**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment with services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 12 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement a comprehensive care plan including measurable objectives and timeframes to address Resident #1's medical, nursing, and mental and psychosocial needs related to his known history of signing himself out of the facility in a motorized wheelchair that did not belong to him, ambulating to nearby stores to drink alcohol until intoxicated/vomiting/lethargic and smoking marijuana in the surrounding community. As a result, the resident was ordered to be sent to the local ER on several occasions for treatment. An IJ was identified on 05/29/2025. The IJ template was provided to the facility on [DATE] at 1:20 p.m. While the IJ was removed on 05/31/2025, the facility remained out of compliance at a scope of pattern with severity level at 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 that were put into place. This failure placed residents with substance abuse issues at risk of sustaining serious injuries from possible accidents/incidents and an exacerbation/deterioration of health and wellness. Findings include: Record review of Resident #1's face sheet dated 05/28/2025 revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE]. He was diagnosed with end-stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer filter waste and excess fluid from the body), schizoaffective disorder (a chronic mental illness that combines systems of both schizophrenia and mood disorder), gastro-esophageal reflux (a chronic condition where stomach contents regularly flow back up into the esophagus), history of falling, difficulty walking, diabetes mellitus type II (chronic disease where the body either does not produce enough insulin or cannot properly use the insulin it produces) with hypoglycemia (when blood glucose levels drop too low), essential hypertension (persistently high blood pressure with no identifiable cause), chronic ischemic heart disease (long-term condition where the heart's blood supply is reduced due to a mismatch between oxygen supply and demand), chronic obstructive pulmonary disease (chronic lung disease that makes it difficult to breathe) with acute exacerbation (sudden and severe worsening of respiratory symptoms in COPD patients), unspecified cirrhosis of liver (a type of chronic, progressive liver disease where healthy liver cells are replaced by scar tissue), acute cholecystitis (inflammation of the gallbladder, typically caused by a blockage of the cystic duct), dependence on renal dialysis (treatment that cleans the blood when kidneys are unable to do so), and shortness of breath. Resident #1 was his own responsible party. Record review of Resident #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 13 (cognitively intact); Resident #1 exhibited behaviors related to rejection of care; Resident #1 used a manual wheelchair for mobility; Resident #1 was independent with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and transfers and required supervision or touching assistance for showers/bathing; Resident #1 was always continent of bowel and bladder; and Resident #1 was prescribed anticoagulant and antipsychotic medication. Record review of Resident #1's care plan, revised on 05/25/2025 revealed the following care areas: * Resident has impaired visual function and is at risk for falls, injury, and a decline in functional ability. Goals included: Resident will maintain optimal quality of life and not experience a decline in ADL functional abilities, or an injury related to vision loss. Interventions included: Arrange consultation with eye care practitioner. Assist to ensure glasses are labeled and within reach. * Resistant to Care: Resident is resistant to care and at risk for injury, a decline in functional abilities, and not having his needs met. [He] refuses to take his scheduled medications and refuses to go to his scheduled dialysis days. Goal included: Resident will not be a danger to self or others. Interventions included: If refusals continue, notify MD and family, document in resident records. Give a clear explanation of complications of not having his dialysis. Encourage as much participation as possible. Provide resident with opportunities to make decisions about his treatment. * Falls: Patient is a fall risk due to weakness of both lower extremities. Resident has the potential for falls related to unsteadiness on feet, abnormalities of gait and mobility, unspecified lack of coordination, and generalized weakness. Fall: 01/04/2025, 02/01/2025. Goal included: Resident will not sustain a fall related injury by utilizing fall precautions. Interventions included: Encourage resident not to transfer without assistance. Anticipate and meet the resident's needs. Educate the resident about safety reminders and what to do if a fall occurs. Encourage socialization and activity attendance as tolerated. * Therapeutic Leave: Resident is cognitively able to sign out of the facility and make their own informed decisions while they are out. On 04/10/2025 while on therapeutic leave, resident made the decision to consume alcoholic beverages. Goals included: The resident will follow facility policy for out on pass. The resident will be safe and comfortable while out on pass. Interventions included: Educate the resident/family/caregivers about the potential risks associated with signing out on pass. Educate resident/family/caregivers on the facility's policy for therapeutic leave/out on pass. Resident is reminded of his health issues and treatment regimens and the recommendations to avoid the use of alcoholic beverages. Further review of Resident #1's care plan revealed no care areas, goals, or interventions to address his substance abuse concerns. Record review of Resident #1's, Elopement/Wandering Risk Assessment dated 05/24/2025, completed by LVN A revealed, A. Preliminary Data. 1. Is the resident physically able to leave the facility on their own? Yes. Continue assessment. B. Evaluation. Cognition: 1. Is the resident disoriented to place or intermittently confused? Yes . Further review of the assessment revealed Resident #1 scored a 1, which indicated low/no elopement risk. Record review of Resident #1's nursing progress notes for April 2025 and May 2025 revealed: * On 04/02/2025, at 4:10 p.m., SW B wrote, Resident was educated with Administrator, ADON, DON, and SW on the policies for Therapeutic Leave and the expectations for the resident when he is on Therapeutic Leave. Resident verbalized understanding. * On 04/11/2025, at 12:10 a.m., RN E wrote, Resident came back on pass to the facility with alcohol intoxication, vitals and assessment done. All within normal baseline. NP notified. New order to transfer resident to the hospital for further evaluation but resident refused. Resident was monitored through the shift, comfort care provided to resident satisfaction. * On 04/11/2025, at 11:50 a.m., ADON F wrote, Late Entry: 04/10/2025 at 11:00 p.m. Upon resident's return to the facility, resident arrived propelling himself in his motorized wheelchair. Resident had a slurred speech, he was drooling, smiling, and laughing, slow to respond to questions, and lethargic. Resident said he was tired and wanted to lay down and go to sleep and was assisted back to his room and was unable to stand to assist with his transfer to his bed, so he was transferred to bed with two people assist. In speaking with the resident, he said that he had ingested alcohol, specifically three 40 oz bottles of [brand name of beer] and he would not say if he had ingested any other substances or drinks. Upon assessment by unit nurse, there was no evidence of trauma or physical injuries noted, no indications of any falls or any other incidents at the time of his return. * On 04/12/2025, at 7:17 p.m., LVN A wrote, Police officer called facility and said resident vomited and may have been drinking with his friend and they have called 911 for him to go to the ER and have him evaluated. They then came to the facility, and I gave him a face sheet and medication lists. I accompanied the officer to EMS parked on the street near the facility and found the patient inside the ambulance being attended to by two paramedics with patient leaning to his left side. I placed a call to the Administrator and ADON. Resident apparently signed out at about 12 noon and left the facility with another resident. They apparently went to a nearby store and purchased drinks. He drank until he vomited on himself and became very weak. I asked the paramedics where they were taking him, and they informed me that they were taking him to [a local hospital] ER. NP and RP notified. * On 04/14/2025, at 4:38 p.m., ADON F wrote, Resident was found to be in possession of a cigarette lighter. The resident was educated by the Administrator on the smoking policy and the lighter was placed in the smoker's box for the resident to have access to only when on smoke breaks. The Administrator educated the resident on use of another resident's electric wheelchair and encouraged to use his own, the resident verbalized understanding. * On 04/15/2025, at 2:11 p.m., RN H wrote, Resident signed himself out and came back vomiting. Happened a couple of times. NP notified. Lab work ordered. New order to transfer to ER for further evaluation. * On 04/16/2025, at 5:23 p.m., ADON G wrote, Final lab results received on the drug and alcohol screening, labs placed in NP binder for review . resident remains in the hospital at this time. * On 04/23/2025, at 9:46 p.m., RN E wrote, Resident, who went out on pass, returned to the facility alert but disoriented, drooling from alcohol intoxication also had multiple emesis (vomiting). Resident vitals and assessment done all vital signs were within normal baseline. NP contacted via telehealth/virtual service. New order for Ondansetron 4 MG 1 tablet PO q 6hours as needed . * On 05/01/2025, at 11:59 a.m., the SW wrote, The Social Worker and the Administrator witnessed [Resident #1] taking a power wheelchair without the permission of the resident who owns the power wheelchair. Resident was educated that he cannot take the belongings of other residents while they are out of the facility. Resident was also educated on the importance of not using someone else's wheelchair and the risks that can occur . * On 05/04/2025, at 4:41 p.m., RN H wrote, Resident exchanged wheelchair with his former roommate and resident was educated that it was not safe to do so, resident verbalized understanding. Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/10/2025 at 11:17 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Complaint: Altered Mental Status . Per nurse, patient went out on pass and returned to facility lethargic, drooling from mouth and vomited once one hour ago. Per nurse, patient only knows his name, does not know where he is, and does not know the month, year. States at baseline patient is alert and oriented x 3 (a term that describes a patient's level of consciousness and cognitive function. Patient aware of person, place, and time). Per nurse, patient admitted to drinking 3 bottles of [brand of beer]. Per nurse, patient refused dialysis today and states patient did not go to dialysis yesterday . Patient seen with nurse . Physical Exam: Exam findings per nurse and video observation . Orders: Transfer to ER via 911: AMS/ESRD - missed HD/vomiting/possible alcohol intoxication . Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/23/2025 at 10:02 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Chief Complaint: GI: Vomiting . Nurse notified clinician that the [AGE] year-old-male patient with history of ESRD on dialysis, Schizophrenia, falls, HTN, DM2, went out of the facility for an hour and came back intoxicated. The nurse stated this is a regular occurrence for him. He did have an episode of vomiting. Denies drinking alcohol. Will monitor him for now . Record review of Resident #1's Lab Results Report collected on 04/11/2025 and reported on 04/16/2025 revealed Resident #1 was positive for THC (Cannabis). Observation and interview with Resident #1 on 05/28/2025, at 2:30 p.m. revealed he was in his bed with his eyes closed. Resident #1 opened his eyes and was able to provide his name. Resident #1 stated he lived in the facility a couple of months and living there was alright. He said he went to dialysis. He said he fell out of his wheelchair about six months ago (he did not say why). Resident #1 did not answer questions related to drinking alcohol or taking drugs while outside the facility on pass. He closed his eyes and appeared to be asleep although he responded to questions unrelated to drinking or smoking. In an interview with a random resident on 05/28/2025, at 1:45 p.m., they stated Resident #1 had a known history of taking his former roommate's motorized wheelchair without permission to sign himself out of the facility and drink at nearby stores. The resident stated Resident #1 frequently drank alcohol until he was intoxicated and smoked marijuana in the community around the facility. The resident said one time, Resident #1 was swerving (change or cause to change direction abruptly) all over the sidewalk on his way back to the facility after drinking and fell out of the motorized wheelchair onto the sidewalk. The resident stated the night nurse had to go and find Resident #1 on the sidewalk. In an interview with the SW on 05/28/2025, at 3:24 p.m., she stated Resident #1 was capable of making his own decisions, but he just did not make the right decisions. She said Resident #1 went out on pass and did things he should not do. She said Resident #1 was vomiting once due to intoxication. She said the facility staff could not tell Resident #1 what he could and could not do outside of the facility, and they could only educate him. She said Resident #1 knew what he was doing. She said Resident #1 was his own RP and he did not have any family. She said to her knowledge, Resident #1 only went out twice and got drunk, but she was not there on weekends. She said she was not sure Resident #1's behaviors were addressed on his care plan, but they should have been so all staff are aware of any interventions. She stated she was not responsible for updating resident care plans. She stated she reviewed chart notes and assessed Resident #1's cognition to see if he could make his own decisions. She said Resident #1's BIMS score was high. She said possible negative outcomes of Resident #1 leaving the facility and getting drunk were that he could die, get injured, and go to the hospital. In an interview with the Administrator on 05/28/2025, at 4:32 p.m., he stated the residents had rights. He said Resident #1's BIMS score was 15, but he did not make proper decisions. He said the facility staff had to make sure they did not infringe on the residents' rights. He said Resident #1 signed himself out and returned intoxicated between five and seven times. He said he had undocumented conversations with Resident #1 about how unsafe it was for him to leave the facility and get drunk. He said the conversations were not documented because he did not go into the facility's computer system to write progress notes. He said Resident #1 was still capable of wheeling himself down the road to the store in his own manual wheelchair. He said the residents previously went to the gas station at the end of the street (the residents still had to cross a busy two-lanes road), but the store staff said they could not go there anymore. He said now, the residents go down to a store further down the road. He said he did not know if Resident #1's behaviors were care planned, but they should have been. In an interview with MDS Nurse C on 05/29/2025, at 12:25 p.m., she stated her duties included completing assessments and reviewing/updating resident care plans. She said she was responsible for residents whose last names began with A - K, so she did not update Resident #1's care plan. She said another MDS nurse who worked part-time was responsible for updating Resident #1's care plan. She said the MDS nurses reviewed and updated care plans every three months when they did quarterly MDS assessments. She said she was aware of Resident #1's behaviors related to smoking and drinking, and those behaviors should be a part of his care plan if the incidents happened. She said it was important to address those issues in Resident #1's care plan because if anything happened, they had the information in the care plan to show they were not giving him what he went outside to get (drugs and alcohol). She said negative outcomes of Resident #1's behaviors were possible if the facility did not intervene. She said Resident #1 could have serious health issues if the facility did not intervene. She said a resident's care plan should address all their behaviors. In a telephone interview with Resident #1's physician on 05/30/2025, at 10:00 a.m., he stated he was familiar with Resident #1, and he was aware the resident frequently went out on pass to drink and smoke. He said Resident #1 denied drinking and smoking, but he had a history of noncompliance with dialysis and medications. He said Resident #1 was alert and oriented to be able to sign himself out. He said Resident #1 had recently been admitted to the hospital a lot and once, at the hospital, they found he had taken drugs. He said Resident #1 kept denying, so it was hard to address it. He said the negative outcome of Resident #1's behaviors were that one day, Resident #1 is fine, and then in a couple of days, he signs out and takes something (drugs or alcohol) and something happens that leads him back in the hospital. He said he asks the facility staff to do their best to monitor Resident #1. He said once Resident #1 was off drugs and was perfectly normal, it would be safe for him to be out alone. He stated when Resident #1 was in that state (under the influence of drugs and alcohol), it was not safe for him to be out alone. He said if a resident was alert, oriented, and making the right decisions, you could not tell them they could not go out because that would be restraining them. He said he would imagine it was not safe for Resident #1 to be out like that (under the influence of drugs and alcohol), but he had the right to sign himself out. He said the facility may have to get a contract with Resident #1 to say if he continued with these behaviors, they could not handle his needs because they do not want anything bad to happen. In an interview with the VP of Operations on 05/30/2025, at 10:30 a.m., he stated the Administrator was no longer employed at the facility and Resident #1 called 911 and was transferred to the hospital related to stomach pains on 05/28/2025. In an interview with LVN A on 05/31/2025, at 2:11 p.m., he stated on 04/12/2025, around 1:00 p.m., the police called the facility and said Resident #1 had fallen out of his wheelchair and was vomiting at the church next to the facility. He said the police went to the facility and then he (LVN A) followed them to see Resident #1. He said he thought the police saw Resident #1 on the ground and called 911. He said when he arrived at the scene, he saw Resident #1 inside the ambulance. He said Resident #1 said he had gone to the store. He said Resident #1 went to the hospital and returned to the facility about two days later. LVN A said he heard the motorized chair Resident #1 fell out of belonged to his friend. In a telephone interview with MDS Nurse D on 06/02/2025, at 11:19 a.m., she stated she was responsible for updating care plans for residents whose last names began with J-Z. She said she made sure MDS assessments were done and care plans were updated. She said she got the information to update care plans by reading progress notes, reading physician's orders, talking to staff, and she observed and talked to the residents. She said she observed Resident #1 around the facility, and he was mostly independent. She even though she read through Resident #1's progress notes, she was not aware of his drinking or drug use. She said she knew he signed himself out of the facility because she saw him in the group when they went out. MDS Nurse D then said she heard Resident #1 smoked weed (marijuana). She said smoking marijuana would be something they needed to add to his care plan. She said it was her understanding that the ADON updated anything that was acute (not long-term issues). She said she only worked 20 hours per week, so she was not at the facility most days. She said she was aware of Resident #1's smoking, but not his drinking. She said she only looked at progress notes when it was time to update the MDS assessments. She said she never saw any notes about Resident #1's drinking alcohol. She said she did not have an answer for why she did not address Resident #1's smoking in his care plan. She said the ADON was at the facility more than she was and they should have updated Resident #1's care plan to address his drinking. She said in her opinion, anybody could update the care plan. She said it was important to address Resident #1's behaviors related to smoking and drinking because it was pertinent information and they needed to act on things like that to keep the resident safe. She said the nursing facility was not a place to get drunk and do drugs. She said the IDT needed to get together, call a care plan meeting, talk, and update things to make sure all Resident #1's behaviors were on his care plan. In an interview with ADON F and ADON G on 06/02/2025, at 11:45 a.m., ADON G said MDS Nurse D was not in the building a lot, so she should review progress notes daily to ensure care plans were updated appropriately. ADON F said they handled (updated care plans) regarding things that were acute, but Resident #1's drinking and drug use were not acute because he had those behaviors a while. ADON G said it was important to address those behaviors in the care plan so all staff know what is going on. ADON G said a negative outcome of not having the behaviors care planned would be that the behaviors continued and but the resident's safety at risk. Record review of the facility's policy, titled, Comprehensive care Plans revised on 09/04/2024 revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Definitions: Person-centered care means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care . 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment . Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. B. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment . d. The resident's goals for admission, desired outcomes, and preferences for future discharge . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed . Record review of the facility's policy, titled, Behavior Management revised on 04/15/2014 revealed, Policy: The purpose of the policy is to optimize the quality of life and function of patients that experience behavioral symptoms that require person centered approaches to meet the health, physical, psychosocial, and behavioral health needs. Fundamental Information: Individualized, person-centered approaches may help reduce potentially distressing or harmful behaviors and promote improved functional abilities and quality of life for dementia patients. Fundamental principles of care for a patient with behaviors include an interdisciplinary approach that focus on the individualized needs of the patient . Procedure. Determine whether there is a medical, physical, functional, physiological, emotional, psychiatric, social, or emotional cause of the behaviors . Considerations: Person-Centered Care - evaluate if the environment is supportive and promotes comfort toward understanding, preventing, relieving, and recognizes individual needs and preferences . Evaluations are completed on new or worsening behaviors . Identify the frequency, intensity, duration, severity, and impact of behaviors, as well as the location, surroundings, or situation. Identify interventions or approaches to prevent, modify, relieve, or address the behaviors or distress. Patient behaviors or distress are documented as it occurs and the effectiveness of interventions. Individualized Care Plan Approaches - individualized approaches are used as a first line intervention (except in a documented emergency situation or if clinically contraindicated) . Consistent interventions are used that focuses on a patient's individual needs . Monitor and follow-up care plan is done by the interdisciplinary team who reviews the patient's progress towards goals. Summarize effectiveness of non-pharmacological and pharmacological interventions (quarterly and as indicated), for target behaviors and/or psychological symptoms and changes in a resident's level of distress or emergence of adverse consequences. Adjust interventions as needed and identified when care objectives are not met . An IJ was identified on 05/29/2025 at 1:20 p.m. The IJ template was provided to the Administrator on 05/29/2025 at 1:20 p.m. and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 05/31/2025 at 10:42 a.m. Issue Cited: Care Plans Failure to develop and implement a comprehensive person-centered care plan 5/30/25 1. Immediate Action Taken On 5-29-25 resident #1 is currently in hospital with diagnosis of gastroenteritis (inflammation of the lining of the stomach and intestines) and ESRD. 2. Identification of Residents Affected or Likely to be Affected: A. On 5/29/25 by 3pm DON/designee identified 11 residents who sign out of the facility independently, had charts reviewed and determined by their capabilities according to their functional ability assessment (MDS section GG), and make their own choices and decisions according to their BIMs, they were reviewed for any behaviors, none were found, and care plan interventions are in place. 