideal. Notifications of serious injury or the potential for serious injury, life threatening events or the potential for life threatening events and any significant health issue must be made immediately . The Administrator was notified on 1/19/23 at 11:36 a.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 1/19/23 at 11:36 a.m. The facility's Plan of Removal was accepted on 1/19/23 at 4:33 p.m. and included: All residents with active physician orders Intake and Output monitoring were discontinued on 01/19/2023. Education (provided by DON or ADON) All nurses were in-serviced on Appropriately Notifying the Physician of changes in condition in a timely manner on 01/19/2023. This in-service includes competency checks by pre-test post-test. Each nurse will be in-serviced prior to returning to shift. This will be completed by 01/19/2023. Nursing will not return to shift without the in-service and pre-test post-test. All nurses were in-serviced on Policy and Procedure for obtaining a UA on 01/19/2023 which includes entering the UA as a one-time order. This in-service will be completed by 01/19/2023. Nurse administration in-serviced to assign fluid consumption and voiding by CNA as monitoring tasks unless I/O monitoring ordered by physician on 01/19/2023. All nurses were in-serviced on appropriately monitoring I&Os to include monitoring residents who are at risk for dehydration to ensure they are being assessed appropriately and not dehydrated 01/19/2023. This in-service will be completed by 01/19/2023. Nursing will not return to shift without the in-service. All nurses were in-serviced on Notifying the Physician if a UA is not obtained on 01/19/2023. Nursing will not return to shift without the in-service. On 1/20/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a randomly selected sample of residents indicated all residents reviewed who had an order for intake and output monitoring had that order discontinued on 1/19/23 Interviews of nursing staff (2-nurses on the 6:00 a.m.-2:00 p.m. shift; 1 nurse on the 7:00 a.m.- 3:00 p.m. shift, 2 nurses on the 8:00 a.m.- 5:00 p.m. shift, 2-nurses on the 2:00 p.m.- 10:00 p.m. shift; 1 nurse on the 10:00 p.m.- 6:00 a.m. shift) were performed. During these interviews' staff were able to correctly identify when to notify the physician of a resident's change in condition or unable to obtain labs; the appropriate procedure for obtaining a UA on a resident, and how to appropriately monitor resident's fluid intake and output who are at risk for dehydration. On 1/20/23 at 9:45 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to 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 maintain acceptable parameters of hydration status for 1 of 3 (Resident #1) residents reviewed for nutrition and hydration The facility did not ensure Resident #1 was monitored for fluid intake per orders which resulted in her admission to the hospital with a diagnosis of severe dehydration. The facility did not ensure Resident #1 was monitored for urine output per orders which resulted in her admission to the hospital with a diagnosis of severe dehydration. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 11:00 a.m. on 1/19/23. While the IJ was removed on 1/20/23, the facility remained out of compliance at actual 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 harm or death related to abnormal electrolyte balances, dehydration, and kidney failure. Findings include: 1. Record review of the consolidated physician orders dated 1/20/23 indicated Resident #1 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses including diabetes, cognitive communication disorder, urinary tract infection, hypokalemia, and paranoid schizophrenia. The physician orders indicated Resident #1 had an order to document fluid intake every shift starting 5/31/21 and was discontinued on 1/19/23. The physician orders indicated Resident #1 had an order to document urine output every shift starting 5/31/21 and was discontinued on 1/19/23. The medical records indicated Resident #1 had an order to obtain a urinary analysis (UA) on 1/05/23. The physician orders indicated Resident #1 had an order for furosemide (a diuretic used to treat fluid build-up that increases urination) 40mg daily starting 9/13/21. Record review of the comprehensive MDS dated [DATE] indicated Resident #1 usually understood others and usually made herself understood. The MDS indicated Resident #13 had a BIMS score of 13 and was cognitively intact. The MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required supervision with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The MDS indicated Resident #1 was occasionally incontinent. Record review of the care plan revised on 12/27/22 indicated Resident #1 had a potential fluid deficit related to diuretic use with intervention including obtain and monitor lab/diagnostic work as ordered, observe and document intake and output as per facility policy, monitor/document/report to the physician signs and symptoms of fluid deficits including but not limited to: decreased or no urine output, cracked lips, new onset of confusion, and fatigue/weakness. Record review of a dietician progress note dated 1/17/22 indicated Resident #1's estimated daily fluid needs were 2682 milliliters. The dietician progress note indicated Resident #1 had good intake. Record review of Resident #1's intake and output record for 1/01/23 through 1/09/23 indicated her fluid intake had only been documented on the following dates and shifts: 1/02/23 at 1:01 a.m. 1/02/23 at 6:37 p.m. 1/03/23 at 1:15 am 1/04/23 at 1:27 a.m. 1/05/23 at 1:16 a.m. 1/06/23 at 1:19 a.m. 1/06/23 at 8:15 p.m. 1/07/23 at 7:05 p.m. 1/08/23 at 12:40 a.m. 1/08/23 