2. Actions to Prevent Occurrence/Recurrence: A. On 5/30/25 by 10:00 am the RNC reviewed the policy on Comprehensive Care Plans with no changes made. B. On 5/29/25 by 7:30pm DON/designee reviewed the care plans for those 11 residents identified as independently capable of signing out of the facility and making their own choices and decisions. None were found to have unsafe behaviors. Care plans were reviewed, and no updates were needed. If and when Resident #1 returns from hospital the care plan will be reviewed and updated with any unsafe behavior and the CNAs and Nurses will be in-serviced to the updated care plan at that time by DON/designee. C. On 5/30/25 by 9am the Regional Nurse Consultant in-serviced the IDT on updating comprehensive care plans to include measurable objectives, timeframes, and interventions for those residents identified as independently signing themselves out of the facility with a focus on unsafe behaviors, goals, and interventions while out of facility. The Administrator/ or designee and DON/ or designee were in-serviced by the RNC beforehand. D. DON/designee will monitor comprehensive care plans for all residents identified as capable of signing themselves out of the facility independently for any unsafe behaviors present and report findings to IDT in morning meeting and revise care plans as needed. E. All findings will be discussed during QAPI monthly and plan of care will be revised as needed. F. On 5/29/25 the facility's Administrator/ or designee notified the Medical Director regarding the Immediate Jeopardy the facility received related to Failure to Develop and Implement a Comprehensive Person-Centered Care Plan and reviewed plan to sustain compliance. Monitoring of the plan of removal included the following: Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/30/2025 revealed the IDT team (DON, Activity Director, ADON F, ADON G, MDS Nurse C, Treatment Nurse, , and a representative from the rehabilitation department) was educated by the RNC on comprehensive care plans, including measurable goals and individualized interventions. Record review of the facility's, Comprehensive Care Plans policy revealed it was reviewed by the RNC on 05/29/2025. Record review of the facility's plan of removal documentation revealed the MDS assessments and care plans for all eleven residents identified as independently capable of signing out of the facility and making their own choices and decisions were reviewed by the DON. Interviews were conducted with staff on 05/31/2025 from 10:45 a.m. until 3:00 p.m. from all shifts (nurses and CNAs worked 12-hour shifts) including the VP of Operations, RNC, DON, ADON F, ADON G, LVN A (day shift), MDS Nurse C, RN P (day shift), CNA Q (day shift), RN R (night shift), Receptionist[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure the resident received adequate supervision and assistance devices to prevent accidents as was possible for 1 (Resident #1) of 5 residents reviewed for accidents and supervision. -The facility failed to ensure a system was in place to adequately supervise Resident #1 when he left the faciity on [DATE] and did not return. The facility failed to notify law enforcement or conduct a thorough search for Resident #1. As of 03/21/25, the facility did not know Resident #1's whereabouts. An immediate Jeopardy (IJ) was identified on 03/21/25. The IJ Template was provided to the facility on [DATE] at 2:09 p.m. While the IJ was removed on 03/23/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). This failure placed residents at risk for harm, significant injury, or death. The findings included: Record review of Resident #1's admission Record, dated 03/21/25, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnosis included candidiasis (fungal infection caused by overgrowth of a type of yeast), cellulitis (serious bacterial infection of the skin), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), cognitive communication deficit (one or more cognitive processes involved in communication), and unsteadiness on feet. Record review of Resident #1's physician order's revealed he was taking the following medications: potassium chloride for on Lasix, furosemide for edema, metoprolol succinate for essential (primary) hypertension, melatonin for insomnia, aripiprazole for schizoaffective, atorvastatin calcium for high LDL, ergocalciferol for supplement, trazodone for insomnia, and sertraline HCL related to depression unspecified. Resident's medications were due. Record review of Resident #1's MDS Assessment, dated 02/26/25, revealed a BIMS score of 13, indicating cognition was intact. Further review revealed the resident did not exhibit wandering behavior. The resident was independent (completes activity by himself with no assistance from a helper) with self-care, except shower/bathe self (required supervision or touching assistance) and mobility functional abilities. Record review of Resident #1's Care Plan Report, undated, revealed resident was in the facility for long-term care placement as a result of a continued need for the services of skilled nursing staff as evidenced by an inability to provide self-care and discharge planning is not needed. Resident was not care planned for leaving out on pass. Record review of Resident #1's Elopement/Wandering Risk Assessment, dated 03/15/25, reflected Category: Elopement Risk-Low, no plan of care needed .Score: 1.0. Record review of Resident #1's progress notes, entered by ADON B and dated 03/19/25 at 16:20 [4:20 p.m.], revealed Resident left facility out on pass. Record review of Resident #1's progress notes, entered by Nurse A and dated 03/20/25 at 6:42 [a.m.], revealed Resident did not return from off pass. Observation on 03/21/25 at 7:28 a.m. revealed the facility's Sign out Book was on the counter at the Nurse's Station. The Release of Responsibility for Leave of Absence form for Resident #1 was blank. During a telephone interview on 03/21/25 at 9:15 a.m., Nurse A said she was told by Nurse B that Resident #1 went out on pass on 03/19/25. She said she did not see him for her entire shift, 6:00 p.m. to 6:00 a.m., on the 19th. She said she documented in the resident's progress notes that he did not return. She said usually, residents sign out before they go out on pass, and were supposed to sign back in with the date and time. She said Nurse B did not give her any additional information. She said it could be the nurse's responsibility to make sure the resident signed out or any staff who the resident was under and said she was not sure but thinks the receptionist too. During an interview on 03/21/25 at 9:44 a.m., the DON said ADON A and B both reported to her that Resident #1 went out on pass on Wednesday, 3/19, in the afternoon around 4:00 p.m. She said to her knowledge, the resident did not tell anyone he was leaving or where he was going. She said the ADONs did not say when they expected Resident #1 to return. She said she did not know where Resident #1 was currently. She said the resident did not sign out. She said residents should sign out, but she did not believe they were required to say where they were going or who they were leaving with. She said she has been told the resident used a ride service himself to and from the facility in the past. She said the resident had a BIMS score of 13/14, was his own RP, and has family emergency contacts. She said she did not consider Resident #1 leaving the building an emergency at the time. She said residents were allowed to be on pass for 72 hours. She said the resident did not have a telephone. During an interview on 03/21/25 at 9:58 a.m., ADON A, said Resident #1 went out on pass on Wednesday, 3/19/25, and she believed ADON B told her. She said she did not know where the resident went. She said she did not know where the resident was now. She said she would have to check to see if the resident signed out. She said if residents go out on pass, they can stay out for 72 hours, residents let them know where they were going, when they plan to return, and sign back in when they return. She said Resident #1's medications did not go with him as far as she was aware. She said the resident had a high BIMS score, she believed it was a 13 or 14 and was cognitively intact. During an interview on 03/21/25 at 10:11 a.m., ADON B said the Staffing Coordinator/CNA reported to him, the DON, and ADON A that Resident #1 went out on pass. He said she did not say where he was going. He said he did not ask any additional questions. He said he did not know if he signed out. He said he did not know where Resident #1 was currently. He said he did not know if he had any of his medications with him. He said he did not know when Resident #1 was expected to return. He said residents can stay out on pass for up to 72 hours. During an interview on 03/21/25 at 10:51 a.m., the Receptionist said she worked Wednesday the 19th and saw Resident #1 leave the facility. She said the resident asked her if he could go outside and she said she thought he meant to sit outside. She said she asked the Staffing Coordinator/CNA if he was allowed to go outside and she said yes, he was okay and so she let him go outside. She said after she let Resident #1 go outside, she received a telephone call and walked to the hall and told the nurse she had a call. She said when she returned, she sat down, and the Staffing Coordinator/CNA asked her where the resident was, and she said he should be sitting outside. She said the Staffing Coordinator/CNA said he was not out there and asked if he signed the book, and she said no he did not. She said the Staffing Coordinator/CNA told her everyone needed to sign out. She said the Staffing Coordinator/CNA told ADON B and he went to go find the resident on foot, and that was when ADON B was told by another resident that he saw Resident #1 get into a car. She said Resident #1 did not tell her he was going to leave the facility. During an interview on 03/21/25 at 11:01 a.m., the Staffing Coordinator/CNA said she saw Resident #1 go outside and went on the porch and sat in a rocking chair. She said when she went back by, she saw him down the walkway and he got into a white vehicle. She said she notified the ADONs and the DON. She said they said he was out on pass. She said early that morning, 3/19/25, before 7:00 a.m., Resident #1 mentioned wanting to go to another facility and she told him to talk to the social worker. She said she did not know where the resident was now. During an interview on 03/21/25 at 11:11 a.m., the Administrator said he was out on PTO on the 19th and the 20th. He said he was notified that Resident #1 got into a white vehicle and forgot to sign out by the ADONs at approximately 4-5 o'clock, could not recall the day, but wanted to say it was Wednesday, 3/19/25. He said no one knew where he was. He said initially when Resident #1 first left, they tried to find the white SUV to get him to sign out, but they were unsuccessful. He said he would have to review what their Therapeutic Leave policy stated. He said there had not been any other attempts to find him because they knew he left out on pass. He said even if residents leave and forget to sign out, they try to call them or try to see in what general direction they went and try to redirect them to go back and sign out. He said ultimately, Resident #1 had a high enough BIMS score, and the facility did not want to infringe upon his rights. During an interview on 03/21/25 at 12:44 p.m., the DON said she just called the phone number listed for Resident #1 on his face sheet and a family member answered. She said the family member told her she was happy they called her because she had some concerns about a group home he was at previously. She said the resident's sister believed the Owner/Manager of the group home sent someone to pick him up. She said the family member told her the resident made his own decisions. During an interview on 03/21/25 at 1:01 p.m., the Administrator and DON said they just got off the phone with the Owner/Manager of the group home and was told Resident #1 was with her. They said the Owner/Manager told them the resident called her Tuesday, 3/18/25, night and said he wanted to go back and so she sent an Uber to pick him up. They said they asked to speak with the resident but was told she was driving and would have him call them when she got to where she was going. During an interview on 03/25/25 at 10:54 a.m., the Owner/Manager of the group home said Resident #1 was no longer at her personal care home and believed he went to another home. Record review of the facility's Therapeutic Leave policy, revised 07/14/2023, read in part .Compliance Guidelines .13. The resident or resident representative will sign a release form indicating the date and time the resident is leaving, location, (including address if going to a specific residence) of where resident is going, a telephone number where resident can be reached .17. If the resident has not returned from therapeutic leave as expected, the facility will attempt to contact the resident and resident representative and document attempts in the medical record . Record review of the facility's Missing Resident Policy, revised 08/15/23, read in part .Definitions .Elopement occurs when a resident leaves the premises or a safe area without authorization (an order for discharge or leave of absence) and/or any necessary supervision to do so . The Administrator was notified on 03/21/25 at 2:09 p.m. that an IJ was identified due to the above failures and the IJ template was provided. The following Plan of Removal (POR) was accepted on 03/22/25 at 2:55 p.m.: Plan of Removal Tag Cited: F-689 Issue Cited: Free of Accidents/Hazards/Supervision Failure to ensure residents receive adequate supervision to prevent elopement 1.Immediate Action Taken On 3/21/25 @ 4:35pm DON/designee located and visited Resident #1 at the Personal Care Home in a nearby city. Resident #1 had a safe discharged to the Personal Care home on 3/21/25 with the assistance of the Personal Care Home manager and the Administrator delivered all medications. DON evaluated resident #1 at the Personal Care Home to ensure his safety and well-being. The Administrator was responsible for the facility's decision not to call the resident/RP/police. Administrator and DON were in-service by Regional Nurse Consultant on 3/21/25 by 6:00pm on the Missing Resident Policy, which was reviewed on 3/21/25 at 11:41am with no changes made, along with notifying the police/RP/physician and the state agency when resident is not located in the facility or on facility grounds. The nearby hospital should not be contacted. Don/designee will have the 1:1 training with the receptionist on Therapeutic Leave policy and to notify charge nurse of residents that have not returned from leave that day when the receptionist shift is over and the Missing Resident Policy by 3/22/25 at 10 am. Residents therapeutic leave sign out book will be located at receptionist desk on 3/21/25 by 7:30pm, for her/him to know who is leaving. The Charge nurses will be responsible for tracking of the residents leaving after 5:30pm. Don/designee will educate charge nurses on 3/21/25 by 8pm on giving a follow-up call to resident/RP that did not return from therapeutic leave for the day and document in progress notes. Any charge nurse not present will not be allowed to work their next shift until receiving the education. 2. Identification of Residents Affected or Likely to be Affected: A. On 3/21/25 by 11 pm DON/designee will have 100% of resident's Elopement Risk Assessment completed to identify all elopement risk residents. No new resident identified. B. On 3/21/25 by 11pm DON/designee will identify all the residents with the physical ability to have therapeutic leave. 59 residents were identified. 3. Actions to Prevent Occurrence/Recurrence: A. DON/designee will In-service all staff on the Missing Person Policy on 3/21/25 by 7pm. Any staff not present will not be allowed to work their next shift until they have the training. B. DON/designee will In-service all staff on the Therapeutic Leave Policy on 3/21/25 by 7pm. Any staff not present will not be allowed to work their next shift until they have the training. On 3/21/25 at 8:08am the Regional Nurse Consultant emailed the Therapeutic Policy after reviewing, no changes were made. C. Missing Person Drill will be completed and documented with all staff on 3/21/25 by 7pm. Any staff not present will not be allowed to work their next shift until they have the drill. D. The Elopement binder will be updated with any newly identified residents on 3/21/25 by 7pm. E. All the residents identified as Elopement Risk will have their care plans updated by DON/designee on 3/21/25 by 11 pm. F. All residents identified with physical ability for Therapeutic Leave will have their care plan updated by DON/designee on 3/21/25 by 11 pm. G. DON/designee will educate and be completed by 3/22/25 by 4pm, residents/responsible party on the Therapeutic Leave Policy for those residents identified with the physical ability for therapeutic leave. H. Administrator will have an ad hoc meeting with the Medical Director on IJ findings and actions taken will be completed on 3/21/25 by 7:45pm. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ________________. On 03/22/25-03/23/25, the state surveyor monitoring confirmed the facility implemented their plan or removal (POR) to sufficiently remove the IJ by: Observation on 03/23/25 at 7:15 a.m. revealed the sign out book was located at the nurse's station. Record review on 03/23/25 revealed, the Regional Nurse Consultant in-serviced the Administrator and the DON on the Missing Person policy on 03/21/25. Record review on 03/23/25 revealed, the Receptionist received 1:1 training on 03/22/25 on the Therapeutic Leave policy and when to notify the charge nurse of residents who have not returned from leave that day when the shift was over. Record review on 03/23/25 of in-service sign in sheet revealed charge nurses were educated on 03/21/25 on follow-up calling the resident/RP who have not returned from Therapeutic Leave and documenting it in the progress notes. Record review on 03/23/25 revealed an Elopement Risk assessment was completed for 100% of the residents on 03/21/25 and no new residents were identified. Record review on 03/23/25 revealed residents with the physical ability to have therapeutic leave was completed on 03/21/25 and 59 residents were identified. Record review of in-service trainings dated 03/21/25 and 03/24/25 revealed 44 staff were in-serviced on the Missing Person and Therapeutic policy. Record review on 03/23/25 of the facility's Elopement binder revealed it was updated. Record review on 03/23/25 of resident Care Plans revealed those who were identified with physical ability for Therapeutic Leave was updated. Record review on 03/23/25 of Therapeutic Leave documentation revealed contact/attempted contact was made with residents/responsible party for those identified with the physical ability for Therapeutic Leave was completed. Record review of Ad hoc sign in sheet on 03/23/23 revealed meeting was completed with the Medical Director on the IJ findings on 03/21/25. Interviews were conducted from 03/22/25 to 03/23/25 with staff from all shifts and all interviewees verbalized an understanding on the Therapeutic Leave and Missing Person policies. Interviewed staff included the Administrator, ADON A, ADON B, Receptionist A, Receptionist B, Nurse C, Nurse D, Nurse E, CNA A, CNA B, CNA C, and CNA D. The Administrator was notified the Immediate Jeopardy was removed on 03/23/2025 at 2:16 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, encompassing the resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders for 1 of 12 residents (Resident #1) reviewed for behavioral services. The facility failed to ensure Resident #1 received adequate behavioral health care services to prevent and treat substance abuse disorder when Resident #1 frequently signed himself out of the facility to go to nearby stores and consume alcohol, resulting in intoxication, vomiting, and lethargy to the point of falling out of his wheelchair. Resident #1 was also known by staff to sign himself out and smoke marijuana in the community surrounding the facility, resulting in a positive laboratory finding for THC. An IJ was identified on 05/29/2025. The IJ template was provided to the facility on [DATE] at 1:20 p.m. While the IJ was removed on 06/01/2025, the facility remained out of compliance at a scope of pattern with severity level at 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 that were put into place. This failure could place residents who require behavioral health services at risk not receiving having their needs met and, deterioration of health Findings include: Record review of Resident #1's face sheet dated 05/28/2025 revealed he was a [AGE] year-old male who was initially admitted to the facility on [DATE]. He was diagnosed with end-stage renal disease (the final stage of chronic kidney disease where the kidneys can no longer filter waste and excess fluid from the body), schizoaffective disorder (a chronic mental illness that combines systems of both schizophrenia and mood disorder), gastro-esophageal reflux (a chronic condition where stomach contents regularly flow back up into the esophagus), history of falling, difficulty walking, diabetes mellitus type II (chronic disease where the body either does not produce enough insulin or cannot properly use the insulin it produces) with hypoglycemia (when blood glucose levels drop too low), essential hypertension (persistently high blood pressure with no identifiable cause), chronic ischemic heart disease (long-term condition where the heart's blood supply is reduced due to a mismatch between oxygen supply and demand), chronic obstructive pulmonary disease (chronic lung disease that makes it difficult to breathe) with acute exacerbation (sudden and severe worsening of respiratory symptoms in COPD patients), unspecified cirrhosis of liver (a type of chronic, progressive liver disease where healthy liver cells are replaced by scar tissue), acute cholecystitis (inflammation of the gallbladder, typically caused by a blockage of the cystic duct), dependence on renal dialysis (treatment that cleans the blood when kidneys are unable to do so), and shortness of breath. Resident #1 was his own responsible party. Record review of Resident #1's quarterly MDS dated [DATE] revealed he had a BIMS score of 13 (cognitively intact); Resident #1 exhibited behaviors related to rejection of care; Resident #1 used a manual wheelchair for mobility; Resident #1 was independent with eating, oral hygiene, toileting hygiene, dressing, personal hygiene, and transfers and required supervision or touching assistance for showers/bathing; Resident #1 was always continent of bowel and bladder; and Resident #1 was prescribed anticoagulant and antipsychotic medication. Record review of resident #1's care plan, revised on 05/25/2025 revealed the following care areas: * Behavioral Problem: Resident has a behavior problem as evidenced by: displaying verbal and sexually inappropriate behavior by exposing his private area to female residents and female staff. Goal included: Resident's inappropriate behavior will not result in harm or injury to self or others. Interventions included: Educate resident on the privacy issues associated with his behavior. Encourage as much as possible to detour injury. Intervene as necessary to protect the rights and safety of others. Remove resident to an alternate location when needed to protect the rights and safety of other. Resident will be receiving psychiatric visits with [Psychiatric Provider] to monitor his behaviors per physician orders. * Therapeutic Leave: Resident is cognitively able to sign out of the facility and make their own informed decisions while they are out. On 04/10/2025 while on therapeutic leave, resident made the decision to consume alcoholic beverages. Goals included: The resident will follow facility policy for out on pass. The resident will be safe and comfortable while out on pass. Interventions included: Educate the resident/family/caregivers about the potential risks associated with signing out on pass. Educate resident/family/caregivers on the facility's policy for therapeutic leave/out on pass. Resident is reminded of his health issues and treatment regimens and the recommendations to avoid the use of alcoholic beverages. Further review of Resident #1's care plan revealed no care areas, goals, or interventions to address his substance abuse concerns. Record review of Resident #1's nursing progress notes for April 2025 and May 2025 revealed: * On 04/02/2025, at 4:10 p.m., SW B wrote, Resident was educated with Administrator, ADON, DON, and SW on the policies for Therapeutic Leave and the expectations for the resident when he is on Therapeutic Leave. Resident verbalized understanding. * On 04/11/2025, at 12:10 a.m., RN E wrote, Resident came back on pass to the facility with alcohol intoxication, vitals and assessment done. All within normal baseline. NP notified. New order to transfer resident to the hospital for further evaluation but resident refused. Resident was monitored through the shift, comfort care provided to resident satisfaction. * On 04/11/2025, at 11:50 a.m., ADON F wrote, Late Entry: 04/10/2025 at 11:00 p.m. Upon resident's return to the facility, resident arrived propelling himself in his motorized wheelchair. Resident had a slurred speech, he was drooling, smiling, and laughing, slow to respond to questions, and lethargic. Resident said he was tired and wanted to lay down and go to sleep and was assisted back to his room and was unable to stand to assist with his transfer to his bed, so he was transferred to bed with two people assist. In speaking with the resident, he said that he had ingested alcohol, specifically three 40 oz bottles of [brand name of beer] and he would not say if he had ingested any other substances or drinks. Upon assessment by unit nurse, there was no evidence of trauma or physical injuries noted, no indications of any falls or any other incidents at the time of his return. * On 04/12/2025, at 7:17 p.m., LVN A wrote, Police officer called facility and said resident vomited and may have been drinking with his friend and they have called 911 for him to go to the ER and have him evaluated. They then came to the facility, and I gave him a face sheet and medication lists. I accompanied the officer to EMS parked on the street near the facility and found the patient inside the ambulance being attended to by two paramedics with patient leaning to his left side. I placed a call to the Administrator and ADON. Resident apparently signed out at about 12 noon and left the facility with another resident. They apparently went to a nearby store and purchased drinks. He drank until he vomited on himself and became very weak. I asked the paramedics where they were taking him, and they informed me that they were taking him to [a local hospital] ER. NP and RP notified. * On 04/14/2025, at 4:38 p.m., ADON F wrote, Resident was found to be in possession of a cigarette lighter. The resident was educated by the Administrator on the smoking policy and the lighter was placed in the smoker's box for the resident to have access to only when on smoke breaks. The Administrator educated the resident on use of another resident's electric wheelchair and encouraged to use his own, the resident verbalized understanding. * On 04/15/2025, at 2:11 p.m., RN H wrote, Resident signed himself out and came back vomiting. Happened a couple of times. NP notified. Lab work ordered. New order to transfer to ER for further evaluation. * On 04/16/2025, at 5:23 p.m., ADON G wrote, Final lab results received on the drug and alcohol screening, labs placed in NP binder for review . resident remains in the hospital at this time. * On 04/23/2025, at 9:46 p.m., RN E wrote, Resident, who went out on pass, returned to the facility alert but disoriented, drooling from alcohol intoxication also had multiple emesis (vomiting). Resident vitals and assessment done all vital signs were within normal baseline. NP contacted via telehealth/virtual service. New order for Ondansetron 4 MG 1 tablet PO q 6hours as needed . * On 05/01/2025, at 11:59 a.m., the SW wrote, The Social Worker and the Administrator witnessed [Resident #1] taking a power wheelchair without the permission of the resident who owns the power wheelchair. Resident was educated that he cannot take the belongings of other residents while they are out of the facility. Resident was also educated on the importance of not using someone else's wheelchair and the risks that can occur . * On 05/04/2025, at 4:41 p.m., RN H wrote, Resident exchanged wheelchair with his former roommate and resident was educated that it was not safe to do so, resident verbalized understanding. Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/10/2025 at 11:17 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Complaint: Altered Mental Status . Per nurse, patient went out on pass and returned to facility lethargic, drooling from mouth and vomited once one hour ago. Per nurse, patient only knows his name, does not know where he is, and does not know the month, year. States at baseline patient is alert and oriented x 3 (a term that describes a patient's level of consciousness and cognitive function. Patient aware of person, place, and time). Per nurse, patient admitted to drinking 3 bottles of [brand of beer]. Per nurse, patient refused dialysis today and states patient did not go to dialysis yesterday . Patient seen with nurse . Physical Exam: Exam findings per nurse and video observation . Orders: Transfer to ER via 911: AMS/ESRD - missed HD/vomiting/possible alcohol intoxication . Record review of Resident #1's physician progress note (this was a telehealth/virtual visit) dated 04/23/2025 at 10:02 p.m. revealed, . Details: Nurse Name: [RN E]. Patient Name: [Resident #1]. Primary Chief Complaint: GI: Vomiting . Nurse notified clinician that the [AGE] year-old-male patient with history of ESRD on dialysis, Schizophrenia, falls, HTN, DM2, went out of the facility for an hour and came back intoxicated. The nurse stated this is a regular occurrence for him. He did have an episode of vomiting. Denies drinking alcohol. Will monitor him for now . Record review of Resident #1's Lab Results Report collected on 04/11/2025 and reported on 04/16/2025 revealed Resident #1 was positive for THC (Cannabis). Record review of Resident #1's, Psychiatric Subsequent Assessment dated 04/24/2025 revealed, . History of Presenting Illness: Last visit was on 03/24/2025 . Collateral Information: On 04/24/2025, I attended a multidisciplinary care conference meeting with the DON, ADON, MDS, administrator, medical records, and SW. The case was discussed in detail, and it was concluded; 1. Patient was sent to the hospital due to after the staff found him at the store unable to move. Patient was under the influence of alcohol. 2. Patient does not follow his dialysis schedule . Record review of Resident #1's, Clinical Treatment Plan Review (Plan of Care) completed by the psychiatric provider and dated 04/29/2025 revealed, . History of Presenting Illness: . Patient was referred to psychological services for: Agitation, Irritability, Memory Loss, Short Term Memory Problems, Long Term Memory Problems, Noncompliance, Resistance to ADL/Medications, Sexually Inappropriate Behavior, Attention Seeking Behavior, Medication Evaluation, Other: Resident is refusing dialysis. In addition, he was touching himself in his genitals in an inappropriate way . Family/Social History: . Patient endorsed history of drug/alcohol abuse . Summary of Progress: Patient has been less active with therapy during this treatment cycle due to a new interpersonal relationship and frequent trips outside the facility . Treatment Plan: Treatment is expected to result in an improvement in condition or prevention of decline that would otherwise be expected. Treatment is expected to help improve patient's emotional, cognitive, social, behavioral functioning symptomatology. Psychotherapy in addition to psychotropic medication is the treatment of choice for this patient . Further review of Resident #1's Clinical Treatment Plan Review (Plan of Care) revealed no mention of a plan to address Resident #1's substance abuse concerns. Record review of Resident #1's, Psychiatric Subsequent Assessment dated 05/01/2025 revealed, . History of Presenting Illness: Last visit was on 04/24/2025 . Further review of Resident #1's, Psychiatric Subsequent Assessment revealed no documentation to show his substance abuse issues were addressed. Record review of Resident #1's, Psychiatric Subsequent Assessment dated 05/28/2025 revealed, . History of Presenting Illness: This is a post hospital follow up. After my last visit the patient was admitted into the hospital due to AMS, and general weakness. Psych meds were not changed. My last visit was on 05/01/2025 . Collateral Information: On 05/28/2025, I attended a multidisciplinary care conference meeting with the ADON, MDS, Medical records, DON, and SW. The case was discussed in detail, and it was concluded: 1. Patient has returned back from the hospital. Patient was drinking and using drugs while out on pass . Observation and interview with Resident #1 on 05/28/2025, at 2:30 p.m. revealed he was in his bed with his eyes closed. Resident #1 opened his eyes and was able to provide his name. Resident #1 stated he lived in the facility a couple of months and living there was alright. He said he went to dialysis. He said he fell out of his wheelchair about six months ago (he did not say why). Resident #1 did not answer questions related to drinking alcohol or taking drugs while outside the facility on pass. He closed his eyes and appeared to be asleep although he responded to questions unrelated to drinking or smoking. In an interview with the SW on 05/28/2025, at 3:24 p.m., she stated Resident #1 was capable of making his own decisions, but he just did not make the right decisions. She said Resident #1 went out on pass and did things he should not do. She said Resident #1 received psychiatric services to see why he refuses dialysis so much. She said she was not sure if Resident #1's substance abuse issues were discussed during his psychiatric sessions. She said Resident #1 was vomiting once due to intoxication. She said the facility staff could not tell Resident #1 what he could and could not do outside of the facility, and they could only educate him. She said Resident #1 knew what he was doing. She said Resident #1 was his own RP and he did not have any family. She said to her knowledge, Resident #1 only went out twice and got drunk, but she was not there on weekends. She said Resident #1's behavior of going out and getting drunk had decreased and he went out a lot less. She said Resident #1 had been sleeping a lot more recently and he had several hospitalizations. She said she spoke to Resident #1 about the risks of him going out drunk. She said possible negative outcomes of Resident #1 leaving the facility and getting drunk were that he could die, get injured, and go to the hospital. In an interview with the Activity Director on 05/28/2025, at 3:45 p.m., she stated Resident #1 was known to take his former roommate's motorized wheelchair. She stated Resident #1 had been caught smoking weed (marijuana) and drinking beer. She said a group of residents were at a nearby store drinking and the store workers called the police. She said the police went to the facility and told them they had to keep the residents from going there, but once they sign out, the residents go their own way. She said the residents needed more things to do inside the facility. She said she left the facility at 5:00 p.m. daily and she had only observed Resident #1 return to the facility intoxicated a couple of times. She said Resident #1 was in the hospital about a week or so and yesterday (05/27/2025) or Monday (05/26/2025), he was sick and throwing up. She said Resident #1 refused dialysis a lot. She said Resident #1 used another resident's motorized wheelchair to go to the store because he could not physically wheel himself out to store in his manual wheelchair. She said Resident #1 kept taking his former roommate's wheelchair, so they moved Resident #1 to another room. She said she had no knowledge of Resident #1 falling out of a wheelchair but about 7-8 months ago, she observed him outside with his manual wheelchair stuck and leaning off a curb. She said she pulled over and pushed his wheelchair all the way back to the facility. She said Resident #1 was leaning over in his wheelchair and he kept saying he was sick. She said she did not know of he was intoxicated at that time. She said the residents had to pass a busy road and cross the road to get to the store. She said it was not safe for the residents to travel that way, but they had their rights. She said the Administrator told the staff that the residents had their rights. In an interview with the Administrator on 05/28/2025, at 4:32 p.m., he stated the residents had rights. He said Resident #1's BIMS score was 15, but he did not make proper decisions. He said the facility staff had to make sure they did not infringe on the residents' rights. He said Resident #1 signed himself out and returned intoxicated between five and seven times. He said he had undocumented conversations with Resident #1 about how unsafe it was for him to leave the facility and get drunk. He said the conversations were not documented because he did not go into the facility's computer system to write progress notes. He stated Resident #1 received psychiatric services, but he sometimes refused to talk or participate during his sessions. He said he was not sure if Resident #1's smoking and drinking were addressed during the sessions. He said addressing Resident #1's smoking and drinking in his psychiatric sessions would be helpful to reinforce what the facility staff try to educate him on related to those behaviors. In a telephone interview with Resident #1's physician on 05/30/2025, at 10:00 a.m., he stated he was familiar with Resident #1, and he was aware the resident frequently went out on pass to drink and smoke. He said Resident #1 denied drinking and smoking, but he had a history of noncompliance with dialysis and medications. He said Resident #1 had recently been admitted to the hospital a lot and once, at the hospital, they found he had taken drugs. He said Resident #1 kept denying, so it was hard to address it. He said the negative outcome of Resident #1's behaviors were that one day, Resident #1 is fine, and then in a couple of days, he signs out and takes something (drugs or alcohol) and something happens that leads him back in the hospital. In an interview with LVN A on 05/31/2025, at 2:11 p.m., he stated on 04/12/2025, around 1:00 p.m., the police called the facility and said Resident #1 had fallen out of his wheelchair and was vomiting at the church next to the facility. He said the police went to the facility and then he (LVN A) followed them to see Resident #1. He said he thought the police saw Resident #1 on the ground and called 911. He said when he arrived at the scene, he saw Resident #1 inside the ambulance. He said Resident #1 said he had gone to the store. He said Resident #1 went to the hospital and returned to the facility about two days later. LVN A said he heard the motorized chair Resident #1 fell out of belonged to his friend. He said Resident never admitted to the drinking and always tried to hide it. He said Resident #1 usually returned to the facility late at night, so he (LVN A) was usually gone by that time (LVN worked the day shift, 7:00 a.m. - 7:00 p.m.). He said the negative outcome of Resident #1's behavior was that he was a dialysis patient and it interfered with his kidneys. He said Resident #1 falling out of the chair while intoxicated and going to the ER was a very negative effect. Record review of the facility's policy, titled, Behavior Management revised on 04/15/2014 revealed, Policy: The purpose of the policy is to optimize the quality of life and function of patients that experience behavioral symptoms that require person centered approaches to meet the health, physical, psychosocial, and behavioral health needs. Fundamental Information: Individualized, person-centered approaches may help reduce potentially distressing or harmful behaviors and promote improved functional abilities and quality of life for dementia patients. Fundamental principles of care for a patient with behaviors include an interdisciplinary approach that focus on the individualized needs of the patient . Procedure. Determine whether there is a medical, physical, functional, physiological, emotional, psychiatric, social, or emotional cause of the behaviors . Considerations: Person-Centered Care - evaluate if the environment is supportive and promotes comfort toward understanding, preventing, relieving, and recognizes individual needs and preferences . Evaluations are completed on new or worsening behaviors . Identify the frequency, intensity, duration, severity, and impact of behaviors, as well as the location, surroundings, or situation. Identify interventions or approaches to prevent, modify, relieve, or address the behaviors or distress. Patient behaviors or distress are documented as it occurs and the effectiveness of interventions. Individualized Care Plan Approaches - individualized approaches are used as a first line intervention (except in a documented emergency situation or if clinically contraindicated) . Consistent interventions are used that focuses on a patient's individual needs . Monitor and follow-up care plan is done by the interdisciplinary team who reviews the patient's progress towards goals. Summarize effectiveness of non-pharmacological and pharmacological interventions (quarterly and as indicated), for target behaviors and/or psychological symptoms and changes in a resident's level of distress or emergence of adverse consequences. Adjust interventions as needed and identified when care objectives are not met . An IJ was identified on 05/29/2025 at 1:20 p.m. The IJ template was provided to the Administrator on 05/29/2025 at 1:20 p.m. and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 05/31/2025 at 5:20 p.m. Issue Cited: Behavioral Services Failure to provide behavioral services 5/31/25 6. Immediate Action Taken On 5-29-25 resident #1 is currently in hospital for diagnosis of gastroenteritis and ESRD. 2. Identification of Residents Affected or Likely to be Affected: A. On 5/29/25 by 5:15pm DON/designee identified 66 residents are currently on behavioral services. The remaining 32 residents had no noted behaviors on admission or currently to warrant a referral for behavioral services. 3. Actions to Prevent Occurrence/Recurrence: A. On 5/30/25, [Psychiatric Provider] Services begins performing a psych evaluation on those 32 residents identified to establish any behavioral service needs, ongoing. No residents are identified as using drugs/alcohol when leaving the facility. If any of the 32 residents are identified as having a need for psych behavioral services, then care plans will be updated to reflect the behavior services. If any of the 32 residents are found to need behavioral services then [Psychiatric Provider] will treat in-house, and the care plan will be updated and nursing staff will be educated. None of the 32 residents require behavioral services at this time. B. Resident #1 is in hospital currently and has been on behavioral services but frequently refused visits. If and when resident #1 returns, psych behavioral services will be updated with his alcohol/drug behaviors and will be seen for appropriate service needs. Resident #1 has a history of refusing medical care including medications, dialysis, and psych services. If residents' refusals continue to jeopardize their health and the facility can no longer meet their needs, then the facility may discharge per HHSC guidelines. C. On 5/30/25 at 9:00 am the RNC reviewed the Behavioral Management policy, with no revisions made. D. On 5/30/25 by 12:00 PM the DON/ or designee will in-service nurses on Behavior Management policy, to include monitoring of behaviors each shift, documentation of any unsafe behaviors, notify physician of unsafe behaviors for new orders, and notify DON/ or designee of unsafe behaviors, no nurse will be able to work a shift without the in-service. The RNC in-serviced the Administrator/ or designee and DON/ or designee beforehand. On 5/30/25 by 6pm DON/designee in-serviced CNAs on Behavior Management policy including responding to behaviors and notifying charge nurse, no CNA will be able to work a shift without the in-service. E. DON/designee will review future admissions for the need of psych services and notify physician for an order for behavioral services. F. DON/designee will monitor 24-hour report for unsafe behaviors identified daily in morning stand-up meeting. G. All findings will be discussed during the morning stand-up meeting with IDT team and report to QAPI and update plan of correction as needed. H. On 5/29/25 the facility's Administrator/or designee notified the Medical Director regarding the Immediate Jeopardy the facility received related to Failure to Provide Behavioral Services and reviewed plans to sustain compliance. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ___5/31/25_________ Monitoring of the plan of removal included the following: Record review of the facility's plan of removal documentation revealed a complete audit of the building was completed by the RNC on 05/29/2025 and 32 residents who did not receive behavioral health services were identified. Further review of the facility's plan of removal documentation revealed psychiatric evaluations were completed on the 32 residents who did not previously receive behavioral health services beginning on 05/30/2025. No substance abuse issues were identified among the 32 residents evaluated. Record review of the Behavior Management policy revealed it was reviewed by the RNC on 05/29/2025. Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/29/2025 revealed the DON was educated by the RNC on the Behavior Management policy, including monitoring behaviors each shift, documentation of any unsafe behaviors, and notifying the doctor of any unsafe behaviors. Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/30/2025 revealed the facility's nurses were educated by the RNC on the Behavior Management policy, including monitoring behaviors each shift, documentation of any unsafe behaviors, and notifying the doctor and DON of any unsafe behaviors. Record review of a facility document, titled, In-Service - Program Attendance Record dated 05/29/2025 revealed the facility's CNAs were educated by the DON, ADON F and ADON G on the Behavior Management policy, including how to respond to behaviors, redirection, providing a calm environment, and notifying the nurse of unsafe behaviors. Interviews were conducted with staff on 06/01/2025 from 9:30 a.m. until 12:00 p.m. from all shifts (nurses and CNAs worked 12-hour shifts) including the VP of Operations, RNC, DON, ADON F, ADON G, RN H (day shift), Receptionist I, Receptionist J, LVN K (day shift), CNA L (day shift), CNA M (day shift), LVN N (night shift), and CNA O (night shift), to verify the in-services were conducted and to validate the staff understanding of requirements, training material, and expectations. The VP of Operations, RNC, DON, ADON F, ADON G, RN H, Receptionist I, Receptionist J, LVN K, CNA L (day shift), CNA M (day shift), LVN N (night shift), and CNA O were able to explain the importance of identifying and addressing unsafe behaviors (alcohol and drug abuse), notifying the nurses, DON, and physician of unsafe behaviors, documenting behaviors, responding appropriately to residents who exhibit behaviors, and monitoring residents who exhibit behaviors related to alcohol and drug abuse for their entire shift. The RNC was informed the Immediate Jeopardy was removed on 06/01/2025 at 12:09 p.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 25 of 30 residents (Resident #204, #206, #92, #78, #9, #77, #73, #67, #39, #71, #74, #75, #20, #7, #44, #36, #50, #14, #30, #16, #82, #88, #70, #94, and #38) reviewed for infection control. The facility failed to ensure that Residents (#44, #36, #50, #14, #30, #16, #82, #88, #70, #94, and 38) who received negative COVID test results were not accommodated in a shared room alongside Residents(Resident #92, #78, #9, #77, #73, #39, #71, #74, #75, #20 and #7) who had tested positive for COVID 19 and were identified as droplet isolation precaution Residents. The facility failed to ensure transmission-based precaution protocols evidenced in the inadequate placement of notices and insufficient provision of Personal Protective Equipment (PPE) in the vicinity of residents' rooms or within their immediate proximity for the following residents: (Resident 71), (Resident #20), (Resident #74), (Resident #42), (Resident #75), (Resident #39), (Resident #67), (Resident #73), (Resident #7), (Resident #77), (Resident #9), (Resident #78), (Resident #92), (Resident #206), and (Resident #204). The facility failed to ensure that staff (CNA T and CNA J) implemented appropriate use of PPE and transmission-based precautions prior to enter and exiting residents' (Resident #91, #80, #74, #71, #77, and #92) rooms. The facility failed to ensure staff (CNA T, CNA J and ADON A) wash or sanitize hands after providing care to Residents (Resident #91, #80, #71, #74, #77, #92, and #352) rooms. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:45p.m. While the IJ was removed on [DATE] at 2:05p.m, the facility remained out of compliance at a scope of pattern and a severity level of Actual harm that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures have the potential to affect residents by placing them at an increased and unnecessary risk of exposure to communicable diseases and infections. Findings included: Record review of Resident #204's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #206's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #92's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #78's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #9's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #77's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #73's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #67's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #39's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #71's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #74's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #75's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #20's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #7's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old; Resident had a diagnosis of COVID 19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) dated [DATE]. Record review of Resident #82's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old with primary diagnosis of metabolic encephalopathy (a problem in the brain, caused by a chemical imbalance in the blood). Record review of Resident #44's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old with a primary diagnosis of polyosteoarthritis (a common type of arthritis that affects many joints at once, causing pain, swelling, and stiffness). Record review of Resident #36's face sheet dated [DATE] revealed resident was admitted to the facility on [DATE], age [AGE] years old with primary diagnosis of Chronic Kidney Disease (occurs when a disease or condition impairs kidney function). Record review on [DATE] of lab results and clinical charts for Residents #204, #206, #92, #78, #9, #77, #73, #67, #39, #71, #74, and #75 revealed positive COVID 19 nasal swab results dated [DATE]; and indicated the identified residents were all under droplet isolation precautions. Record review on [DATE] of lab results and clinical charts for Residents #44, #50, #14, #30, #16, #83, #88, #70, 94, and #38 revealed negative COVID 19 nasal swab results dated [DATE]. Record review on [DATE] of lab results and clinical chart for Resident #20 revealed positive COVID 19 nasal swab results dated [DATE]; and indicated the identified resident was under droplet isolation precautions. Record review on [DATE] of lab results and clinical chart for Resident #36 revealed negative COVID 19 nasal swab results dated [DATE]. Record review on [DATE] of lab results and clinical chart for Resident #7 revealed positive COVID 19 nasal swab results dated [DATE]; and indicated the identified resident was under droplet isolation precautions. Record review on [DATE] of lab results and clinical chart for Resident #82 revealed negative COVID 19 nasal swab results dated [DATE]. Record review of facility's infection control tracking and trending log dated [DATE] revealed no documented tracking of Staff and Residents who tested positive for the COVID19 for the month of [DATE]. Record review on [DATE] at 4:00 pm the facility furnished test outcomes from [DATE]st, 23rd, and 26th, 2023, indicating positive COVID 19 test results for 14 residents (Residents #204, #206, #92, #78, #9, #77, #73, #67, #39, #71, #74, #75, #20, #36, and #7). Record review resident roster and observations on [DATE] revealed that these identified positive COVID 19 residents resided in various location on all designated halls (100 hall, 200 hall, 300 hall, 500 hall, and 600 hall) reserved for the facility's residents, and were accommodated in a shared room alongside Residents (#44, #36, #50, #14, #30, #16, #82, #88, #70, #94, and 38) who had tested negative for COVID 19 as of [DATE]. Observation, record review and interview on [DATE] at 09:30am revealed that there were no droplet isolation precaution postings and insufficient PPE observed in or around Resident #71's room and the door. Resident #71 resided on the 100 hall of the facility, in shared room [ROOM NUMBER] with Resident #44. Both Resident #71 and Resident #44 were observed inside the designated room # 1 with the room door open at that time. Resident #71 was lying in bed without a facemask. Resident # 44 was sitting in a chair without a facemask. Resident #44 was interviewed at the time of observation and stated that he had tested negative for COVID 19 last week on [DATE] but was told that he had to continue to cohort with Resident #71 who had tested positive on the same date ([DATE]). Resident #44 stated that he was not provided a facemask and was afraid that would get sick from Resident #71. Resident # 44 stated that he had shared the concern with the facility staff, but various unidentified staff never provided him with a facemask and told him that he had to continue to reside in the room with positive COVID 19 Resident #71. Observation on [DATE] at 12:15PM revealed Resident #19 in her room being fed by Staff Z. Staff Z had a surgical mask on. In an interview with Staff Z at 12:15 PM, he said he does not know if Resident #19 was positive for Covid or not. Interview conducted on [DATE], at 9:13 am, ADON B stated that the administrator was absent due to a doctor's appointment. ADON B also reported the presence of active COVID-19 cases within the facility; initially detected on [DATE]. ADON B stated he was uncertain regarding the number of residents and staff who tested positive for COVID-19 and was also unsure about the total number of residents tested for the virus. Interview on [DATE] at 9:29 am, Nurse A, the nurse assigned to hall 6, stated that only rooms [ROOM NUMBER] on the 600 hall and were COVID 19 Isolation rooms. Nurse A stated that they were out of supplies and administration staff had not restocked the PPE. It was not identified how long the facility had been out of supplies. Interview with the DON, on [DATE] at 1:00pm stated she and the Administrator were informed by the Regional Nurse on [DATE] that Residents who tested positive for COVID 19 should remain in the rooms with those residents who had tested negative for COVID 19. The DON also revealed that she had been out of the facility since [DATE], as the DON, ADON A, and ADON B tested positive for COVID on [DATE]. She stated that she returned to the facility on [DATE] just prior to the interview. The DON also revealed that Resident #19 was positive with COVID. Observation on [DATE] at 1:30PM, revealed two facility staff moving residents from the 100 halls. Both staff had a face max on no other form of PPE was observed. In an interview with the two staff on at 2:30PM, Staff X and staff Y said they were asked by the facility Administrator to move all the covid positive residents to the 200 halls with the positive residents and leave the negative residents in their room. Staff Y said he tested positive on [DATE]. He said he had some symptoms flue-like on [DATE] and took covid test on [DATE]. He said the test was positive for covid. He said at that time, he called the facility to inform the DON and Administrator that he had Covid. He said he was asked to stay home for 5 days. He said he came back to work on [DATE] During the Resident Council Meeting on [DATE] at 2:30 p.m., Resident #28, was very emotional after learning that there were several people in the facility with COVID. His eyes started watering and he said, I have been in the hospital for 5 months and almost died. I have seen people die around me, and they aren't telling us anything. Resident #59 said, there is no designated COVID hall, and they are not transferring people out of rooms who are negative and COVID is spreading. Resident #17 said, Yes, it's spreading, and I don't have my 2nd COVID Booster. Record review on [DATE], of clinical chart revealed that Residents (#28, #59, and 17) who attended the Resident Council meeting was pending COVID results in Point Click Care. Interview on [DATE] at 3:00 pm with the Administrator and IP A (also identified as ADON A) who stated that had been trained on transmission-based precautions and is responsible for the tracking a trending of communicable diseases within the facility. Documentation of the IP A's trainings was requested at the time of the interview. Interview [DATE] at 4:45 pm with Nurse A, the nurse assigned to hall 6, stated she worked part time at the facility for 1 Year. She stated that she had not complete COVID 19 training but had been trained on airborne precautions. Nurse A stated that the person who initially set up the COVID Isolation rooms, did not set them up correctly. She stated there were negative and positive residents in the same room, and the risk of having them in same room can cause a spread in COVID 19 to other residents. Nurse A stated that not washing and sanitizing hands and having the correct PPE could also cause spread in COVID 19. Interview on [DATE] at 3:42 pm, CNA O stated that she started working at the facility one month ago. CNA O stated that she completed skill competencies and training with a nurse upon hire, but she was not able to articulate or identify what competencies and training were completed. CNA O stated that the supply person or administration staff would normally stock the door with PPE each morning. CNA O stated that the correct PPE was not provided or stoked on the door yesterday, [DATE] morning when she was entering and exiting rooms and no bags were in rooms for doffing PPE. Interview with the Administrator on [DATE] at 4:00 pm, the administrator revealed updated information regarding the facility' s identified Infection Preventionist. The Administrator stated that IP A had not completed the CDC required training, Nursing Home Infection Preventionist Training Course. The Administrator stated that as of [DATE] the DON was the designated the IP. The Administrator state that no one had been monitoring the tracking and trending of the COVID 19 infection in the facility. The Administrator stated that she DON and ADON A had been out sick for at least 5 days since both had tested positive on [DATE]. Record review on [DATE] at 4:00 pm the facility furnished test outcomes from [DATE]st, 23rd, 26th, and 28th 2023, indicating positive COVID 19 test results for 29 residents. The total number of COVID 19 positive Residents had doubled from the previous test results. Interview on [DATE] at 4:12 pm with the Administrator and the DON, the Administrator stated that they would be moving residents that are negative out of rooms with individuals who are positive and notifying families. The Administrator stated that this process is late due to the misinterpretation of the policy, and the information that they received from the Regional Nurse consultant who advised the Administrator and the DON to not designate a hot zone (a designated hall for COVID positive residents) and to not move negative residents who were placed in cohort rooms with COVID positive residents. Interview on [DATE] at 4:25 with the Regional Nurse who stated that she informed the Administrator to isolate, place signage on doors, and test on days 1,3, and 5. She stated that on [DATE], she informed the Administrator and the DON to keep positive COVID residents in a cohort room with negative COVID because the negative residents had already been exposed to positive residents. Regional Nurse stated that this was the facility policy. During the interview, the Regional Nurse and the surveyor team reviewed facility's policy titled Novel Coronavirus Prevention and Response Section 8, Procedure when COVID -19 is suspected or confirmed, Letter F, page 5 indicated Do NOT cohort residents with other residents with COVID 19 infection unless they are also confirmed to have COVID 19 infection through testing. Regional Nurse stated that she had previously, on [DATE] misinterpreted the policy and had advised the Administrator and the DON based on the initial previous interpretation of the written policy. The Regional Nurse stated that she had been trained on transmission-based precautions and is responsible for the tracking a trending of communicable diseases within the facility. The Regional Nurse stated as result of her misadvising the Administrator and the DON the facility staff and Residents were placed at risk for being infected with COVID 19. Observation on [DATE] at 5:00 am, CNA T was observed entering droplet precaution room [ROOM NUMBER] without Personal Protective Equipment (PPE) and proceeded to administer incontinent care to Resident #91 while wearing gloves. Subsequently, after concluding the care, CNA T neglected to remove the gloves, sanitize or wash her hands before attending to Resident #80, assisted in adjusting the resident in bed. She returned to the designated clean linen cart with contaminated gloved hands, removed linen, and interacted with the cart without prior hand hygiene. Using the same contaminated gloves, CNA T proceeded to touch the doorknob of room [ROOM NUMBER], then entered room [ROOM NUMBER] without additional PPE (N95, gown, and face shield), continuing to provide incontinent care and emptied Resident #71's urinal. Following this, CNA T omitted hand washing and proper hand hygiene measures before attending to Resident #74, assisted the resident with a blanket. Droplet precaution room [ROOM NUMBER] door remained open. Interview on [DATE] at 5:43 am, CNA T expressed uncertainty regarding why PPE was not utilized, and hand hygiene practices were neglected. CNA T stated that Residents #91, #81, #71 and #74 were on Droplet Precautions due to testing positive for COVID 19. CNA T also acknowledged the risk of infection transmission in the absence of proper PPE and hand hygiene measures. CNA mentioned undergoing infection control training previously but was unable to articulate the specifics or content of the training provided. CNA T stated that she had received training on providing incontinent care to Residents. Observation on [DATE] at 5:05am, CNA J was observed entering identified Droplet Precaution rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) without the appropriate Personal Protective Equipment (PPE), including face shields, N95 masks, and gowns, while providing incontinent care to Residents #77 in room [ROOM NUMBER] and Resident #92 in room [ROOM NUMBER]. Upon exiting room [ROOM NUMBER], proper hand hygiene measures were not implemented. CNA J did not wash or sanitize her hand after exiting Residents #77 room before she provided care to Resident #92. Interview on [DATE] at 5:15am, CNA J acknowledged the error of failing to don PPE and wash hands. CNA J stated that Resident #77 and Resident #92 were on Droplet Precautions due to testing positive for COVID 19. She verbalized an understanding that the transmission of infection can occur when PPE and hand hygiene protocols were not followed. She stated that such error put residents and staff at risk for infection. CNA J mentioned receiving infection control training, some time ago, but was unable to specify the content covered during the training sessions. Interview on [DATE] at 8:11AM, the DON stated Resident #50 and Resident #83 were newly diagnosed as COVID positive as of [DATE]. The DON stated they should have followed the same protocol as before; it worked before. The DON stated the facility should have followed CDC guidelines not to room negative residents with positive residents. The DON stated they kept the negative and positive residents together because the Administrator and the DON were instructed to do so, by the Regional Nurse. The DON continued and stated that the Regional Nurse rationale was that the residents were already exposed and there was no reason to move them. The DON stated that the system failure placed Residents were placed at risk for being infected with COVID 19. The DON stated that the facility was working to ensure that all isolated rooms were stocked with proper PPE and signage. The surveyor informed the DON that staff had been observed entering rooms without PPE and was not implementing hand hygiene before and after care. The surveyor inquired but the DON's expectation related that to hand hygiene and the donning PPE. The DON stated that staff had been in-serviced and trained on proper hand hygiene and PPE. The surveyor required documentation of staff trainings. Interview on [DATE] at 12:00pm, the Administrator stated staff were notified of the COVID 19 outbreak on [DATE]. The Administrator stated that she was not able to verify how the staff was notified and who notified staff. The Administrator stated the floor nurses were monitoring residents for signs/symptoms and were made aware they were responsible, and doctors' orders to assess all residents for signs and symptoms had been added to the PCC. The Administrator could not articulate a plan to mitigate the risk at the time of the meeting. The Administrator stated that the Epidemiology Department had not been notified of the COVID 19 outbreak at the time of the interview. The Administrator did not reveal why the information had not been reported. The Administrator stated that the Business Office Manager is responsible for reporting to Epidemiology Department. Interview on [DATE] at 12:40, the Business office Manager stated that she was made aware of COVID positive residents at the facility on [DATE] when she returned to work. She stated that she had been out of the facility the previous week due to a personal family member's death. She stated that in her absence, the Administrator is supposed to report COVID 19 to the health department. Business office Manager stated that a report was submitted to the health department on [DATE] that included 14 residents who tested positive for COVID 19 on [DATE] and not for the total 29 residents that were currently in the building. The facility failed to provide failed to provide proof of in-services and staff training for infection control and transmission-based precaution requested on [DATE], [DATE], and [DATE] at various times. requested as of [DATE]. Thes was determined to be an immediate jeopardy (IJ) on [DATE] due to the above failures. The administrator was notified and provided the IJ template on [DATE] at 1:45p.m. The immediacy was lowered on Sunday, [DATE] at 2:05p.m. with the facility Administrator and DON, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. Plan of Removal - Infection Prevention and Control 1. Immediate Action Taken A. On [DATE] the DON/designee moved all COVID positive residents to hall 200 that will serve as a dedicated COVID unit for all residents who are COVID Positive. B. On [DATE] roommates with high exposure to COVID positive residents are being monitored every shift by license nurse for signs/symptoms of COVID with documentation on LN MAR. All other residents are being monitored for signs/symptoms of COVID through License Nurse rounds during shift. Asymptomatic residents with a higher-risk exposure, will have a series of 3 viral tests for SARS-CoV-2 infection. Testing will be done immediately (but not earlier than 24 hours after exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. (This will typically be at day 1 (when day of exposure is day0), day 3, and day 5). Then testing will be repeated every 3-7 days until no new cases are identified for at least 14 days. C. On [DATE] residents in Isolation for COVID had appropriate signage placed on door (Contact Isolation signage, Droplet Isolation signage, and Donning and Doffing PPE signage) to alert staff of required PPE. D. On [DATE] residents who tested positive for COVID, had physician notification and orders received to place residents in Droplet Isolation. Each resident in Isolation had appropriate and adequate PPE outside of each room. This will be replenished as needed E. On [DATE] the DON who is currently the designated Infection Preventionist for the facility received 1:1 education on the Infection Preventionist Job duties that include: Education, training, experience, or certification in infection control and prevention. Completed specialized training in infection prevention and control through accredited continuing education. Develop and implement an ongoing infection prevention and control program to prevent, recognize, and control the onset and spread of infections to provide a safe, sanitary, and comfortable environment. Establish facility-wide systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases of residents, staff, and visitors. Develop and implement written policies and procedures in accordance with current standards of practice and recognized guidelines for infection prevention and control. Oversee the facility's antibiotic stewardship program. Oversee resident care activities that increase risk of infection (i.e., use and care of urinary catheters, wound care, incontinence care, skin care, point-of-care blood testing, and medication injections). Lead the facility's Infection and Prevention Control Committee. Develop action plans to address opportunities for improvement. Participate on the facility's QAA Committee. Perform duties as assigned. F. The Infection Preventionist will use a system of surveillance to utilized prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards G. On [DATE] the facility assigned dedicated staff to the COVID unit. This will be ongoing until outbreak is over to the extent possible 2. Identification of Residents Affected or Likely to be Affected: A. On all other residents were tested for COVID-19 with only 1 other resident identified who tested COVID positive. Total COVID-19 residents 29. 