at 10:09 a.m. 1/08/23 at 11:57 p.m. Record review of Resident #1's intake and output record for 1/01/23 through 1/09/23 indicated her urine output had only been documented on the following dates and shifts: 1/02/23 at 1:01 a.m. 1/02/23 at 6:44 p.m. 1/03/23 at 1:15 a.m. 1/04/23 at 1:27 a.m. 1/05/23 at 1:16 a.m. 1/06/23 at 1:19 a.m. 1/06/23 at 8:15 p.m. 1/07/23 at 7:02 p.m. 1/08/23 at 12:40 a.m. 1/08/23 at 10:09 a.m. 1/08/23 at 11:57 p.m. Record review of Resident #1's intake and output record indicated her average fluid intake for 12/31/22 through 1/06/23 was 487 milliliters and her averaged urine output was 216 milliners. The intake and output record indicated her average fluid intake for 1/07/23 through 1/13/23 was 297 milliliters and her average urine output was 1 milliliter. Record review of Resident #1's medication administration record (MAR) indicated she had not missed any doses of her furosemide 40 mg from 1/01/23 through 1/09/23. The MAR indicated Resident #1 did not receive her furosemide 40 mg on 1/10/23 due to her condition. Record review of the nursing progress note dated 1/05/23 at 3:03 p.m. indicated Resident #1 required spoon feeding by the nurse and only drank a small amount of water. Record review of the nursing progress note dated 1/09/23 at 1:13 p.m. indicated Resident #1 refused breakfast and lunch. The nursing progress note indicated Resident #1 drank 8 ounces of water. The nursing progress note indicated Resident #1 voided a small amount of urine. The nursing progress note indicated mouth care was performed on Resident #1. Record review of the nursing progress note dated 1/09/23 at 6:55 p.m. indicated Resident #1 refused her supper tray and consumed 4 ounces of water per nurse. Record review of the nursing progress note dated 1/10/23 at 6:33 a.m. indicated Resident #1 did not void on the 10:00 p.m.- 6:00 a.m. shift. The nursing progress note indicated the nurse got Resident #1 to drink 8 ounces of water. Record review of the nursing progress note date 1/10/23 at 9:38 a.m. indicated Resident #1 refused breakfast. Record review of the nursing progress note dated 1/10/23 at 12:38 a.m. indicated Resident #1 refused lunch. The nursing progress note indicated Resident #1 would not open her eyes to verbal stimuli. The nursing progress noted indicated Resident #1 was assessed by the Medical Director. The nursing progress noted indicated Resident #1 received an order to transfer her to the emergency department for evaluation and treatment. Record review of the nursing progress noted dated 1/10/23 at 12:50 p.m. indicated Resident #1 was transferred to the emergency department via ambulance. Record review of Resident #1's hospital records dated 1/10/23 indicated she was admitted to the hospital with diagnoses of acute metabolic encephalopathy (a problem in the brain that encompasses delirium and the acute confusional state with causes including dehydration, malnutrition, and metabolic imbalances), dehydration, fluid depletion, and acute kidney injury (a condition in which kidneys suddenly cannot filter waste from the blood with causes including severe dehydration, low blood volume after bleeding, and excessive vomiting or diarrhea). The hospital records indicated Resident #1's sodium level was elevated with a level of 155 milliequivalents/liter (normal sodium level is 135-145 milliequivalents/Liter). The hospital records indicated Resident #1 was suffering from urinary retention and altered mental status upon arrival at the hospital. The hospital records indicated the nursing home staff noted Resident #1 had altered level of consciousness since 1/03/23 and progressively getting worse. The hospital records indicated the nursing home staff noted Resident #1 was not eating, drinking, or urinating. During an interview on 1/18/23 at 12:44 p.m. CNA A said residents were monitored once every 8 hours for fluid intake and urine output. CNA A said Resident #1 was encouraged to drink often. CNA A said fluid intake was documented by estimating the size of the cups of fluid residents consumed. CNA A said urine output was estimated by how many wet briefs were changed during a shift or by asking continent residents how much they had urinated during a shift. CNA A said Resident #1 would not drink for 2 days. CNA A said signs and symptoms of dehydration included little to no urine output, chapped lips, tough skin, and lethargy. CNA A said Resident #1 had chapped lips. CNA A said Resident #1 always had chapped lips due to being a mouth breather. CNA A said she did not know why Resident #1's fluid intake or urine output had not been documented routinely. CNA A said fluid intake and urine output did not get documented when the CNAs ran out of time during their shift. During an interview on 1/18/23 at 12:40 p.m. CNA B said fluid intake and urine output should be documented every shift. CNA B said fluid intake was estimated and documented by the size of the cup of fluid the residents consumed. CNA B said urine output was estimated and documented by how many times a resident required a wet brief change or by measuring foley catheter contents. CNA B said if fluid intake or urine output was not documented it was due to the CNAs not charting. CNA B said signs and symptoms of dehydration included dry mouth and lethargy. CNA B said Resident #1 had a dry mouth, decreased urine output, and was lethargic. CNA B said she reported Resident #1's dry mouth, decreased urine output, and lethargy to the charge nurse. CNA B said she noticed Resident #1's change in condition on 1/09/23. During an interview on 1/18/23 at 12:53 p.m. LVN C said fluid intake and urine output was documented every shift by the CNAs. LVN C said if a resident had a