3.Actions to Prevent Occurrence/Recurrence: A. On [DATE] the DON/Designee started In-Service education with all staff on the Coronavirus Prevention and Response Plan that: Prompt identification, treatment to prevent the spread, source control, community surveillance, signs/symptoms to report and notify physician, testing considerations, response to an Outbreak, Hospital admission Levels prevention, interventions to prevent respiratory germs into the facility, procedure when COVID-19 is suspected or confirmed, Managing /staff with High Exposure, return to work criteria for HCP and duration of transmission-based precautions for residents. This education will be completed on [DATE] at 7:30 pm, and no staff will be allowed to work until they have completed this education. This education will be provided to all newly hired staff ongoing. B. On [DATE] the DON/Designee started In-Service education with all staff on Transmission-Based Precautions Policy that: Defines different Isolation Precautions, standard precautions, to residents who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission, when to Initiation of Transmission-Based Precautions, Discontinuation of Transmission-Based Precautions, Recommended PPE for each type of precaution. This education will be completed on [DATE] at 7:30 pm, and no staff will be allowed to work until they have completed this education. This education will be provided to all newly hired staff ongoing. [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and timeframes to meet residents' physical, mental and psychosocial needs for 1 of 10 residents (CR#1) reviewed for care plans. The facility failed to implement CR #1's care plan, which included 1:1 monitoring for a history of diet noncompliance, to ensure he ate nothing by mouth. On 12/1/23, CR #1 was unsupervised during a meal and ate food that was not compliant with his diet, resulting in his death after a choking incident. An Immediate Jeopardy (IJ) situation was identified on 12/6/2023 at 2:55 p.m. While the IJ was removed on 12/8/2023 at 4:42pm, the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. This failure could place residents with no food by mouth (NPO) diet at risk of choking or death. Findings included: Record review of a list of NPO (no food by mouth) residents provided by DON listed 10 residents that were not able to eat any food by mouth. Record review of CR#1' face sheet revealed a [AGE] year-old male that was admitted to the facility on [DATE], CR#1 had diagnoses which included: Cerebral Palsy (a disorder of movement, muscle tone, or posture), Dysphagia (difficulty swallowing, a common complication with cerebral palsy), Gastrostomy tube(a tube inserted through the belly that brings nutrition directly to the stomach), pneumonitis due to the inhalation of food and vomit( inflammation in lung tissue), Schizoaffective Disorder(a mental health disorder in which there is a combination of symptoms of schizophrenia and mood disorder), and epilepsy(a disorder in which cell activity in the brain is disturbed, causing seizures). Record review of CR#1's quarterly MDS assessment dated [DATE] revealed under Section C500- Brief Interview of mental status was 14 (indication of cognitvely intact). Section E- Behavior revealed A. Physical Behaviors (such as hitting and kicking)- directed towards others, B. Verbal behaviors towards others (such as screaming/using profanity), C. Other behaviors towards self (such as rummaging, pacing) were all coded as (1) - meaning behaviors of this type occurred 1 to 3 days. Section GG0120- Mobility Devices revealed a manual wheelchair was used. Section GG0130- Functional ability coded A. Eating (01)- coded for dependent on helper for all efforts. K0520- Nutritional Approaches revealed B. Feeding Tube was used for nutritional needs. Record review of MDS dated [DATE] revealed CR#1 was discharged due to death in facility. Record review of care plan date initiated and revised on 11/13/2023 revealed CR#1 has behavior problem as evidenced by noncompliant with NPO (nothing by mouth). CR#1 takes food from trays, takes water pitchers and water in them and goes to machine and buys soda. CR#1 will have no signs and symptoms of aspiration and noncompliance will decrease through target date of 1/24/2023. Interventions: educate the resident on possible outcomes, minimize potential for noncompliant behavior and CR#1 requires 1:1 monitoring. Record review of physician order dated 5/19/2023 revealed CR#1 had a pureed texture, mildly thick-nectar consistency. Record review of physician order dated 5/31/2023 revealed CR#1 had a pureed texture, thin liquid consistency. Record review of physician order dated 8/6/2023 revealed CR#1 had an NPO texture diet until additional swallow evaluations related to Dysphagia, unspecified. G-tube would be used for nutritional needs. Record review of physician order dated 11/13/2023 revealed CR#1 had an NPO diet texture (Nothing by mouth) Record review of nursing progress note dated 12/1/2023 written by RN A revealed CNA A heard someone coughing. CNA A investigated and learned that it was CR#1. CNA A asked if CR#1 had eaten any food. CR#1 shook his head no. She asked again and he said yes. CNA A called for help and RN A began the Heimlich maneuver. RN A swept his mouth and then began to suction. Some food particles were removed. RN A then provided oxygen at 100% and no vitals could be palpated. The Heimlich maneuver was unsuccessful, 911 was called and nurses began to provide Cardiopulmonary resuscitation. CR#1 became cyanotic (turning blue) and unresponsive. Emergency Medical Services (EMS) arrived and continued cardiopulmonary resuscitation and CR#1 left the facility via ambulance. Record review of Emergency Medical Service report dated 12/1/2023 at 18:16 (6:16 p.m.) the local EMS was dispatched to a choking call that was upgraded to a cardiac arrest with law enforcement and fire department. Upon arrival CR#1 was laying supine on the floor. There were three staff members in the room performing Cardiopulmonary resuscitation. One male was ventilating with a self-inflating resuscitator bag connected to oxygen. There was a female performing chest compressions, and another female at the feet of the patient. Staff reported that they found CR#1 choking. Staff performed the Heimlich maneuver without success. CR#1 was apneic and pulseless. Medic took over from staff. Assessment revealed CR#1 airway was completely obstructed with what appeared to be chewed up banana. Cardiac monitor revealed asystole (a type of cardia arrest, which is when the heart stops beating entirely. CR#1 was taken to a local hospital via stretcher. CR#1 remained asystole throughout patient care. Interview with DON on 12/5/23 at 1:49 p.m. she stated CR#1 care plan included 1:1 monitoring since he tried to take regular food from residents and vending machines and attempted to eat by mouth although he had a G-tube. She said staff such as CNA's, nurses, housekeeping and restorative aides were used to sit with him to prevent him from taking regular diet food. She said she was not sure of the date that the 1:1 ended. CR#1 was said to be doing much better with seeking food so at some point the monitoring ended. She said that the updates to care plans were made by the MDS nurse. Interview with the Administrator on 12/5/2023 at 3:46 p.m. revealed CR#1 was being redirected with activities due to his behaviors. She said that he was on 1:1 monitoring for both hitting his head and seeking regular food although he had a G-tube. She said he had no behaviors for a while. She could not recall how long it had been since his last behavior. She said she continued to bring him into her office to listen to music and even moved his room across from her office so at mealtimes she could watch him. She said on 12/1/2023 CR#1 took a dinner roll from his roommate (Resident #2) and ate some of it causing him to choke. She said that he was not currently on 1:1 monitoring because it had been a long time since he had any behaviors. She could not recall when the monitoring stopped. She said the staff were doing the best they could because they were not able to get CR#1 discharged or transferred to another facility. Other facilities would not admit him due to behaviors, G-tube, or previous nursing facilities stays. She said she do not know why the care plan had not been updated. Interview with RN A on 12/5/2023 at 4:31 p.m., revealed to her to state on 12/1/2023 she heard CNA A calling for help after learning that CR#1was cough and possibly choking. She said that she began trying the Heimlich maneuver and was unsuccessful. She swept his mouth for food and then suctioned. She stated that very little food particles came up. She stated that she had help from two other nurses. She said CR#1 was turning blue, and she gave him oxygen. She said that CPR was initiated, and EMS took over when they arrived. She said that CR#1 was constantly trying to get regular food from other residents' plates. She said he would get angry if anyone tried to stop him from acquiring regular food although he had a G-tube. Interview with CNA A on 12/5/23 at 4:47 p.m., states she said CR#1 had a G-tube and would take other residents' food. She said he was able to walk a little and would sneak into other resident rooms for their food. She said that the Administrator had informed all staff to pay attention to him and make sure he did not take other people's food. She said usually when they (CNA's) pass the trays they would keep the cart further away from him so he would not try to get food while they are with other residents. She stated that the Administrator did an in-service about 2 or 3 weeks ago and informed them that he still had an NPO - nothing by mouth diet. She said she provided 1:1 monitoring for CR#1 for several months around June/July 2023 and it ended sometime in July or August. She said she could not remember. She said she would sit in his room and make sure he did not get regular food and was not hitting his head. She said he would get upset if anyone took regular food away from him and he would pull out his g-tube and they had to call 911. She said that he would pull out the G-tube because he wanted to eat. She said on 12/1/2023 at approximately 6 p.m. she heard someone coughing and immediately went to CR#1's room and looked at Resident #2's tray. She noticed the dinner roll was not there. She asked him if he ate something he nodded no. She said she asked again CR#1 did you eat something, and he nodded up and down as to say yes and pointed to his roommate's tray. She does not know why the roommate did not stop him from taking his dinner roll. She said she did not ask Resident #2. She said she called the nurse right away. RN A started the Heimlich maneuver, she swept his mouth, and another nurse came into the room to assist RN A. She left the room when they started working on him. Interview with MDS nurse on 12/6/2023 at 1:25pm, revealed her to state CR#1 was on 1:1 monitoring when he was admitted . She said she had been employed at the facility since July 2023. She said she participated in care plan meetings and provided MDS quarterly, upon significant change and readmissions for all residents of the facility. She said sometimes it took a while to make updates because there were so many residents. She could not explain why CR#1's care plan had an intervention 1:1 staff monitoring due to him trying to take food. She said if she recall correctly, he had not attempted to take or eat regular diet food and it should have been removed off the interventions. Record review of the Comprehensive care plans policy dated 2/10/2021 stated it is the policy of this facility to develop and implement a comprehensive person-centered car plan for each resident, consistent with resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy explanation and Compliance Guidelines included: 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Record review of the MDS nurse job description revealed responsibilities included MDS completion in a timely, accurate documentation-supported and case mix optimized manner; development of individualized care plans reflective of the residents' status; oversight of the resident care data collection tool; coordination of assessments and services by other clinical departments; liaison to rehab team; audit and survey preparation, implementation and response; managed care clinical authorizations and justifications. The Administrator and DON were notified of an IJ on 12/6/2023 at 2:55pm, due to the above failure. The Administrator was given a copy of the Immediate Jeopardy template and Plan of Removal (POR) was requested. The following plan of removal submitted was accepted on 12/7/2023 at 2:06pm. 1. Immediate Action Taken A. Resident # 1 expired in facility on 12/1/2023 B. 100% audit of all resident's care plans were reviewed to ensure that appropriate interventions to reflect care that resident is receiving. This audit was conducted by MDS nurse and will be completed by 10:00 am on 12/7/2023 2. Identification of Residents Affected or Likely to be Affected: A. 100% audit of all resident's care plans were reviewed to ensure that appropriate interventions to reflect care that resident is receiving. This audit was conducted by MDS nurse and will be completed by 10:00 am on 12/7/2023. One other resident was identified as having the potential for taking food or fluids from meal trays. This resident's care plan was updated on 12/6/2023 will appropriate interventions, and does not require 1:1 supervision per the Interdisciplinary Care Plan Team. The C.N.A.'s [NAME] has been updated to identify this potential issue. B. On 12/7/2023 10 residents were identified as being NPO. MDS Nurse/Designee reviewed and revised care plans of these 10 residents if applicable 3.Actions to Prevent Occurrence/Recurrence: A. Care plans will be updated and reviewed weekly by Interdisciplinary care team during the care plan Meeting to validate that all goals and interventions are resident specific. The weekly care plan conference meeting will be conducted on 12/7/2023. B. Regional Reimbursement nurse will complete random weekly audits of care plan interventions to validate that goals and interventions reflect each resident's need. C. All care plan reviews and updates will be discussed monthly in QAPI D. On 12/6/2023 DON/Designee began in-service education with all licensed nurses and C.N.A.'s on following care plans. This education will be completed by 10:00am 12/7/2023. No license nurse or C.N.A. will be allowed to work until this education has been completed. 4. On 12/6/2023 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to care plans and reviewed plan to sustain compliance Date Facility Asserts Likelihood for Serious Harm No Longer Exists: _____12/7/2023____________ Monitoring of the plan of removal included the following: Interviews with two CNA's and three nurses between 12/7/2023-12/11/2023 revealed they had been trained on following care plans. Staff stated they were clear on the expectation to follow care plans and reporting and documenting changes in mental or physical conditions to nurses on duty, DON and/or Administrator. Record review of care plans for the 10 identified residents with NPO diets revealed no concerns were found. Record review of Resident #3's face sheet, MDS, nursing progress notes and care plans were reviewed due to resident identified as having the potential for taking food off the food trays. A family care plan meeting was held with FM on 12/7/2023 and there was a plan to prevent resident from receiving food that was not the accurate consistency. Record review of weekly care plan meeting sign-in revealed it was held on 12/7/2023. The DON and Regional Nurse Consultant were informed the Immediate Jeopardy was removed on 12/8/2023 at 4:42 p.m. The facility remained out of compliance at a severity level of isolated and a scope and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective system that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (CR #1) reviewed for accidents and supervision. The facility failed to provide adequate supervision to ensure CR#1 ate nothing by mouth when he had a Gastrostomy tube (G-tube) for enteral feedings due to dysphagia and history of aspiration/choking. On 12/1/23, CR #1 was unsupervised during a meal and ate food that was not compliant with his diet, resulting in his death after a choking incident. An Immediate Jeopardy (IJ) situation was identified on 12/6/2023 at 2:55 p.m. While the IJ was removed on 12/8/2023 at 4:42pm, the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. This failure could place residents at risk of injuries due to lack of supervision by facility staff. Findings Included: Record review of CR#1's undated face sheet revealed a [AGE] year-old male that was admitted to the facility on [DATE]. CR#1 had diagnoses which included: Cerebral Palsy (a disorder of movement, muscle tone, or posture), Dysphagia (difficulty swallowing, a common complication with cerebral palsy), Gastrostomy tube(a tube inserted through the belly that brings nutrition directly to the stomach), pneumonitis due to the inhalation of food and vomit( inflammation in lung tissue), Schizoaffective Disorder(a mental health disorder in which there is a combination of symptoms of schizophrenia and mood disorder), and epilepsy(a disorder in which cell activity in the brain is disturbed, causing seizures). Record review of CR#1's quarterly MDS assessment dated [DATE] revealed under Section C500- Brief Interview of mental status was 14 (which indicated cognitively intact). Section E- Behavior revealed A. Physical Behaviors (such as hitting and kicking)- directed towards others, B. Verbal behaviors towards others (such as screaming/using profanity), C. Other behaviors towards self (such as rummaging, pacing) were all coded as (1) - meaning behaviors of this type occurred 1 to 3 days. Section GG0120- Mobility Devices revealed a manual wheelchair was used. Section GG0130- Functional ability coded A. Eating (01)- coded for dependent on helper for all efforts. K0520- Nutritional Approaches revealed B. Feeding Tube was used for nutritional needs. Record review of care plan initiated and revised on 11/13/2023 revealed CR#1 has behavior problem as evidenced by noncompliant with NPO (nothing by mouth). CR#1 takes food from trays, takes water pitchers and water in them and goes to machine and buys soda. CR#1 will have no signs and symptoms of aspiration and noncompliance will decrease through target date of 1/24/2023. Interventions: educate the resident on possible outcomes, minimize potential for noncompliant behavior and CR#1 requires 1:1 monitoring. Record review of physician order dated 5/19/2023 revealed CR#1 had a pureed texture, mildly thick-nectar consistency. Record review of physician order dated 5/31/2023 revealed CR#1 had a pureed texture diet with thin liquid consistency. Record review of physician order dated 8/6/2023 revealed CR#1 had an NPO texture diet until additional swallow evaluations related to Dysphagia. Record review of physician order dated 11/13/2023 revealed CR#1 had an NPO diet texture (Nothing by mouth) Record review of a nursing progress note written by RN A dated 12/1/2023 revealed CNA A heard someone coughing. CNA A investigated and learned that it was CR#1. CNA A asked if CR#1 had eaten any food. CR#1 shook his head no. She asked again and he said yes. CNA A called for help and RN A began the Heimlich maneuver. RN A swept his mouth and then began to suction. Some food particles were removed. RN A then provided oxygen at 100% and no vitals could be palpated. The Heimlich maneuver was unsuccessful, 911 was called and nurses began to provide Cardiopulmonary resuscitation. CR#1 became cyanotic (turning blue) and unresponsive. Emergency Medical Services (EMS) arrived and continued cardiopulmonary resuscitation and CR#1 left the facility via ambulance. Record review of room change for CR#1 revealed multiple changes occurred due to readmissions and for monitoring. CR#1 most recent room change was on 10/12/2023. Record review of Emergency Medical Service report dated 12/1/2023 at 18:16 (6:16pm) the local EMS was dispatched to a choking call that was upgraded to a cardiac arrest with law enforcement and fire department. Upon arrival CR#1 was laying supine on the floor. There were three staff members in the room performing Cardiopulmonary resuscitation. One male was ventilating with a self-inflating resuscitator bag connected to oxygen. There was a female performing chest compressions, and another female at the feet of the patient. Staff reported that they found CR#1 choking. Staff performed the Heimlich maneuver without success. CR#1 was apneic and pulseless. Medic took over from staff. Assessment revealed CR#1 airway was completely obstructed with what appeared to be chewed up banana. Cardiac monitor revealed asystole (a type of cardia arrest, which is when the heart stops beating entirely. CR#1 was taken to a local hospital via stretcher. CR#1 remained asystole throughout patient care. Record review of a speech therapy evaluation and treatment plan for certification dates 8/18/2023-10/16/2023 revealed: Current Referral: Reason for referral were CR#1 risk of aspiration, nursing staff reported consistent coughing/choking with puree/thin liquids diet. Treatment approaches: Evaluation of speech sound production and language assessment, evaluation of oral and pharyngeal swallow function. Initial assessment: The [NAME] Assessment of swallow ability ([NAME]) consisted of 24 clinical items comprised of four main components: (1) general patient examination (alertness and cooperation), (2) oral preparation phase (saliva, lip, seal, and tongue movement), (3) oral phase (gag reflex and palatal movement), (4) pharyngeal (cough reflex and voluntary cough). [NAME] are interpreted as no abnormality (=178), mild dysphagia (168-177) severe dysphagia (=138). The risks of aspiration were defined based on the total scores. CR#1 score was 130 which meant severe dysphagia. CR#1 had speech therapy 3 times per week for 5 weeks. The recommendation for CR#1 was no food by mouth (NPO) diet. Record review of speech therapy CR#1 treatment plan for 10/6/2023-12/4/2023 changed from 3 times per week to 4 times per week. CR#1 would remain on a NPO diet based upon his evaluation. Interview with the DON on 12/5/23 at 1:49 p.m., revealed her to state that CR#1 was his own RP. She said they had been trying to get him a guardian. However, he had a Brief Interview of Mental status (BIM) of 14- (which meant cognitively intact). She said that he had multiple speech evaluations and swallow studies between June 20023 -November 2023 in which the recommendation was no food by mouth or NPO. She said CR#1 wanted to eat food from his roommate and off other trays as he found them. She said he was placed on 1:1 monitoring due to this behavior. She said she learned in June 2023 that CR#1 had been admitted from a group home. At the group home, CR#1 was said to have swallowed bleach, and this added to his swallowing issues. She said that he was placed on 1:1 monitoring as an intervention. She said 1:1 was provided by CNA's, nurses, housekeeping for a month or more. She said his behavior got better, then he started pulling out his G-tube. Interview with the Speech therapist on 12/5/23 @ 3:13 p.m. revealed she began working at the facility in July 2023. She said the most recent evaluation on CR#1 was 10/6/2023-11/30/23. She said dysphasia, communication and auditory services were provided. Trials of various consistencies were done such as, pudding moderately thick, thin, and multiple others were tried with CR#1. He had therapy 3-times per week for 15-30 minutes. She said signs/symptoms of aspiration were discussed and CR#1 sometimes he did not follow her instructions. She said CR#1 was impulsive, she would cue him to only take 1 sip of a liquid and he would take 2-3 sips and start coughing. She said she took breaks and would sometimes work with him on safety. She said she educated CR#1 on bolus and holding liquids in his mouth and demonstrated swallowing hard. She said 1-step directions were given so they were easier to follow. She said the trials for various consistencies did not do well. She said he would start coughing which indicated to her that thin nor thickened could be tolerated. She said he was on an NPO diet. She stated that orders were put in PCC and all nurses where all nursing staff are aware of changes in d orders and plan of treatment. Interview with the Administrator on 12/5/2023 at 3:46 p.m. revealed that CR#1 was being redirected with activities due to his behaviors. She said that he was on 1:1 monitoring for both hitting his head and seeking regular food although he had a G-tube. She said he had not sought food or had any other behaviors in a while. She could not recall how long it had been since his last behavior. She said she continued to bring him into her office to listen to music and even moved his room across from her office so at breakfast and lunch mealtimes she could watch him. She said she had watched him for several weeks and as needed. Also, that she had staff (CNA, RN, Housekeeping) all to monitor him for several months. She said he was not on 1:1 monitoring because it had bee a long time since he had any behaviors. She said that it was believed that on 12/1/23 CR#1 took a dinner roll from his roommate (Resident #2) and ate some of it causing him to choke. She said that he was not currently on 1:1 monitoring because it had been a long time since he had any behaviors. She said he had been moved several times to be closest to the nursing station so they could monitor him. Interview with RN A on 12/5/2023 at 4:31 p.m., revealed to her to state on 12/1/2023 she heard CNA A calling for help after learning that CR#1was coughing and possibly choking. She said that she began trying the Heimlich maneuver and was unsuccessful. She swept his mouth for food and then suctioned. She stated that very little food particles came up. She stated that she had help from two other nurses. She said CR#1 was turning blue, and she gave him oxygen. She said that CPR was initiated, and EMS took over when they arrived. She said that CR#1 was constantly trying to get regular food from other residents' plates. She said he would get angry if anyone tried to stop him from acquiring regular food although he had a G-tube. Interview with CNA A on 12/5/23 at 4:47 p.m., said CR#1 had a G-tube but would take other residents' regular food. She said he was able to walk a little and would sneak into other resident rooms for their food and tried to get food off his roommate's tray. She said that the Administrator had informed all staff to pay attention to him and make sure he did not take other residents' food. She said usually when CNA's pass the trays, they would keep the cart further away from him so he would not try to get food while they were with other residents. She stated that the Administrator did an in-service about 2 or 3 weeks ago and informed them that he still had an NPO - nothing by mouth diet. She said she provided 1:1 monitoring for CR#1 for several months around June/July 2023 and it ended sometime in July or August. She said she could not remember. She said she would sit in his room and make sure he did not get regular food and was not hitting his head. She said he would get upset if anyone took regular food away from him and he would pull out his g-tube and they had to call 911. She said that he would pull out the G-tube because he wanted to eat. She said on 12/1/2023 at approximately 6 p.m. she heard someone coughing and immediately went to CR#1's room and looked at Resident #2's