foley catheter it was the nurse's responsibility to document urine output. LVN C said documenting fluid intake and urine output was listed in the electronic medical records under orders and was a physician's order. LVN C said she was unaware why fluid intake or urine output would not be documented. LVN C fluid intake and urine output should always be documented every shift. LVN C said the importance of documenting fluid intake and urine output was to monitor resident hydration status and could indicate a resident had a urinary tract infection. LVN C said signs and symptoms of dehydration included headache, dizziness, poor skin turgor, decreased urine output, dark urine, and confusion. During an interview on 1/18/23 at 12:58 p.m. LVN D said fluid intake and urine output should be monitored daily. LVN D said it was the nurse's and CNA's responsibility to document fluid intake and urine output every shift. LVN D said documenting fluid intake and urine output every shift was listed under the orders in the electronic medical records and was a physician's order. LVN D said the importance if documenting fluid intake and urine output was to monitor for dehydration. LVN D said signs and symptoms of dehydration included lethargy, swollen tongue, not communicating, and decreased urination. LVN D said Resident #1 had signs and symptoms of dehydration including swollen tongue, not waking up, and not voiding. During an interview on 1/18/23 at 1:06 p.m. the Medical Director said he would not have ordered fluid intake and urine output to be monitored in a nursing home. The Medical Director said if there was a physician order for fluid intake and urine output to be monitored he expected the nursing facility to follow the physician order. The Medical Director said when he assessed Resident #1 on 1/10/23 while making rounds she looked very dehydrated. The [NAME] Director said he gave the order for Resident #1 to be sent to the emergency department on 1/10/23. During an interview on 1/18/23 at 1:29 p.m. CNA A said she had reported Resident #1's change in condition to the charge nurse on 1/09/23. During an interview on 1/18/23 at 1:32 p.m. LVN D said she notified the physician on 1/10/23 of Resident #1's signs and symptoms of dehydration while he was in the facility making rounds. During an interview on 1/18/23 at 1:43 p.m. the Nurse Practitioner said she was vaguely familiar with Resident #1. The Nurse Practitioner said she had not been notified of Resident #1's dehydration or change in condition. During an interview on 1/19/23 at 8:17 a.m. the Psychiatric Nurse Practitioner said she had ordered the UA on Resident #1 on 1/05/23. The Psychiatric Nurse Practitioner said she had ordered the UA on Resident #1 due to the nursing facility reporting increased hallucinations and an increase in incontinent episodes for 2-3 days. The Psychiatric Nurse Practitioner said she was not notified of the UA not being obtained on Resident #1. During an interview on 1/19/23 at 8:27 a.m. CNA B said she first noticed the change in condition with Resident #1 on 1/09/23. During an interview on 1/19/23 at 8:31 a.m. CNA A said Resident #1 had tried to drink 4-6 ounces of water by assistance from the nurse. CNA A said Resident #1 would not arouse to eat on 1/09/21. CNA A said on 1/05/23 or 1/06/23 Resident #1 required assistance with eating and drinking. CNA A said Resident #1 did not usually require assistance with eating and drinking. CNA A said Resident #1 usually drank lots of fluids, fed herself, and carried a pitcher of water at all times. CNA A said on 1/05/23 or 1/06/23 Resident #1 was not getting up or carrying around her water pitcher. CNA A said she reported the changes in Resident #1 to the charge nurse. During an interview on 1/19/23 at 8:40 a.m. LVN D said on 1/09/23 she noticed Resident #1 was not eating or drinking. LVN D said on 1/09/23 Resident #1 drank some water in the morning but would not arouse for food or fluid the rest of the day. LVN D said Resident #1 had been incontinent on bladder on 1/09/23 which was outside of her baseline. LVN D said she did not report to the physician Resident #1's decrease in food intake, decrease in fluid intake, increased need for assistance, or incontinence on 1/09/23 when she noticed the change in condition. During an interview on 1/19/23 at 9:04 a.m. the Dietary Manager said the Dietician came to the facility monthly. During an interview on 1/19/23 at 9:54 a.m. the Dietary Manager said there had not been a dietician assessment on Resident #1 since 2022. The Dietary Manager said Resident #1 had not had an assessment from the Dietician because she had not had any triggers such as significant weight loss. During an interview on 1/19/23 at 10:55 a.m. the Dietician said she had been working at the facility since September 2022. The Dietician said she had not performed and assessment on Resident #1 since she began working at the facility. The Dietician said she had not performed an assessment on Resident #1 because she had not had any triggers from a nutritional standpoint. Record review of the facility's Intake, Measuring and Recording policy dated 6/2020 indicated, The purpose of this procedure is too accurately determining the amount of liquid a resident consumes in a 24-hour period. Verify that there is a physician's order for this procedure and/or that the procedure is being performed per facility policy .Record the fluid intake as soon as possible after the resident has consumed fluids. At the end of your shift total the amounts of all liquids the resident consumed. Record all fluid intake on the intake and output record . Record review of the facility's Output, Measuring and Recording policy dated 6/2020 indicated, The purpose of this procedure is to accurately determine the amount of urine that a resident excretes in a 24-hour period. Verify there is a physician's order for this procedure and/or that the procedure is being performed per facility policy . Record review of the facility's undated Diets, Nutrition, and Hydration policy indicated, .The dietary manager, with assistance from the Dietician, will calculate daily fluid requirements for all residents with risk factors indicating a concern with fluid intake .Increased fluid needs may occur if the resident is suffering from one of the following: 1. Fever, 2. Dehydration, 3. Pressure Sores, 4. Burns, 5. Infections, 6. Urinary Tract Infection, 7. Hot Weather, 8. Vomiting, and 9. Diarrhea . The administrator was notified on 1/19/23 at 11:36 a.m. that an Immediate Jeopardy situation was identified due to the above failure. The administrator was provided the Immediate Jeopardy template on 1/19/23 at 11:36 a.m. The facility's Plan of Removal was accepted on 1/19/23 at 4:33 p.m. and included: All residents with active physician orders Intake and Output monitoring were discontinued on 01/19/2023. Education (provided by DON or ADON) All nurses were in-serviced on Appropriately Notifying the Physician of changes in condition in a timely manner on 01/19/2023. This in-service includes competency checks by pre-test post-test. Each nurse will be in-serviced prior to returning to shift. This will be completed by 01/19/2023. Nursing will not return to shift without the in-service and pre-test post-test. All nurses were in-serviced on Policy and Procedure for obtaining a UA on 01/19/2023 which includes entering the UA as a one-time order. This in-service will be completed by 01/19/2023. Nurse administration in-serviced to assign fluid consumption and voiding by CNA as monitoring tasks unless I/O monitoring ordered by physician on 01/19/2023. All nurses were in-serviced on appropriately monitoring I&Os to include monitoring residents who are at risk for dehydration to ensure they are being assessed appropriately and not dehydrated 01/19/2023. This in-service will be completed by 01/19/2023. Nursing will not return to shift without the in-service. All nurses were in-serviced on Notifying the Physician if a UA is not obtained on 01/19/2023. Nursing will not return to shift without the in-service. On 1/20/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a randomly selected sample of residents indicated all residents reviewed who had an order for intake and output monitoring had that order discontinued on 1/19/23 Interviews of nursing staff (2-nurses on the 6:00 a.m.-2:00 p.m. shift; 1 nurse on the 7:00 a.m.- 3:00 p.m. shift, 2 nurses on the 8:00 a.m.- 5:00 p.m. shift, 2-nurses on the 2:00 p.m.- 10:00 p.m. shift; 1 nurse on the 10:00 p.m.- 6:00 a.m. shift) were performed. During these interviews' staff were able to correctly identify when to notify the physician of a resident's change in condition or unable to obtain labs; the appropriate procedure for obtaining a UA on a resident, and how to appropriately monitor resident's fluid intake and output who are at risk for dehydration. On 1/20/23 at 9:45 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to 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 laboratory services were obtained to meet the needs for 1 of 3 (Resident #1) residents reviewed for laboratory services. The facility did not ensure Resident #1 had a urinary analysis performed per orders which resulted in Resident #1 being admitted to the hospital with diagnoses of acute metabolic encephalopathy (a problem in the brain that encompasses delirium and the acute confusional state with causes including dehydration, malnutrition, and metabolic imbalances), dehydration, fluid depletion, and acute kidney injury (a condition in which kidneys suddenly cannot filter waste from the blood with causes including severe dehydration, low blood volume after bleeding, and excessive vomiting or diarrhea). This failure resulted in an identification of an Immediate Jeopardy (IJ) at 11:00 a.m. on 1/19/23. While the IJ was removed on 1/20/23, the facility remained out of compliance at actual 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. This failure could place the residents at risk of not receiving lab services as ordered and suffering from an undetected infection. Findings include: 1. Record review of the consolidated physician orders dated 1/20/23 indicated Resident #1 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses including diabetes, cognitive communication disorder, urinary tract infection, hypokalemia, and paranoid schizophrenia. The physician orders indicated Resident #1 had an order to document fluid intake every shift starting 5/31/21 and was discontinued on 1/19/23. The physician orders indicated Resident #1 had an order to document urine output every shift starting 5/31/21 and was discontinued on 1/19/23. The medical records indicated Resident #1 had an order to obtain a urinary analysis (UA) on 1/05/23. Record review of the comprehensive MDS dated [DATE] indicated Resident #1 usually understood others and usually made herself understood. The MDS indicated Resident #13 had a BIMS score of 13 and was cognitively intact. The MDS indicated Resident #1 did not reject evaluation or care. The MDS indicated Resident #1 required supervision with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. The MDS indicated Resident #1 was occasionally incontinent. Record review of the care plan revised on 12/27/22 indicated Resident #1 had a potential fluid deficit related to diuretic use with intervention including obtain and monitor lab/diagnostic work as