tray. She noticed the dinner roll was not there. She asked him if he ate something, and he nodded no. She said she asked again CR#1 did you eat something, and he nodded up and down as to say yes and pointed towards his roommate. She does not know why the roommate did not stop him from taking his dinner roll. She said she did not ask Resident #2. She said she called the nurse right away because CR#1 was choking. RN A started the Heimlich maneuver, she swept his mouth, and another nurse came into the room to assist RN A. She left the room when they started working on him. Interview with Resident #2 on 12/6/23 @ 2:25 p.m., he questioned whether he was in trouble because CR#1 took his dinner roll. He said he did not give it to him. He said on the day that this incident occurred, CR#1 was standing near his bed acting like he was watching his television. He said he asked CR#1 why he was not looking at his own television. He said when he started doing something in his bed, he noticed that his dinner roll was gone. He said he looked at his roommate (CR#1) and he was chewing something. He said then he began to cough, and then staff came in to find out what was going on. He said he left the room because staff were working on him. Resident #2 said CR#1 had been his roommate for about 2 months. He said that CR#1 was constantly trying to stash food. He said that if he knew he could not eat and still tried, maybe he wanted to choke and die. He said he would do things to cause himself harm. Interview with Dietary Manager, on 12/6/2023 @ 2:40 p.m., revealed her to state she has been employed at the facility for 7 years. She said that CR#1 was NPO and had a G-tube. She said staff informed her that he would try to grab food off trays in the hall and she began having them bring the carts back to the kitchen as soon as the meals had been passed out to the residents, and they tried to ensure trays were not left in residents' rooms after residents with regular diets were done eating. She said that she stopped putting self-serve coffee out for residents to prevent CR#1 from getting coffee. Interview with the FM on 12/8/2023 at 3:20 p.m., revealed that CR#1 passed away on 12/1/2023. She said that it was her understanding that CR#1 passed away from choking on a dinner roll that he had taken from another resident's tray. She said it was difficult to find a nursing facility closer to where his family resided. She said since he had a G-tube, and bad behaviors such as hitting, spitting, and trying to eat other residents' food made it difficult and several facilities would not admit him. She said the medical examiner told her on 12/4/2023 CR#1 passed away from choking and was going to prepare his death certificate. As of this interview, she had not received it. Record review of the facility's abuse, neglect and exploitation policy revealed it to state it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation and misappropriation of resident property. Record review of incidents, accidents and supervision policy stated it is the policy of this facility to provide an environment that is free of hazards over which the facility has control and provides supervision and assistive devices to each residet to prevent avoidable accidents. The Administrator and DON were notified of an Immediate Jeopardy on 12/6/2023 at 2:55 p.m., due to the above failure. The Administrator was provided with a copy of the IJ template, and a plan of removal (POR) was requested. The following plan of removal submitted by the facility was accepted on 12/7/2023 at 2:06pm. 1. Immediate Action Taken A. Resident # 1 expired in facility on 12/1/2023 B. On 12/6/2023 the DON/designee completed rounds throughout the facility to identify other residents who have potential for taking food or fluids from other meal trays. One other resident was identified as having the potential for taking food or fluids from meal trays. This resident's care plan was updated on 12/6/2023 will appropriate interventions. The C.N.A.'s [NAME] has been updated to identify this potential issue. C. On 12/7/2023 the DON/Designee started in-service education with all licensed nurses and C.N.A.'s on the Comprehensive Care Plan Policy which guides the Interdisciplinary Care Team on: measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents' progress. Alternative interventions will be documented, as needed, Care Plans will be update or revised as applicable at least quarterly and as needed base on resident care changes, Care Plan interventions flow to [NAME] system that provides directions to C.NA.'s on care resident requires. This will be completed on 12/7/2023 at 10;00 am and no licensed nurse or C.N.A. will be allowed to work until they have received this education. 2. Identification of Residents Affected or Likely to be Affected: A. On 12/6/2023 the DON/designee completed rounds throughout the facility to identify other residents who have potential for taking food or fluids from other meal trays. One other resident was identified as having the potential for taking food or fluids from meal trays. This resident's care plan was updated on 12/6/2023 will appropriate interventions. The C.N.A.'s [NAME] has been updated to identify this potential issue 3.Actions to Prevent Occurrence/Recurrence: A. On 12/6/2023 DON/Designee started in-service education on with all staff on: Emergency Response to Choking Training on Heimlich Maneuver Minimizing accessibility to food and liquids (busing table in D/R once a resident has completed a meal, covers for carts out in hallway to minimize a resident's accessibility) This training will be completed on 12/6/2023 by 7:00 pm. No staff member will be allowed to work until this training has been completed. B. Department managers will be assigned daily to monitor meal service to ensure that carts out in the hallway are not accessible to the residents during mealtimes. The schedule of meal monitoring will be the responsibility of the administrator, and this will be reviewed daily during morning meetings. On 12/6/2023 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Accidents and Supervision to sustain compliance Date Facility Asserts Likelihood for Serious Harm No Longer Exists: ________12/7/2023_______ Monitoring of this plan of removal included the following: Observation on 12/9/2023 revealed of facility management in the dining room monitoring residents during lunch. Observation on 12/11/2023 revealed of plastic cart covers that zipped to cover entire cart. Interviews with three CNA's and two nurses between 12/7/2023-12/11/2023 on morning, evening and overnight shifts revealed that they had been in-serviced on emergency response to choking, Heimlich maneuver training, and minimizing accessibility to food after mealtimes. They stated that they understood the procedure in an emergency. They would call the charge nurse or any nurse available in an emergency and follow the chain of command for reporting the events to the Administrator, DON, and family members. A subsequent interview with the DON on 12/8/2023@2:15 p.m. revealed her to state the Heimlich maneuver training had been completed as well as emergency response to choking. She said no staff were permitted to work until they had been trained. She said she had three that would receive training when they came back to work on the following week. Record review of training on 12/6/2023 of Heimlich maneuver revealed that LVN A provided Heimlich maneuver training . The DON and Regional Nurse Consultant were informed the Immediate Jeopardy was removed on 12/8/2023 at 4:42 p.m. The facility remained out of compliance at a severity level of isolated and a scope and severity of actual harm due to the facility's need to evaluate the effectiveness of the corrective system that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control, in that: -Wound Care Nurse failed to perform hand hygiene when moving from a dirty to clean while performing Resident #1's wound care. This failure could place residents at risk for infections. Findings included: Record review of the admission sheet (undated) for Resident #1 revealed he was [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. His diagnoses included pressure ulcer of sacral region, stage 4 (deep wound reaching the muscles, ligaments, or bones), paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs) and neuromuscular dysfunction of bladder (a problem in your brain, spinal cord, or central nervous system makes you lose control of your bladder). Record review of Resident#1's Quarterly MDS dated [DATE] revealed BIMS score of 15 out of 15 indicating intact cognition. Further review of Section M0150. Risk of Pressure Ulcers/Injuries- Is this resident at risk of developing pressure ulcers/injuries? Coded- Yes. M0210. Unhealed Pressure Ulcers/Injuries-Does this resident have one or more unhealed pressure ulcers/injuries? Coded- Yes. M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage. C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Number of Stag 3 Pressure ulcers coded-2. Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry coded-2. D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 Pressure ulcers coded-2. Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry coded 2. Record review of Resident#1's care plan initiated 09/27/2023 and revised on 10/03/2023 revealed the following: Focus: Pressure ulcer: Stg 4 R ischium Resident has a pressure ulcer and is at risk for infection, pain, and a decline in functional abilities. Goal: Resident's pressure ulcer will show signs of healing through next week date. Target Date: 01/09/2024. Interventions: Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling. Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected. Record review of Resident #1's physician order dated 11/15/23 revealed an order to cleanse stage 4 to the R ischium with NS or skin cleanser pat dry apply collagen then gauze moistened with vashe solution cover with dry dressing change qd/PRN every day shift. Observation and interview on 11/20/23 at 10:15a.m., with Resident #1 revealed he was resting on an air mattress. He said, facility was not providing proper wound care. I asked to be sent to the hospital and found out that my wounds were infected with MRSA. Observation on 11/20/23/06/22 at 10:30 a.m., revealed Wound Care Nurse performing wound care on Resident #1 assisted by CNA A. Prior to start of the treatment, Resident #1 was assisted onto his left side. Observation revealed a dressing dated 11/19/23 on a wound to the R ischium area approximately 3 cm in diameter. Wound Care Nurse did not clean the R ischium from the inside to out. Wound Care nurse then removed her soiled gloves, without sanitizing/washing her hands, donned new gloves and continued the wound care treatment. Wound Care Nurse applied collagen then gauze moistened with vashe hypochlorous acid solution (wound cleanser) and covered with dry dressing. In an interview on 11/20/23 at 12:15 p.m., with the Wound Care Nurse, she said the resident was on isolation for MRSA to the wound. She said she was nervous she should have performed hand hygiene before donning (putting) clean gloves as it placed the risk for cross contamination and infections to the wound. She said the company that provided the wound care supplies came to the facility on Friday (11/17/23) and did competency check off with her. She said she signed in-service on infection control a week ago she could not recall the exact date. In an interview on 11/20/23 at 2:39p.m., with the DON, she said she expected staff to follow standard infection control techniques. To perform handwashing before the treatment, if hands become soiled, between gloves change, and after as it placed risk for infections. She said staff were provided training on infection control and hand hygiene on the 15th of this month. She said Wound care company representative did Wound Care Nurse's competency check off last Friday (11/17/23). She said, I spot checked Wound Care Nurse in October 3 weeks ago or a month ago can't recall the exact date. She said the potential risk to resident due to this failure was cross contamination. Record review of facility's Wound Management policy (Revision Date: 2/7/2019) revealed read in part: .Anticipated Outcome: To promote wound healing of various types of wounds and provide evidence-based treatments in accordance with current standards of practice and physician orders. Process: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change . Record review of facility's Hand Hygiene policy (Date Implemented: 11/12/2027) revealed read in part: .Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Policy Explanation and Compliance Guidelines: 1. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). 2. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 6. Additional considerations: b. The use of gloves does not replace hand washing. Wash hands after removing gloves . Record review of facility's Infection Prevention and Control Program policy (Date implemented: 10/24/2022) revealed read in part: .Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 4. Standard Precautions: b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident's right to be free from neglect for 1 resident (Resident #1) of 10 residents reviewed for neglect in that: 1. The facility failed to have an effective system in place to monitor for STAT diagnostic/laboratory results, 2. The facility failed to ensure staff were trained on where to check for and follow up on diagnostic/laboratory results. 3. The facility failed to have a communication system in place to ensure timely continuity of care and interventions/treatment. 4. The facility failed to report to the ordering physician Resident #1's stat x-ray results of a fracture to the right hip, femur, and pelvis in a prompt manner. An IJ was identified on 05/26/2023. The IJ template was provided to the facility Administrator on 05/26/2023 at 5:50pm. While the Administrator was notified at 11:50am on 05/29/2023 that the IJ was removed, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to all staff had not been trained to monitor for STAT diagnostic/lab results following up with the results to the physician in a timely manner. This failure resulted in delayed diagnosis of sacral osteomyelitis and antibiotic administration for Resident #1 with the potential to place residents who received diagnostic testing at risk for neglect, delayed treatment, and hospitalization. Findings: Resident #1 Record review of Resident #1's face sheet dated 05/12/2023 revealed an [AGE] year-old male admitted to the NF on 04/02/2023 with the following diagnoses; cerebral infarction (disrupted blood flow to the brain), respiratory failure, hypertension (high blood pressure), dysphagia (difficulty swallowing), functional quadriplegia (loss of control of both arms and both legs), type two diabetes mellitus, heart disease, sacral (below the spine and above the tailbone) ulcer stage 4, pressure ulcer of left ankle, renal (kidney) disease, tracheostomy (opening created at the front of the neck so that a tube can be inserted in the windpipe to help one breathe), gastrostomy (opening in the stomach done surgically for the introduction of food), and colostomy (surgical operation creating an opening in the abdomen/stomach to expel waste). Record review of Resident #1's admission assessment MDS dated [DATE] revealed BIMS score of 9 (cognition moderately impaired). Further review revealed that resident was totally dependent on staff with assistance of activities of daily living. Record review of Resident #1's Nursing progress Notes dated 05/04/2023 documented by the Wound Care Nurse revealed in part: .Resident visited per wound care docotor this a.m., upon observation stage 4 of the sacrum shows signs of improvement .Arterial wound of L(left) second toe is currently stable .wound has no noted exudate with 100% necrotic eschar noted to wound bed, tratement order for site continue as ordered, arterial wound of the L (left) 3rd toe is also stable .wound has no noted exudate with 100% necrotic eschar noted to wound bed, treatement order continue as ordered .no signs of infection noted to sites . Record review of Resident #1's Care Plan dated 05/12/2023 revealed that resident was being care planned for falls and ADL performance deficit related to: impaired mobility and limited ROM. Record review of Resident #1's Physician Progress Notes dated 05/04/2023 revealed in part: .chief complaint/nature of presenting problem: Patient reports severe pain in right hip, right femur, patient has severe chronic comorbidities, patient's right lower extremity is seen over the left lower extremity. Patient appears more alert and verbal today, reports significant discomfort to the right hip, right femur . Record review of Resident #1's Physician orders revealed the following orders: -Dated 05/04/2023 X-ray right hip, pelvis, right femur STAT (right away) -Dated 05/04/2023 Tylenol Extra Strength tablet 500mg 1 tablet every 8 hours for pain for 7 days crush via peg. Record review of Resident #1's MAR for the month of May 2023 revealed that the NF was administering Tylenol extra strength as ordered by the physician. Record review of Resident #1's STAT X-ray results of the right hip, pelvis, right femur dated 05/04/2023 revealed in part: .Age-indeterminate (the radiologist cannot tell based on the x-rays alone if it is new or old) avulsion fracture at greater trochanter (any of two bones by which muscles are attached to the upper part of the thigh bone) of femur is noted. No other acute fracture or dislocation . Record review of the NF 24-hour communication dated 05/04/2023 was documented that the STAT X-ray was done of the right hip, pelvis, and femur (there was no mention that the physician was notified of results). Further review of the 24-hour communication on 05/06/2023 was documented that Resident #1 refused dialysis, G-tube (gastrostomy) and trach (tracheotomy) care; colostomy bag changed. There was no further documentation regarding the results of Resident #1's STAT right hip X-ray or if the physician and been notified. Further review of the results of Resident #1's STAT X-ray results of right hip, pelvis, right femur dated 05/04/2023 revealed that the weekend supervisor initialed on 05/07/2023 and that she notified the physician on 05/07/2023 with orders to send Resident #1 out for treatment and evaluation. Record review of the NF Staff Time Sheet dated 05/04/2023 revealed that LVN F clocked in to work at 5:48pm and LVN C clocked in to work at 7:19pm. Interview on 05/17/2023 at 4:15 pm via phone, LVN C said he worked on 05/04/2023 6pm-6am and was Resident #1's nurse. LVN C said he was not aware that Resident #1 had an X-ray done on his right hip. LVN C said he worked at the NF on a PRN basis and did not recall that he had received in report that resident had STAT X-ray done on right hip. LVN C said he received and gave shift report using the 24-hour communication form. Interview on 05/28/2023 at 11:30 am via phone, LVN D said she was working on 05/04/2023 6am-6pm shift and that she was Resident #1's nurse on that day. LVN D said Resident #1's doctor came to the NF on 05/04/2023 and that she remembered resident complaining of pain to his right hip. LVN D said the NP had also come to the NF on 05/04/2023 and gave orders on multiple residents. LVN D said LVN C were the nurses to relieve her but were running late for work. Therefore, she had to give report to LVN F who was working another hall. LVN D said LVN F was upset that he had to take report for LVN C, and she just gave LVN F a verbal report not using the 24-hour communication form. LVN D said although she did not mention in her verbal report to LVN F that Resident #1 had a STAT order for an X-ray of the right hip that had been done, she did write it on the 24-hour communication form. LVN D said she knew she was supposed to utilize the 24-hour communication form, it was just a lot happening on 05/04/2023. Interview on 05/28/2023 at 12:37 pm, LVN F said he worked at the NF part time during the evening shift 6pm-6am. LVN F said the normal process when clocking in to work was to count the narcotics cart. LVN F said he completed walking rounds along with verbal report utilizing the 24-hour report form. LVN F said he did not recall receiving a report from LVN D nor giving report to LVN C regarding Resident #1. Record review of Resident #1's Nursing Progress Notes revealed the following documented by LVN D dated 05/04/2023 at 8:19 am: incomplete documentation that read .9:49 am patient refused . 05/05/2023 documented by LVN C revealed in part at 7:11am: .Refused dialysis MD/RP aware . 05/05/2023 documented by LVN O at 2:15pm: .Resident refused dialysis. NP aware and educated patient about the importance of hemodialysis. Nurse attempted 3 times. Resident still refused . 05/07/2023 documented at 10:13 am by Weekend Supervisor read in part: .Physician notified regarding x-ray results. Received new order to send out for evaluation of fracture. Resident resting quietly in bed at this time denies pain . Record review of Resident #1's hospital records dated 05/07/2023 revealed in part: XXX[AGE] year-old male who is bedbound, was sent from NH for evaluation of right hip pain. X-ray at outside facility was questionable for right hip fracture. Upon examination it was noted necrotic (death of living tissue) changes in his left 2nd and third toes. He also has a stage 4 sacral decubitus ulcer. CT pelvis was completed rising suspicion for sacral osteomyelitis (infection of bone). He did not meet the suspicion for sepsis .Right hip pain likely referred pain. No CT evidence of fracture .Noted Orthopedic Surgery input. No need for surgical intervention for hip or femur. Will start on empiric (therapy begun on the basis of a clinical or educated guess) Zyvox and Levaquin (antibiotics) . Interview on 05/12/2023 at 11:14 am, The Administrator said Resident #1 was still in the hospital in ICU. The Administrator said she was not at the NF regarding the incident with Resident #1 and that she started working at the NF on 05/08/2023. The Administrator said she found out later the STAT X-rays done on Resident #1 right hip revealed a fracture. Further interview with the Administrator said she was not aware that there had been a delay in reporting Resident #1's STAT X-ray results of the right hip done on 05/04/2023 to the doctor until 05/07/2023. Interview on 05/12/2023 at 3:42 pm, The Weekend Supervisor said she worked only on the weekends double shift 6am-10pm. The weekend supervisor said when she saw Resident #1's X-ray results of the right hip at the nurse's station on 05/07/2023, she was not sure if the physician had been notified and therefore texted the doctor on 05/07/2023. The weekend supervisor said when she contacted Resident #1's doctor, he had not been notified of the STAT X-ray results that he had ordered on 05/04/2023 until she had presented the results to him on 05/07/2023. The weekend supervisor said the doctor gave her orders to send Resident #1 out to the hospital for further evaluation and treatment. The weekend supervisor said she received reports on the residents at the NF from the ADON through text or facetime. The weekend supervisor said the ADON never mentioned to her that a STAT X-ray of the right hip, right femur, and pelvis had been ordered on Resident #1. The weekend supervisor said when she called the ADON on 05/07/2023, the ADON told her that she was not aware that a STAT X-ray had been order for Resident #1. The weekend supervisor said the nurses on duty on the weekend were not aware that a STAT X-ray of the right hip had been ordered on Resident #1. The weekend supervisor said she went to Resident #1's room to see if resident was in pain. She said resident said he was not in any pain. Interview on 05/12/2023 at 4:40pm, LVN A said she worked Hall 500 and that Resident #1 resided on Hall 600. LVN A said when she reported to work, she went and checked on the residents before taking a verbal report from the nurse. LVN A said when she takes a verbal report from the nurse, she also utilized the 24-hour report sheet to ensure she was receiving all needed information to ensure the continuity of care. LVN A said not all the nurses utilized the 24-hour report sheet. LVN A said the 24-hour communication report sheet was kept at the nurse's station in a binder. Interview on 05/12/2023 at 4:55pm, the ADON said the doctor was making rounds at the NF on 05/04/2023 and Resident #1 said he was in pain. The ADON said the doctor ordered an X-ray of the right hip on Resident #1. The ADON said honestly, she did not know that there had been a delay in notifying the physician regarding Resident #1 X-ray results taken of the right hip on 05/04/2023. The ADON said the X-ray of Resident #1's right hip was ordered STAT. The ADON said that radiology came to the NF late on 05/04/2023. The ADON said the nurses should have caught that and it should have been discussed in the shift-to-shift report. The ADON