ordered, observe and document intake and output as per facility policy, monitor/document/report to the physician signs and symptoms of fluid deficits including but not limited to: decreased or no urine output, cracked lips, new onset of confusion, and fatigue/weakness. Record review of the nursing progress note dated 1/05/23 at 3:03 p.m. indicated Resident #1 received a new order for a UA. During an interview on 1/18/23 at 12:53 p.m. LVN C said when a lab order was received for a UA a lab requisition should be completed and nurses should obtain the UA. LVN C said if a resident refused a UA the nurse should document the refusal in the electronic medical records. During an interview on 1/18/23 at 12:58 p.m. LVN D said when a lab order for a UA was received it should be entered into the electronic medical records, a lab requisition should be completed and put into the lab book, and the nurses should collect the UA. LVN D said if a resident refused a lab it should be documented in the electronic medical records. LVN D said she was aware Resident #1 had an order for a UA. LVN D said the UA was not obtained. LVN D said the UA was not obtained because Resident #1 was incontinent. LVN D said an in and out catheter was not attempted on Resident #1. During an interview on 1/18/23 at 1:32 p.m. LVN D said she did not notify the physician or nurse practitioner that the UA was not obtained on Resident #1. During an interview on 1/18/23 at 1:43 p.m. the Nurse Practitioner said she was vaguely familiar with Resident #1. The Nurse Practitioner said she was aware of the order for the UA on Resident #1. The Nurse Practitioner said the order for the UA was wrote by the Psychiatric Nurse Practitioner. The Nurse Practitioner said she had been notified by an evening nurse the facility was unable to obtain the UA on Resident #1. The Nurse Practitioner said she recommended the facility perform an in and out catheterization on Resident #1 to obtain the UA. The Nurse Practitioner said she was not informed the in and out catheter had not been performed. The Nurse Practitioner said she expected to be informed if the in and out catheter was unsuccessful or unable to be performed. During an interview on 1/19/23 at 8:17 a.m. the Psychiatric Nurse Practitioner said she had ordered the UA on Resident #1 on 1/05/23. The Psychiatric Nurse Practitioner said she had ordered the UA on Resident #1 due to the nursing facility reporting increased hallucinations and an increase in incontinent episodes for 2-3 days. The Psychiatric Nurse Practitioner said she was not notified of the UA not being obtained on Resident #1. Record review of the facility's Lab and Diagnostic Test Results-Clinical Protocol dated 6/2020 indicated, The physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs. The staff will process the test requisition and arrange for tests . The Administrator was notified on 1/19/23 at 11:36 a.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 1/19/23 at 11:36 a.m. The facility's Plan of Removal was accepted on 1/19/23 at 4:33 p.m. and included: All residents with active physician orders Intake and Output monitoring were discontinued on 01/19/2023. Education (provided by DON or ADON) All nurses were in-serviced on Appropriately Notifying the Physician of changes in condition in a timely manner on 01/19/2023. This in-service includes competency checks by pre-test post-test. Each nurse will be in-serviced prior to returning to shift. This will be completed by 01/19/2023. Nursing will not return to shift without the in-service and pre-test post-test. All nurses were in-serviced on Policy and Procedure for obtaining a UA on 01/19/2023 which includes entering the UA as a one-time order. This in-service will be completed by 01/19/2023. Nurse administration in-serviced to assign fluid consumption and voiding by CNA as monitoring tasks unless I/O monitoring ordered by physician on 01/19/2023. All nurses were in-serviced on appropriately monitoring I&Os to include monitoring residents who are at risk for dehydration to ensure they are being assessed appropriately and not dehydrated 01/19/2023. This in-service will be completed by 01/19/2023. Nursing will not return to shift without the in-service. All nurses were in-serviced on Notifying the Physician if a UA is not obtained on 01/19/2023. Nursing will not return to shift without the in-service. On 1/20/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of a randomly selected sample of residents indicated all residents reviewed who had an order for intake and output monitoring had that order discontinued on 1/19/23 Interviews of nursing staff (2-nurses on the 6:00 a.m.-2:00 p.m. shift; 1 nurse on the 7:00 a.m.- 3:00 p.m. shift, 2 nurses on the 8:00 a.m.- 5:00 p.m. shift, 2-nurses on the 2:00 p.m.- 10:00 p.m. shift; 1 nurse on the 10:00 p.m.- 6:00 a.m. shift) were performed. During these interviews' staff were able to correctly identify when to notify the physician of a resident's change in condition or unable to obtain labs; the appropriate procedure for obtaining a UA on a resident, and how to appropriately monitor resident's fluid intake and output who are at risk for dehydration. On 1/20/23 at 9:45 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and 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 that a resident who needs respiratory care consistent with professional standards of practice for 1 of 14 (Resident # 5) reviewed for respiratory care. The facility did not ensure Resident #5 had replacement laryngectomy supplies (laryngectomy replacement tube) in the facility or at the bedside and a bag valve mask (handheld device used to provide rescue breaths during cardiac pulmonary resuscitation) at the bedside. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 2:27 p.m. on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of 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 respiratory infection, respiratory distress and respiratory failure. Findings included: 1.Record review of an undated face sheet indicated Resident #5 was an [AGE] year-old male, admitted to the facility on [DATE] with the diagnoses including malignant neoplasm of the laryngeal cartilage (cancer of the voice box), absence of larynx (no voice box), Chronic obstructive lung disease (group of lung diseases that block airflow), and malignant neoplasm of glottis (cancer of the true vocal cords). Record review of the consolidated physician orders dated [DATE] indicated Resident #5 had orders to suction each shift, laryngectomy tube care every morning, and cleanse stoma area with normal saline and pat dry each shift. Record review of the MDS dated [DATE] indicated Resident #5 usually understands and was usually understood. Resident #5's BIMS score was an 11 indicating moderate cognitive impairment. Resident #5 requires extensive assistance of one staff for bed mobility, dressing, toilet use, and personal hygiene. Resident #5 requires extensive assistance of two staff for transfers and total assistance of one staff with bathing. The MDS section other Major Surgery was marked involving the endocrine organs, neck, lymph nodes or thymus. Section O of the MDS indicated Resident #5 required suctioning over the last 14 days. Record review of the care plan dated [DATE] indicated Resident #5 had a laryngectomy and had a laryngectomy tube with a goal of no symptoms of infection around the stoma (airway opening) or any signs of respiratory distress. The care plan interventions for Resident #5 included clean or replace neck straps if the old one was dirty, nursing would monitor and assess the skin around the stoma for redness, drainage and signs of warmth, clean the stoma with normal saline pat dry and re-insert, clean laryngectomy tube with water and mild soap, monitor oxygen saturation, monitor for symptoms of infection around the stoma, nursing to ensure a suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at bedside at all times. During an observation and interview on initial tour on [DATE] at 10:45 a.m., Resident #5 was sitting in his wheelchair in his room. There was a suction machine sitting at bedside. There were no visible replacement tubes or oxygen available in the room . During an interview with LVN H she indicated there were no replacement tubes in the facility. LVN H indicated there was no oxygen nor a bag valve mask (mask with a bag used for rescue breathing) at bedside. LVN H indicated Resident #5's family had an extra replacement laryngectomy tube at home, but he had the replacement tube in use now. LVN H indicated the facility did not have the replacement tubes because of the expense she was told. LVN H indicated in an emergency she would have to call 911. On [DATE] at 11:30 a.m., a call and a message was placed to the Nurse Practitioner at his office with no return phone call received regarding Resident #5's laryngectomy tube and care needed. During a telephone interview on [DATE] at 11:35 a.m., the physician indicated Resident #5 was at risk to lose his airway due to a mucus plug. The physician indicated he expected Resident #5's airway to be maintained via the larygectomy tube using an AMBU bag until EMS could arrive. The physician indicated the facility did not have the training to sustain Resident #5's airway by using another airway sustaining device such as an endotracheal tube (a tube placed directly in the tracheal). During an interview on [DATE] at 11:40 a.m., the Administrator indicated the facility had no replacement tubes or emergency supplies but had suction at bedside. The Administrator indicated if anything went wrong with Resident #5, they would call EMS. During an interview on [DATE] at 11:42 a.m., the Regional Nurse, indicated it was not procedural to have a bag valve mask at bedside for Resident #5 . During an interview on [DATE] at 11:45 a.m., the DON indicated the laryngeal tube was to keep Resident #5's airway open. The DON indicated she was unsure why the facility had not purchased any replacement laryngeal tubes. During an interview on [DATE] at 11:50 a.m., the ADON indicated hopefully the extra laryngeal tube will arrive tomorrow [DATE]. The ADON indicated she believed the Administrator found a laryngeal tube in Dallas. During an interview on [DATE] at 12:50 p.m., LVN H indicated the NP wanted a tracheostomy kit at bedside and oxygen with humidification for Resident #5. Record review of a nursing note dated [DATE] indicated the NP ordered oxygen at 2-4 liters via nasal cannula if oxygen was below 90%, a concentrator at bedside along with bag mask, tracheostomy kit, and suction for Resident #5. Record review of in-services conducted in 2022 indicated there were no in-services provided to the staff related to Resident #5's laryngeal tube. The facility did conduct an in-service regarding respiratory training on [DATE] but the material did not reveal any in-service material on laryngectomy tubes or laryngectomy care. During an interview on [DATE] at 1:39 p.m., LVN H indicated if she activated EMS for Resident #5 it would take EMS 5-10 minutes to arrive and it would take 5 more minutes to get the local hospital. LVN H indicated if she had to administer rescue breathing (breaths supplied by a mask and bag) for Resident #5, she would apply the mask to his mouth and provide ventilation until EMS could get him out of the facility. During an interview on [DATE] at 1:44 p.m., the DON indicated the EMS response