said when the weekend supervisor called her on 05/07/2023 she told the weekend supervisor to call the doctor. The ADON said there was a different DON working at the NF at that time of when the STAT X-ray was ordered for Resident #1. The ADON said she attended the morning meetings and that Resident #1's STAT X-rays done on 05/04/2023 (Thursday) was never discussed in the following morning meeting on 05/05/2023. Further interview with the ADON said the reason Resident #1's STAT X-ray of the right hip, pelvis, and femur was not discussed was because the NF Administrator was late arriving at the NF, and it was her last day working at the NF. Therefore the morning meeting on 05/05/2023 did not happen. The ADON said the NF at the time did not have a permanent DON as well, but an interim DON. The ADON said the NF did not have a policy that the nurses had to document on the 24-hour communication report sheet as a form of communication regarding the residents care. Further interview on 05/12/2023 at 5:15 pm, the Administrator said regarding Resident #1, the NF had done in-services on abuse and neglect when she began work on 05/08/2023, documentation, level of pain assessment, shift reporting, notifying the Administrator/DON/Doctor before sending a resident out to the hospital. Further interview with the Administrator said the Regional Director of Operations called the incident regarding Resident #1 into the state and that the Regional Director of Operations was the one that completed the facility incident investigation regarding Resident #1 STAT X-ray results of fracture on right hip, right pelvis and femur. The Administrator was unable to provide a specific date as to when the Regional Director of Operations called the incident in to the state. Interview on 05/12/2023 at 5:15pm. the DON said she started working at the NF on 05/08/2023 and what she knew about Resident #1 was that resident had a lot of contractures and complained of pain. The DON said the nurse medicated the resident for pain but it was not effective, and the doctor said to send resident to the hospital to be evaluated. The DON said it was discovered at the hospital that Resident #1 had a fracture but could not say where the fracture was. The DON said when Resident #1 went to the hospital on [DATE] the nurses called the hospital to see how the resident was doing. The DON said that was when the NF found out that Resident #1 had a fracture. The DON said she never read the NF Incident Investigation Report regarding Resident #1. Interview on 05/17/2023 at 9:30 am via phone, Radiology said a STAT X-ray was done on Resident #1's right hip on 05/04/2023 and the results were called to the NF on 05/04/2023 spoke to a Staff Member XX. Radiology said they did not get a last name or title. Radiology said the results were verbally given to Staff Member XX at 9:54 pm and faxed to the NF on 05/04/2023. Radiology said the STAT X-ray results were faxed again to the NF on 05/07/2023 at 11:28am. Interview on 05/17/2023 at 10:00am the Administrator said the NF had 3 fax machines in the NF Further interview 05/17/2023 at 2:13 pm, the Administrator said the NF did not have an employee by the name of [Staff Member XX] that worked at the NF. Observation on 05/17/2023 at 12:00 pm revealed Resident #1 on Hall-600 sitting in a Geri-chair that was in a reclined positioned. Resident was easily aroused and denied any pain at that time. Interview on 05/17/2023 at 12:50 pm via phone Physician A of Resident #1 revealed he reviewed Resident #1' s hospital records on 05/16/2023. Physician A said the hospital records reached the conclusion, after a CT scan of the right pelvis, that resident did not have a fracture. Physician A said while Resident #1 was at the hospital, Resident #1 was seen by the Orthopedic doctor. Physician A said Resident #1 had multiple comorbidities and his prognosis was poor. Physician A said Resident #1 was a good candidate for hospice, but the family of the resident would have to make that choice. The physician said because resident had been assessed by the hospital would base his plan of care off the hospital conclusion and continue to monitor Resident #1. Attempted interview via phone on 05/17/2023 at 1:47 pm with LVN O; no answer. Interview on 05/17/2023 at 2:15 pm, the DON said the nurses were supposed to do verbal reports and look at the 24-hour communication report on the computer. The DON said the NF trying to get rid of paper, using only the computer to document resident care. The DON said she would have to look at the computer to see if the staff was charting on the 24-hour form on the computer. The DON said a STAT order should be followed up in 2 hours if results were not received. The DON said some of the nurses were timid when it came to calling the physician and not all nurses use critical thinking. The DON said she would be doing further in-service with staff on a lot of issues including notifying the doctor whenever there was a change in a resident (s) condition. The DON said she spoke with the Regional Nurse who informed her that whenever there is a change in a resident condition, the nurses should be using and INTERACT form. The DON said she had not been privy to reviewing the form, but it seems to be like a glorified SBAR. The DON said she had not reviewed Resident #1's chart at all because she had been busy with training and doing in-services with the Nursing Staff. The DON said the Administrator had reviewed Resident #1's medical records. The DON said she had learned that the NF had 3 different fax machines that consisted of an e-fax (send to the computer), fax in the medication room, and work room (copy room). The DON said she was unsure where the results for diagnostic testing would be faxed. The DON said it was the nurses that completed shift reports as well as the ADONs that was supposed to be reviewing the 24-hour communication form. The DON said the ADON was supposed to bring the 24-hour communication report sheet to the morning meetings. The DON said it was ultimately the DON that ensured that the 24-hour communication forms were being done. The DON said the 24-hour communication form was another form of communication that was relied upon to ensure the continuity of care for the residents. Further interview on 05/17/2023 at 2:32 pm, The Administrator said when a resident had to be discharged to the hospital, she would do a look back for the past 72-hours that included reviewing the 24-hour communication reports that were kept in a binder at the nurse's station. The Administrator said she also reviewed what was documented in PCC to ensure that residents care was being met. The Administrator was not able to answer that if she had done those things, why did she not see that there was a delay in notifying Resident #1's physician of STAT X-ray results of the right hip. The Administrator said it was the ADONs that were responsible for reviewing the 24-hour communication form which were brought to the morning meetings to be further discussed. The Administrator said she was told by the ADON that all diagnostic results was faxed to the medication fax room (. The Administrator said even if a diagnostic result went to another fax room, the staff should have been following up on Resident #1's STAT X-ray results that were taken on 05/04/2023. Interview on 05/17/2023 at 2:55 pm, LVN E said she thought the NF had 1 fax machine which was in the copy room. LVN E said diagnostics were good about calling the NF on anything that was critical and having the person's name who they spoke to; including the time they spoke with that person. Interview on 05/17/2023 at 3:54 pm, the DON said the Weekend Supervisor was supposed to get the resident reports from the DON or ADON when they reported to work. The DON said she did not think that the NF had a permanent DON at the time of the incident regarding Resident #1, but an interim DON. Interview on 05/27/2023 at 11:13 am, the Weekend Supervisor said she normally checked the fax machine in the copy room [ROOM NUMBER]-4 times while on duty. The Weekend Supervisor said STAT diagnostic testing should followed up in 2 hours for the results. The weekend supervisor said the laboratory was good about calling the NF with lab results but was not sure about radiology. The weekend supervisor said she was not sure how Resident #1 STAT X-ray results of the right hip went un-reported to Resident #1's physician. The weekend supervisor said the NF neglected to report to Resident #1's physician, right away, the results of resident STAT X-rays done on the resident's right hip. The Weekend Supervisor said resident was placed at risk for pain and further injury of the right hip. A call was placed to LVN O on 05/27/2023 at 12:12pm with a female answering the phone denying that they were LVN O. It was confirmed with the NF that the number provided to the surveyor for LVN O was the number that they had on file for LVN O. Attempted an interview on 05/27/2023 at 12:44pm via phone with LVN O; no answer, left voicemail with a call back number. Interview on 05/27/2023 at 12:30pm, the ADON said LVN O was an agency nurse. Interview on 05/27/2023 at 12:25 pm, LVN B said she worked at the NF PRN. LVN B said she worked at the NF over a year ago and had just started working back at the NF. LVN B said she did not know how many fax machines that the NF had. LVN B said she believed that diagnostic test results were retrieved from the fax machine in the medication room. LVN B said no one at the NF had in serviced her on all fax machine locations or how often to follow-up for diagnostic results. Interview on 05/28/2023 at 11:20 am, the DON said the NF failed to follow up on Resident #1's STAT X-ray of right hip and report to the physician in a timely manner. The DON said the NF was not following their process. The DON said there was unstable staffing. The DON said there was no consistency with communication among the nursing staff regarding resident care. Interview on 05/29/2023 at 11:08 am, the Administrator said when agency nurses worked at the NF, it was not a guarantee that they will be back the next day and things will go missed. The Administrator said the NF did not have any systems in place to follow-up on STAT Labs/diagnostic testing. The Administrator said everybody was just doing their own thing and not communicating with each other using the 24-hour communication form consistently regarding the residents' care, not following up regarding test results, and reporting the findings to the physician. Further interview with the Administrator said she did not do an investigation regarding Resident #1 stat x-ray of the right hip not being reported to the physician in a prompt manner because the Regional Director of Operations said that he would do the investigation. Interview on 05/29/2023 at 12:55pm The Regional Director of Operations said regarding Resident #1's stat x-ray of the right hip not being reported to the attending physician at the NF in a prompt manner, said he called the incident in to the state and told the Administrator to do the facility investigation. Record review of the NF Policy and Procedures: Abuse, Neglect and Exploitation dated 10/24/2022 revealed in part: .It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing an implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Neglect means failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Record review of the NF policy on Clinical Practice Guidelines Facility 24 Hour Report revised 02/04/2022 revealed in part: .It is the policy of this facility to record relevant information on a 24-hour report form in order to promote continuity of care. The report form will be completed daily for a 24-hour period .Each nurse is responsible for reviewing the information on the shift report at the beginning of his/her shift to identify and prioritize resident needs. The ADON or designee, will review 24-hour shift reports daily in order to identify and prioritize resident needs . An IJ was identified on 05/26/2023. The IJ template was provided to the facility Admministrator on 05/26/2023 at 5:50pm. While the Administrator was notified on 05/29/2023 at 11:50am that the IJ was removed, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to all staff had not been trained to monitor for STAT diagnostic/lab results following up with the results to the physician in a timely manner. PLAN OF REMOVAL F600 Name of facility Date: 05/26/2023 Immediate Action The DON or designee immediately reviewed all residents with recent Diagnostic testing to ensure that timely follow up on results of diagnostic testing, and physician notification were implemented if needed. No other issues identified. This was completed 05/26/2023. The DON or designee immediately reviewed the 24 -hour nurse report to validate communication system is in use by licensed nurse to ensure continuity of care, treatment, and interventions as applicable. This was completed on 05/26/2023. The DON or designee immediately validated that all licensed nurses were knowledgeable on location of fax machine designated to receive diagnostic results including frequency by providing in-service education. This was completed 05/27/2023. No licensed nurse will be allowed to work after 05/27/2023 until they have completed this education. The DON or designee immediately implemented the Diagnostic Tracking tool on 05/27/2023 to effectively monitor diagnostic orders, results of diagnostic testing, and notification of Physician. Facilities Plan to ensure compliance quickly DON/designee began education Immediately on: Diagnostic Tracking Guidelines Education with all licensed nurses including post-test Use of Diagnostic Tracking tool to have an effective system in place to monitor for STAT diagnostic/laboratory results Abuse and Neglect Education with all licensed nurses including post-test 24 Hour Report entry Guidelines Education to have a communication system in place to ensure timely continuity of care and interventions/treatment Documentation Guidelines Education Notification of Change in Condition Education including post-test This education began 5/26/2023 and will end 5/27/2023. Any licensed nurse who has not received this education and post-test will not be allowed to work until this is completed. The facility's Medical Director was notified of the Immediate Jeopardy on 5/26/2023. On 5/27/2023 the facility will conduct an Ad Hoc QAPI meeting to review areas cited and plan for sustaining compliance. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following monitoring: Interview on 05/28/2023 at 1:45 pm, the Weekend Supervisor said she had been in-service in the following areas: abuse/neglect, handwashing, how to access all diagnostic testing by looking in the computer to review and track physician orders. The weekend supervisor said by looking at the tracker, she could see if the order had been processed. That way, she could call the physician/doctor with the results in a timely manner. The weekend supervisor said she had also received in-service on receiving a verbal report using the 24-hour communication form from the unit nurses at the beginning of the shift and at the end of shift and her report would be provided to the ADON. The weekend supervisor said she had been in-serviced on all fax locations at the NF with the copy room being the fax machine for diagnostic results. Interview on 05/28/2023 at 1:50 pm, RN I worked the 6am-6pm shift said she had been in-service on the following: abuse/neglect, tracking ordered diagnostic testing in the system and checking to see if the physician was notified of the results, documentation on all diagnostic testing in PCC and that the physician was notified, shift reporting providing a verbal report are porting using the 24-hour communication form, and the location of the fax machines at the NF. Interview on 05/28/2023 at 2:03 pm, LVN E said she worked the 6am-6pm shift and had been in-serviced on all diagnostic testing, hand washing, abuse and neglect, notifying the physician in a timely manner on STAT diagnostic test results, checking on ordered diagnostic testing to ensure the order had been done and results provided to the physician, documentation, shift reporting using the 24-hour report form. Interview on 05/28/2023 at 2:15 pm, LVN S said she worked full time at the NF 6am-6pm shift. LVN S said she received in-service on abuse and neglect, how to track ordered diagnostic testing in the computer using the tracker, reporting the test results to the physician and notifying the RP as well, document care provided to the residents in the Nursing Progress Notes in PCC as well as documenting on the 24-hour communication form, location of the fax machines at the NF, shift to shift report using the 24-hour communication form. Interview on 05/28/2023 at 2:20 pm, LVN J said she worked the 6am-2pm shift and been in-serviced in the following areas: abuse and neglect, change in resident condition notifying and the RP, documentation, how to track all diagnostic testing using the tracker in the computer to see if the test had been done and reporting results to the physician, verbal shift to shift report with the 24-hour communication form, and location of fax machines with the test results being found on the fax machine in the copy room. Interview on 05/28/2023 at 8:55 pm, LVN G said she worked at the NF part-time 6pm-6am shift. LVN G said she had received in-service on abuse and neglect, communicating all diagnostic testing results to the physician in a prompt manner, verbal shift to shift reporting using the 24-hour communication form, and location of fax machines with the copy room being the fax machine for designated diagnostic test results, and being sure to document actions taken in the care of the resident in PCC and on the 24-hour communication form. Interview on 05/28/2023 at 9:02 pm, LVN K said she worked at the NF full time 6pm-6am. LVN K said she had been in-serviced on abuse and neglect, 24-hour communication shift to shift report, tracking STAT diagnostic testing as well as all diagnostic testing reporting to the doctor in a timely fashion, notifying the family when there is a change in the resident condition as well as the doctor, fax machine locations, and documentation. Interview on 05/28/2023 at 9:15 pm, LVN L said she worked at the NF full time on the 6:00pm-6am shift. LVN L said she had been in-serviced on location of the fax machines with the copy room being the designated fax machine for diagnostic testing, documenting when a resident experience a change in condition notifying the physician and the RP and what was done, being sure to document on the 24-hour communication form, using the 24-hour communication form when giving verbal shift to shift report, reporting all diagnostic testing results to the physician in a timely manner, how to use the tracker in the computer to track diagnostic testing, abuse and neglect. Interview on 05/28/2023 at 9:35pm LVN C, said he had been in-serviced on reporting all diagnostic testing results to the doctor in a timely manner, documenting in PCC and on the 24-hour communication fo[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician order for 1 (Resident #1) of 10 residents reviewed for radiology services in that: -The facility failed to report Resident #1's stat x-ray results of a fracture of the right hip, femur, and pelvis in a prompt manner. An IJ was identified on 05/26/2023. The IJ template was provided to the facility Administrator on 05/26/2023 at 5:50pm. While the Administrator was notified on 05/29/2023 at 11:50am that the IJ was removed, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to all staff had not been trained to monitor for STAT diagnostic/lab results following up with the results to the physician in a timely manner. This failure has the potential to place residents who receive diagnostic testing for delayed treatment and hospitalizations. Findings: Resident #1 Record review of Resident #1's face sheet dated 05/12/2023 revealed an [AGE] year old male admitted to the NF on 04/02/2023 with the following diagnoses; cerebral infarction (disrupted blood flow to the brain), respiratory failure, hypertension (high blood pressure), dysphagia (difficulty swallowing), functional quadriplegia (loss of control of both arms and both legs), type two diabetes mellitus, heart disease, sacral (below the spine and above the tailbone) ulcer stage 4, pressure ulcer of left ankle, renal (kidney) disease, tracheostomy (opening created at the front of the neck so that a tube can be inserted in the windpipe to help one breathe), gastrostomy (opening in the stomach done surgically for the introduction of food), and colostomy (surgical operation creating an opening in the abdomen/stomach to expel waste). Record review of Resident #1's admission assessment MDS dated [DATE] revealed BIMS score of 9 (cognition moderately impaired). Further review revealed that resident was totally dependent on staff with assistance of activities of daily living. Record review of Resident #1's Care Plan dated 05/12/2023 revealed that resident was being care planned for falls and ADL performance deficit related to: impaired mobility and limited ROM. Record review of Resident #1's Physician Progress Notes dated 05/04/2023 revealed in part: .chief complaint/nature of presenting problem: Patient reports sever pain in right hip, right femur, patient has severe chronic comorbidities, patient's right lower extremity is seen over the left lower extremity. Patient appears more alert and verbal today, reports significant discomfort to the right hip, right femur . Record review of Resident #1's Physician orders revealed the following orders: -Dated 05/04/2023 X-ray right hip, pelvis, right femur STAT (right away) Record review of Resident #1's MAR for the month of May 2023 revealed that the NF was administering Tylenol extra strength as ordered by the physician. Record review of Resident #1's STAT X-ray results of the right hip, pelvis, right femur dated 05/04/2023 revealed in part: .Age-indeterminate (the radiologist cannot tell based on the x-rays alone if it is new or old) avulsion fracture at greater trochanter of femur is noted. No other acute fracture or dislocation . Record review of the NF 24-hour communication form dated 05/04/2023 was documented that the STAT X-ray was done of the right hip, pelvis, and femur but not that the physician was notified of results. Further review of the 24-hour communication on 05/06/2023 was documented that Resident #1 refused dialysis, G-tube (gastrostomy)and trach (tracheotomy) care; colostomy bag changed. There was no further documentation regarding the results of Resident #1's STAT right hip X-ray or if the physician and been notified. Further review of the results of Resident #1's STAT X-ray results of right hip, right pelvis, and right femur dated 05/04/2023 revealed that the weekend supervisor initialed on 05/07/2023 that she notified the physician on 05/07/2023 with orders to send Resident #1 out for treatment and evaluation. Record review of the NF Staff Time Sheet dated 05/04/2023 revealed that LVN F clocked in to work at 5:48pm and LVN C clocked in to work at 7:19pm. Interview on 05/17/2023 at 4:15pm via phone LVN C said he worked on 05/04/2023 6pm-6am and was Resident #1's nurse. LVN C said he was not aware that Resident #1 had an X-ray done on his right hip. LVN C said he worked at the NF on a PRN basis and did not recall that he had received in report that resident had STAT X-ray done on right hip. LVN C said he received and gave shift report using the 24-hour communication form. Interview on 05/28/2023 at 11:30am via phone LVN D said she was working on 05/04/2023 6am-6pm shift and that she was Resident #1's nurse on that day. LVN D said resident doctor came to the NF on 05/04/2023 and that she remembered resident complaining of pain to his right hip. LVN D said the NP had also come to the NF on 05/04/2023 and gave orders on multiple residents. LVN D said LVN C was the nurse to relieve her, but was running late for work therefore, she had to give report to LVN F who was working another hall. LVN D said LVN F was upset that he had to take report for LVN C, and she just gave LVN F a verbal report not using the 24-hour communication form. LVN D said although she did not mention in her verbal report to LVN F that Resident #1 had a STAT order for an X-ray of the right hip that had been done, she did write it on the 24-hour communication form. LVN D said she knew she was supposed to utilize the 24-hour communication form it was just a lot happening on 05/04/2023. Interview on 05/28/2023 at 12:37pm LVN F said he worked at the NF part time the evening shift 6pm-6am. LVN F said the normally process when clocking in to work at the NF was to count the narcotic cart. LVN F said he done walking rounds along with verbal report utilizing the 24-hour report form. LVN F said he did not recall receiving report from LVN D nor giving report to LVN C regarding Resident #1. Record review of Resident #1's Nursing Progress Notes revealed the following documented by LVN D dated 05/04/2023 at 8:19am documentation incomplete read as follows: .9:49am patient refused . 