time would be 3 minutes and then another 3 minutes to the local emergency room. The DON indicated she would use the mask valve for respirations on the stoma site itself. The DON indicated the excess air would come out of Resident #5's mouth. The DON indicated the respiratory training in on [DATE] did not include laryngectomy training and the training was only verbal. The DON indicated no computer-based training or use of a manikin. During an interview on [DATE] at 1:47 p.m., LVN C indicated for rescue breathing for Resident #5 he would close his stoma off and perform regular cardiopulmonary resuscitation. LVN C indicated the laryngeal tube does not affect his breathing. LVN C indicated he had not cared for a laryngeal tube before now. The administrator was notified of [DATE] at 2:27 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The administrator was provided the Immediate Jeopardy template and a Plan of Removal was requested. During an interview on [DATE] at 8:45 a.m., the Administrator indicated the laryngeal replacement tube arrived last night and was in the resident's room. The facility's Plan of Removal was accepted on [DATE] at 10:29 a.m. and included: Summary: The facility failed to have the appropriate emergency supplies at bedside: a replacement laryngectomy tube, and an artificial manual breathing unit (Ambu) bag for 1 of 1 resident with a laryngeal tube. The facility failed to train staff and ensure staff competency for laryngectomy tube care. Issues: *The facility failed to have the appropriate supplies at bedside : a replacement laryngeal tube and an artificial manual breathing unit (Ambu) bag. *The facility failed to train staff and ensure staff competency for laryngectomy tube care. Immediate Actions: 1.The resident's physician and responsible party were notified by the Director on Nursing on [DATE]. All nurses were trained on appropriate laryngectomy tube care by the Director of Clinical Services on [DATE]. Ambu bag was placed at Resident #5's bedside on [DATE] An extra laryngectomy tube was obtained and placed at bedside at 9:30 p.m. on [DATE]. Plan was put in place until extra laryngectomy tube arrived as follows: *If tube comes out, clean and replace the tube. *If tube was unable to be replaced call 911. *While waiting on EMS (emergency medical services) to arrive: support the airway by monitoring secretions, suctioning as needed and monitoring oxygen saturations and completing a lung assessment. Provide supplemental oxygen with humidification as needed. 2.Education (provided by DON or ADON) *All nurses were in-serviced on appropriate laryngectomy tube care on [DATE]. This in-service includes competency checks by return demonstration. Each nurse will be in-serviced prior to return to shift. This will be completed by [DATE]. Nursing will not return to shift without the in-service and return demonstration. *All nurses were in-serviced on emergency procedures related to Cardiopulmonary Resuscitation of a person with a laryngectomy tube on [DATE] which includes appropriate placement of the Ambu (mask valve bag ventilation) over the laryngectomy to create a good seal. This in-service will be completed by [DATE]. *All nurses were in-serviced on items that need to be kept at bedside for a resident with a laryngectomy tube beginning [DATE] which includes Ambu bag and replacement laryngectomy tube. This in-service will be completed by [DATE]. Nursing will not return to shift without the in-service. *All nurses were in-serviced on what to do if laryngectomy tube was unable to be replaced on [DATE]. This in-service included: if tube comes out, clean and replace the tube. Additionally, if tube was unable to be replaced Call 911. Then, while waiting on EMS to arrive: Support the airway by monitoring secretions, suctioning as needed and monitoring oxygen saturation and completing a lung assessment, and supplemental oxygen with humidification as needed. This in-service will be completed by [DATE]. Nursing will not return to shift without the in-services. 3. The Medical Director had been notified of the Immediate Jeopardy. 4. An interim QAPI committee meeting was completed on [DATE]. During an observation on [DATE] at 8:25 a.m., Resident #5 was lying in his bed. The emergency care supplies and equipment including a tracheostomy kit, suction, Ambu bag, extra laryngeal tube, and oxygen. The suction machine and Ambu bag were sitting on a bedside table at the head of Resident #5's bed. The oxygen concentrator was stored in the room and the extra laryngeal tube was pinned under the overbed light at the head of Resident #5's bed. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to the Immediate Jeopardy (IJ) by: Interviews of the nursing staff (ADON; DON; 2 nurses on the 6:00 a.m.-2:00 p.m.; 3 agency nurses working various remove shifts; 1 nurse working 2:00 p.m. -10:00; and 2 nurses on the 10:00 p.m. -6:00 a.m.) were performed. During these interviews nurses stated correctly how to support Resident #5's airway until EMS arrived, and what items were needed at bedside to support Resident #5's airway. On [DATE] at 3:11 p.m., the Administrator was informed the IJ was removed: however, the facility remained out of compliance at a severity level of 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. Laryngectomy | Tracheostomy Education, accessed on [DATE] A total laryngectomy is typically performed when the disease cannot be managed with more conservative measures. In a total laryngectomy the entire larynx is removed (including the vocal folds, hyoid bone, epiglottis, thyroid and cricoid cartilage and a few tracheal cartilage rings). The airway is separated from the nose, mouth and esophagus. The trachea is brought forward below the level of the larynx and is sutured to the base of the neck just above the sternal notch, creating a permanent opening in the neck called a stoma. Therefore, the individual does not breathe through the upper airway. Instead, breathing occurs through the stoma. Breathing, speech, and swallowing are significantly changed after the procedure. Since the stoma is the only passageway for breathing, it is important to maintain the airway and suction the trachea through the stoma as needed, using a sterile technique. It is also important to clean the stoma, as crusting of secretions may develop that can block or occlude the stoma. It is important to teach the patient, family and/or caregivers how to care for the stoma properly, and what to do in case of an emergency. A laryngectomy is a procedure which alters the anatomy of the upper airway and results in breathing that occurs only through the stoma. The entire larynx is removed during a total laryngectomy. In tracheostomy, the upper airway is still intact. There is potential upper airway in patients with tracheostomy. Record review of an undated Laryngectomy Tube Care policy indicated the purpose of this procedure was to guide laryngectomy care. General Guidelines included: laryngectomy tubes should be changed as ordered and as needed, laryngectomy care should be provided as often as needed, at least once daily, a suction machine, supply of suction catheters, exam and sterile gloves, and flush solution must be available at the bedside at all times. rescue-breathing.pdf (d1a743corqz1mw.cloudfront.net) accessed on [DATE] Laryngectomees and other neck breathers are at great risk of getting inadequate acute care when they experience breathing difficulties or need cardiopulmonary resuscitation. It is essential that medical personnel learn to identify neck breathers and differentiate partial neck breathers from total neck breathers. Respiratory problems unique to neck breathers are mucus plugs, and foreign body aspiration. Although partial neck breathers inhale and exhale mainly through their stoma they still have a connection between their lungs, and their nose, and mouth. In contrast there is no such connection in total neck breathers. Both partial and total neck breathers should be ventilated through their tracheostomy site. However, the mouth needs to be closed and the nose sealed in partial neck breathers to prevent air escape. An infant or toddler bag valve mask should be used in ventilating through the stoma. Laryngectomees and other neck breathers are at great risk of getting inadequate acute care when they experience breathing difficulties or need cardiopulmonary resuscitation (CPR)1. Many of emergency department (ED) and emergency response services (EMS) personnel do not recognize a patient who is a neck breather, do not know how to administer oxygen to them in the proper way, and may erroneously give mouth-to-mouth breathing when mouth-to-stoma breathing is indicated. This can lead to devastating consequences because it can deprive sick people from the oxygen, they need to survive2. Prepare for Rescue Breathing The steps in rescuing a neck breather are to first determine their unresponsiveness; then activate the emergency medical services; position the person raising their shoulders; expose the neck and remove anything covering the stoma (filter, cloth) that may prevent access to the airway; secure the airway by checking the neck for a stoma, remove anything that blocks the airways such as the filter or HME if present; and clear any mucous from the stoma. It is not necessary to remove the stoma's housing unless it blocks the airway. In emergency situations, laryngectomy tubes and stoma buttons may be removed carefully if they are blocking the airway. The voice prosthesis should not be removed unless it is blocking the airway. The voice prosthesis generally does not interfere with breathing or suctioning. If the prosthesis is dislodged it should be removed and replaced with a catheter to prevent aspiration and fistula closure. If present the tracheal tube may need to be suctioned after insertion of 2-5 cc of sterile saline or removed (outer & inner) to clear any plugs. The stoma should be wiped and suctioned. The next step is to listen for breathing sounds over the stoma. The chest may fail to rise because the tracheostomy tube is blocked. If a tracheostomy tube is used for resuscitation, it should be shorter than the regular one so that it can fit the length of the trachea. Care should be used in inserting the tube so that it does not dislodge the voice prosthesis (see Figure 9). This may require the use of a tube with a smaller diameter Ventilation in neck breathers: The actual rescue breathing for neck breathers is generally similar to the one performed on normal individual with one major exception. In neck breathers ventilation and oxygen administration is done through the stoma (mouth to stoma, Figure 9 - left) or using a mask (infant/toddler or adult turned through 900, Figure 9 - right). It is useless to try mouth-to-mouth ventilation. The website https://pubmed.ncbi.nlm.nih.gov/20520261/ accessed on [DATE] stated .respiratory infections can result from the use of medical devices and respiratory supplies. These devices can contribute to the home care or hospice patient developing a respiratory infection by serving as a reservoir and supporting the growth of microorganisms and by directly infecting patients when this equipment becomes contaminated .Oxygen Therapy: Concentrator. The external filter on the concentrator should be washed with soap and water, air dried, and replaced on the oxygen concentrator minimally on a weekly basis .