05/05/2023 documented by LVN C revealed in part at 7:11am: .Refused dialysis MD/RP aware . 05/05/2023 documented by LVN O at 2:15pm Resident refused dialysis. NP aware and educated patient about the importance of hemodialysis. Nurse attempted 3 times. Resident still refused . 05/07/2023 documented at 10:13am by weekend supervisor read in part: .Physician notified regarding x-ray results. Received new order to send out for evaluation of fracture. Resident resting quietly in bed at this time denies pain . Record review of Resident #1's hospital records dated 05/07/2023 revealed in part: XXX[AGE] year-old male who is bedbound, was sent from NH for evaluation of right hip pain. X-ray at outside facility was questionable for right hip fracture. Upon examination it was noted necrotic (death of living tissue) changes in his left 2nd and third toes. He also has a stage 4 sacral decubitus ulcer. CT pelvis was completed rising suspicion for sacral osteomyelitis (infection of bone). He did not meet the suspicion for sepsis .Right hip pain likely referred pain. No CT evidence of fracture .Noted Orthopedic Surgery input. No need for surgical intervention for hip or femur. Will start on empiric (therapy begun on the basis of a clinical or educated guess) Zyvox and Levaquin (antibiotics) . Interview on 05/12/2023 at 11:14am Administrator said Resident #1 was still in the hospital in ICU. The Administrator said she was not at the NF regarding the incident with Resident #1 and that she started working at the NF on 05/08/2023. The Administrator said she found out later the STAT X-rays done on Resident #1 right hip revealed a fracture. Further interview with the Administrator said she was not aware that there had been a delay in reporting Resident #1's STAT X-ray results of the right hip done on 05/04/2023 to the doctor until 05/07/2023. Interview on 05/12/2023 at 3:42pm The Weekend Supervisor said she worked only on the weekends double shift 6am-10pm. The Weekend Supervisor said when she saw Resident #1's X-ray results of the right hip at the nurse's station on 05/07/2023, she was not sure if the physician had been notified and therefore text the doctor on 05/07/2023. The Weekend Supervisor said when she contacted Resident #1's doctor, he had not been notified of the STAT X-ray results that he had ordered on 05/04/2023 until she had presented the results to him on 05/07/2023. The Weekend Supervisor said the doctor gave her orders to send Resident #1 out to the hospital for further evaluation and treatment. The Weekend Supervisor said she received report on the residents at the NF from the ADON through text or facetime. The Weekend Supervisor said the ADON never mentioned to her that a STAT X-ray of the right hip, right femur, and pelvis had been ordered on Resident #1. The Weekend Supervisor said when she called the ADON on 05/07/2023, the ADON told her that she was not aware that a STAT X-ray had been order for Resident #1. The Weekend Supervisor said the nurses on duty on the weekend were not aware that a STAT X-ray of the right hip had been ordered on Resident #1. The Weekend Supervisor said she went to Resident #1's room to see if resident was in pain. She said resident said he was not in any pain. Interview on 05/12/2023 at 4:40pm LVN A said she worked Hall 500 and that Resident #1 resided on Hall 600. LVN A said when she reported to work, she observed the residents first before taking a verbal report from the nurse. LVN A said when she took a verbal report from the nurse, she also utilized the 24-hour report sheet to ensure she was receiving all needed information to ensure the continuity of care. LVN A said not all the nurses utilized the 24-hour report sheet. LVN said the 24-hour report sheet was kept at the nurse's station in a binder. Interview on 05/12/2023 at 4:55pm ADON said the doctor was making rounds at the NF on 05/04/2023 and Resident #1 said he was in pain. The ADON said the doctor ordered an X-ray of the right hip on Resident #1. The ADON said honestly, she did not know that there had been a delay in notifying the physician regarding Resident #1 X-ray results taken of the right hip on 05/04/2023. The ADON said the X-ray of Resident #1's right hip was ordered STAT. The ADON said that radiology came to the NF late on 05/04/2023. The ADON could not give the time that Radiology came to the NF to do an X-ray of Resident #1's right hip. The ADON said the nurses should have caught that and it should have been discussed in shift-to-shift report. The ADON said when the weekend supervisor called her on 05/07/2023 regarding Resident #1's X-ray of the right hip she told the weekend supervisor to call the doctor. The ADON said there was a different DON working at the NF at that time when the STAT X-ray was ordered for Resident #1 right hip. The ADON said she attended the morning meetings and that Resident #1 STAT X-rays done on 05/04/2023 (Thursday) was never discussed in the following morning meeting on 05/05/2023. Further interview with the ADON said the reason Resident #1's STAT X-ray of the right hip, pelvis, and femur was not discussed was because the NF Administrator was late arriving at the NF, and it was her last day working at the NF therefore the morning meeting on 05/05/2023 did not happen. The ADON said the NF at the time did not have a permanent DON as well, but an interim DON. The ADON said the NF did not have a policy that the nurses had to document on the 24-hour communication report sheet as a form of communication regarding the resident (s) care. Further interview on 05/12/2023 at 5:15pm Administrator said regarding Resident #1, the NF had done in-services on abuse and neglect, documentation, level of pain assessment, shift reporting, notifying the Administrator/DON/Doctor before sending a resident out to the hospital. Further interview with the Administrator said the Regional Director of Operations called the incident regarding Resident #1 into the state and that the Regional Director of Operations was the one that done the facility incident investigation regarding Resident #1 STAT X-ray results of a fracture to resident right hip. Interview on 05/12/2023 at 5:15pm DON said she started working at the NF on 05/08/2023 and what she knew about Resident #1 was that resident had a lot of contractures and complained of pain. The DON said the nurse did medicate resident for pain but was not effective and the doctor said to send resident to the hospital to be evaluated. The DON said it was discovered at the hospital that Resident #1had a fracture but could not say where the fracture was. The DON She said when Resident #1 went to the hospital on [DATE] the nurses called the hospital to see how resident was doing. The DON said that was when the NF found out that Resident #1 had a fracture. The DON said she never read the NF Incident Investigation Report regarding Resident #1. Interview on 05/17/2023 at 9:30am via phone Radiology regarding Resident #1 said a STAT X-ray was done on resident right hip on 05/04/2023 and the results were called to the NF on 05/04/2023 spoke to a staff member XX. Radiology said they did not get a last name or title. Radiology said the results were verbally given to XX at 9:54pm and faxed to the NF on 05/04/2023. Radiology said the STAT X-ray results were faxed again to the NF on 05/07/2023 at 11:28am. Interview on 05/17/2023 at 10:00am the Administrator said the NF had 3 fax machines in the NF that consisted of the following: 1)Copy Room 2)Medication Room 3)e-fax Further interview 05/17/2023 at 2:13pm the Administrator said the NF did not have an employee by the name of XX that worked at the NF. Observation on 05/17/2023 at 12:00pm Resident #1 on Hall-600 sitting in a Geri-chair that was in a reclined positioned. Resident was easily aroused and denied any pain at the present time. Interview on 05/17/2023 at 12:50pm via phone Physician A of Resident #1 at the NF said regarding Resident #1 he reviewed resident hospital records on 05/16/2023. Physician A said the hospital records reached the conclusion after a CT scan of the right pelvis was done that resident did not have a fracture. Physician A said while resident was at the hospital was seen by the Orthopedic doctor. Physician A said resident had multiple comorbidities and prognosis was poor, resident was a good candidate for hospice, but the family of resident would have to make that choice. Physician A said because resident had been assessed by the hospital would base his plan of care off the hospital conclusion and continue to monitor Resident #1. Attempted interview via phone on 05/17/2023 at 1:47pm with LVN O; no answer. Interview on 05/17/2023 at 2:15pm DON said the nurses supposed to do verbal report and use their computer looking at the 24-hour communication report on the computer. The DON said the NF trying to get rid of paper using only the computer to document resident care. The DON said she would have to look at the computer to see if the staff was charting on the 24-hour form on the computer. The DON said a STAT order should be followed up in 2 hours if results not received. The DON said some of the nurses are timid when it came to calling the physician and that not all nurses use critical thinking. The DON said she would be doing further in-service with staff on a lot of issues including notifying the doctor whenever there was a change in a resident (s) condition. The DON said she spoke with the Regional Nurse who informed her that whenever there is a change in a resident condition the nurses should be using and INTERACT form. The DON said she had not been privy to reviewing the form, but it seems to be like a glorified SBAR. The DON said she had not reviewed Resident #1's chart at all because she had been busy with training and doing in-services with the Nursing Staff when she started working at the NF on 05/08/2023. The DON said the Administrator had reviewed Resident #1's medical records. The DON said she learned today that the NF had 3 different fax machines that consisted of an e-fax (send to the computer), fax in the medication room, and work room (copy room). The DON said she was unsure where the results for diagnostic testing would be faxed too. The DON said it was the nurses that done shift report as well as the ADON's that was supposed to be reviewing the 24-hour communication form. The DON said the ADON supposed to bring the 24-hour communication report sheet to the morning meetings. The DON said it was ultimately the DON that ensure that the 24-hour communication forms were being done. The DON said the 24-hour communication forms was another form of communication that was relied upon to ensure the continuity of care for the residents. Further interview on 05/17/2023 at 2:32pm Administrator said when a resident had to be discharged to the hospital, she would do a look back for the past 72-hours that included reviewing the 24-hour communication reports that were kept in a binder at the nurse's station. The Administrator said she also reviewed what was documented in PCC to ensure that residents care was being met. The Administrator was not able to answer that if she done these things why did she not see that there was a delay in notifying Resident #1's physician of STAT X-ray results of the right hip? The Administrator said it was the ADON's that were responsible for reviewing the 24-hour communication form which were brought to the morning meetings to be further discussed. The Administrator said she was told by the ADON that all diagnostic results was faxed to the medication fax room (281-633-9594). The Administrator said even if a diagnostic result went to another fax room, the staff should have been following up on Resident #1's STAT X-ray results that were taken on 05/04/2023. Interview on 05/17/2023 at 2:55pm LVN E said she thought the NF had 1 fax machine which was in the copy room. LVN E said diagnostics were good about calling the NF on anything that was critical and got the person's name who they spoke too including the time they spoke with that person. Interview on 05/17/2023 at 3:54pm DON said the weekend supervisor supposed to get report from the DON or ADON when they report to work. The DON said she did not think that the NF had a permanent DON at the time of the incident regarding Resident #1, but an interim DON. Interview on 05/27/2023 at 11:13am Weekend Supervisor said she normally checked the fax machine in the copy room [ROOM NUMBER]-4 times while on duty. The Weekend Supervisor said STAT diagnostic testing she followed up in 2 hours for the results. The weekend supervisor said laboratory was good about calling the NF with lab results but was not sure about radiology. The Weekend Supervisor said she was not sure how Resident #1 STAT X-ray results of the right hip went un-reported to Resident #1's physician. The Weekend Supervisor said the NF neglected to report to Resident #1's physician right away the results of resident STAT X-rays done on resident right hip. The Weekend Supervisor said this placed resident at risk for pain and further injury of the right hip. A call was placed to LVN O on 05/27/2023 at 12:12pm with a female answering the phone denying that they were LVN O. It was confirmed with the NF that the number provided to the surveyor for LVN O was the number that they had on file for LVN O. Interview on 05/27/2023 at 12:30pm ADON said LVN O was an agency nurse. Attempted interview on 05/27/2023 at 12:44pm via phone with LVN O, no answer, left voicemail with a call back number. Interview on 05/27/2023 at 12:25pm LVN B said she worked at the NF PRN. LVN B said she worked at the NF over a year ago and had just started working back at the NF. LVN B said she did not know how many fax machines that the NF had. LVN B said she believed that diagnostic test results were retrieved from the fax machine in the medication room. LVN B said no one at the NF had in serviced her on all fax machine locations at the NF or how often to follow-up for diagnostic results. Interview on 05/28/2023 at 11:20am DON said she thought the immediate jeopardy occurred because the NF failed to follow up on Resident #1's STAT X-ray of right hip and report to the physician in a timely manner. The DON said the NF was not following their process. The DON said another reason she believes was due to unstable staffing not that she was blaming the previous DON. The DON said there was no consistency with communication among the nursing staff regarding Resident #1's care. Interview on 05/29/2023 at 11:08am Administrator said IJ occurred at the NF because when agency nurses work at the NF not a guarantee that they will be back the next day and things will go missed. The Administrator said the NF did not have any systems in place to follow-up on STAT Labs/diagnostic testing. The Administrator said everybody was just doing their own thing and not communicating with each other using the 24-hour communication form consistently regarding the resident (s) care, not following up regarding test results, and reporting the findings to the physician. Record review of the NF Policy on Diagnostic's Tracking Guidelines dated 08/2013 revealed in part: Purpose: To establish a clinical practice model to track the completion, reporting and monitoring of diagnostic tests (labs, x-rays, Doppler studies etc.) and results .Abnormal Radiology results are communicated to the physician or medical director immediately . Record review of the NF policy on Clinical Practice Guidelines Facility 24 Hour Report revised 02/04/2022 revealed in part: .It is the policy of this facility to record relevant information on a 24-hour report form in order to promote continuity of care. The report form will be completed daily for a 24-hour period .Each nurse is responsible for reviewing the information on the shift report at the beginning of his/her shift to identify and prioritize resident needs. The ADON or designee, will review 24-hour shift reports daily in order to identify and prioritize resident needs . An IJ was identified on 05/26/2023. The IJ template was provided to the facility on [DATE] at 5:50pm. While the IJ was removed on 05/29/2023, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to all staff had not been trained to monitor for STAT diagnostic/lab results following up with the results to the physician in a timely manner. PLAN OF REMOVAL F 773 Name of facility Date: 5/26/2023 Immediate action: The DON or designee immediately reviewed all residents with recent Diagnostic testing to ensure that timely follow up on results of diagnostic testing, and physician notification were implemented if needed. No other issues identified. This was completed 5/26/2023 The DON or designee immediately reviewed the 24 -hour nurse report to validate communication system is in use by licensed nurse to ensure continuity of care, treatment, and interventions as applicable. This was completed 5/26/2023 The DON or designee immediately validated that all licensed nurses were knowledgeable on location of fax machine designated to receive diagnostic results including frequency by providing in-service education. This was completed 5/27/2023. No licensed nurse will be allowed to work after 5/27/2023 until they have completed this education. The DON or designee provided 1:1 education with ADON and all charge nurses that failed to update the 24-hour report regarding the impending results of the stat X-Ray and for not following up on results timely. This was completed 5/27/2023. The DON or designee immediately validated that facility did not fail to notify physician regarding any recent diagnostic testing. This was completed 5/27/2023. Facilities Plan to ensure compliance quickly DON/designee began education Immediately with all licensed nurses on: Reviewing the 24-hour report in morning meeting Policy & Procedure: Diagnostic Tracking Guidelines Education with all licensed nurses including post-test Use of Diagnostic Tracking tool to have an effective system in place to monitor for STAT diagnostic/laboratory results for timely tracking of Diagnostic testing 7 days a week. All ordered diagnostic testing will be recorded on the tracking log in the 24- hour report book, and reviewed 3 times a shift by charge nurses/ADON until results are received and Physician notification of results. If stat results not received within 4 hours, physician will be notified for appropriate orders The lab tracking log will be reviewed in the daily morning meeting and on weekends by the weekend supervisor. Policy & Procedure: Abuse and Neglect Education with all licensed nurses including post-test Policy & Procedure: 24 Hour Report entry Guidelines Education to have a communication system in place to ensure timely continuity of care and interventions/treatment Policy & Procedure: Documentation Guidelines Education Policy & Procedure: Notification of Change in Condition Education including post-test Beginning 5/27/2023 DON or designee will provide this education to all licensed Agency staff, PRN staff, and new hires prior to working On 5/27/2023 the DON or designee will provide 1:1 education with the weekend supervision on all education to ensure oversight of systems on weekends This education began 5/26/2023 and will end 5/27/2023. Any licensed nurse who has not received this education and post-test will not be allowed to work until this is completed. The facility DON or designee conducted a root cause analysis on 5/27/2023 and will take to QAPI committee for review The facility's Medical Director was notified of the Immediate Jeopardy on 5/26/2023. On 5/27/2023 the facility will conduct an Ad Hoc QAPI meeting to review areas cited and plan for sustaining compliance. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 05/28/2023 at 1:45pm Weekend supervisor said she had been in-service in the following areas: abuse/neglect, handwashing, how to access all diagnostic testing by looking in the computer to review and track physician orders. The weekend supervisor said by looking at the tracker, she could see if the order had been processed that way, she could call the physician/doctor with the results in a timely manner. The weekend supervisor said she had also received in-service on receiving a verbal report using the 24-hour communication form from the unit nurses at the beginning of the shift and at the end of shift and her report would be provided to the ADON. The weekend supervisor said she had been in-serviced on all fax locations at the NF with the copy room being the fax machine for diagnostic results. Interview on 05/28/2023 at 1:50pm RN I worked the 6am-6pm shift said she had been in-service on the following: abuse/neglect, tracking ordered diagnostic testing in the system and checking to see if the physician was notified of the results, documentation on all diagnostic testing in PCC and that the physician was notified, shift reporting providing a verbal report are porting using the 24-hour communication form, and the location of the fax machines at the NF. Interview on 05/28/2023 at 2:03pm LVN E said she worked the 6am-6pm shift and had been in-serviced on all diagnostic testing, hand washing, abuse and neglect, notifying the physician in a timely manner on STAT diagnostic test results, checking on ordered diagnostic testing to ensure the order had been done and results provided to the physician, documentation, shift reporting using the 24-hour report form. Interview on 05/28/2023 at 2:15pm LVN S said she worked full time at the NF 6am-6pm shift. LVN S said she received in-service on abuse and neglect, how to track ordered diagnostic testing in the computer using the tracker, reporting the test results to the physician and notifying the RP as well, document care provided to the residents in the Nursing Progress Notes in PCC as well as documenting on the 24-hour communication form, location of the fax machines at the NF, shift to shift report using the 24-hour communication form. Interview on 05/28/2023 at 2:20pm LVN J said she worked the 6am-2pm shift and been in-serviced in the following areas: abuse and neglect, change in resident condition notifying and the RP, documentation, how to track all diagnostic testing using the tracker in the computer to see if the test had been done and reporting results to the physician, verbal shift to shift report with the 24-hour communication form, and location of fax machines with the test results being found on the fax machine in the copy room. Interview on 05/28/2023 at 8:55pm LVN G said she worked at the NF part-time 6pm-6am shift. LVN G said she had received in-service on abuse and neglect, communicating all diagnostic testing results to the physician in a prompt manner, verbal shift to shift reporting using the 24-hour communication form, and location of fax machines with the copy room being the fax machine for designated diagnostic test results, and being sure to document actions taken in the care of the resident in PCC and on the 24-hour communication form. Interview on 05/28/2023 at 9:02pm LVN K said she worked at the NF full time 6pm-6am. LVN K said she had been in-serviced on abuse and neglect, 24-hour communication shift to shift report, tracking STAT diagnostic testing as well as all diagnostic testing reporting to the doctor in a timely fashion, notifying the family when there is a change in the resident condition as well as the doctor, fax machine locations, and documentation. Interview on 05/28/2023 at 9:15pm LVN L said she worked at the NF full time on the 6:00pm-6am shift. LVN L said she had been in-serviced on location of the fax machines with the copy room being the designated fax machine for diagnostic testing, documenting when a resident experience a change in condition notifying the physician and the RP and what was done, being sure to document on the 24-hour communication form, using the 24-hour communication form when giving verbal shift to shift report, reporting all diagnostic testing results to the physician in a timely manner, how to use the tracker in the computer to track diagnostic testing, abuse and neglect. Interview on 05/28/2023 at 9:35pm LVN C said he had be in-serviced on reporting all diagnostic testing results to the doctor in a timely manner, documenting in PCC and on the 24-hour communication form relaying the information in shift report, documenting when there was a change in resident (s) condition, location of the fax machines, and how to track the results of ordered diagnostic testing in the computer. Interview on 05/29/2023 at 9:00am LVN H said he worked the 6:00pm-6:00am shift part time at the NF and been in-service in the following areas: abuse and neglect, timeliness of report STAT diagnostic testing results to the physician, following up on all diagnostic testing results by tracking the ordered test results in the computer, location of all fax machines at the NF and the one designated for diagnostic t[TRUNCATED]