**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed for accident (Resident #1). The facility failed to put interventions in place to prevent Resident #1 from sliding out of the wheelchair during transport on 2/19/24 and ensure that she was secured by the shoulder and lap belt harness, resulting in Resident #1 sliding out of her wheelchair during transport. The facility failed to ensure the transport staff were aware of how to properly position the shoulder and lap belt harness to ensure Resident #1 did not have forward bodily movement in the event of the driver had to quickly stop the van. An Immediate Jeopardy (IJ) situation was identified on 9/24/24 at 4:00p.m. The IJ template was provided to the facility on 9/24/24 at 4:00 p.m. While the IJ was removed on 9/25/24 at 4:30 p.m., 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 that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Failure to properly secure residents on the van placed all residents at risk of falls which could lead to injury or death. Findings included: Record review of Resident #1's face sheet dated 9/23/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Some of her diagnoses were cerebrovascular disease (conditions that affect blood flow to the brain), essential hypertension (high blood pressure), chronic kidney disease stage 4 (kidneys do not filter wastes from the blood). Record review of Resident #1's admission MDS assessment dated [DATE] indicated severe cognitive impairment with a BIMS score of 00. Review of Resident #1's functional abilities and goals indicated she was supervision or touching assistance for sit to stand and partial to moderate assistance for chair and bed transfers. The resident was partial to moderate assistance for walking. Record review of Resident #1's care plan dated 9/20/22 indicated a Resident #1 was a fall risk with an onset of 9/20/22. The intervention was to observe resident when ambulating for unsteady gait, dizziness, decreased balance, weakness and provide assistance as needed. Resident #1 had a diagnosis of chronic kidney disease. The intervention was to follow up with nephrologist (kidney doctor) as ordered and indicated. Resident #1 had end stage kidney disease and received dialysis. The intervention was to encourage resident to attend scheduled dialysis appointments. Resident #1 had an ADL self-care deficit. The interventions with transfers were supervision to limited assistance with transfers, encourage and remind to ask for assistance and provide assistance as needed. Record review of Resident #1' s incident report dated 2/19/24 at 11:38 a.m. indicated the incident location: out of facility during transport. The description of the incident reflected: Received call from facility van driver that while enroute back to the facility another vehicle pulled out in front of the facility van causing the van driver to hit brakes hard which lead to resident sliding out of wheelchair. Van driver pulled into near by parking lot and called EMS to come and assist and assess the resident. Prior to EMS arriving the resident had gotten herself up and sat in the passenger seat of facility van when EMS arrived the resident denied hitting her head, denied EMS the ability to assess resident also refused vital signs and to go to the ER for further evaluation from EMS. The mental status of Resident #1 was oriented to person, place and time. She had impaired memory, gait balance and was confused. The incident report was electronically signed by LVN C on 2/19/24 at 11:38 a.m. Record review of Resident #1's nursing note dated 2/19/24 indicated it was electronically signed by LVN C on 2/19/24 at 11:38 a.m. The note indicated the nurse was informed by Van Driver D that while enroute back to the facility another vehicle pulled out in front of the facility van causing Van Driver D to hit the brakes hard which led to Resident #1 sliding out of her wheelchair. Van Driver D pulled into a nearby parking lot and called EMS to come assist and assess the resident. Prior to EMS arriving the resident had gotten herself up and sat in the passenger seat of facility van. When EMS arrived the resident denied hitting her head, denied EMS the ability to assess her, refused vital signs and refused to go to the ER for further evaluation from EMS, NP notified and called RP no answer left message to return call to facility. Record review of Resident #1's nursing note dated 2/21/24 at 4:10 p.m. indicated Resident #1 had delayed bruising to her forehead. Record review of Resident #1's medication administration record dated February 2024 indicated Resident #1 had a pain level of 6 (which indicated moderately strong pain) on 2/19/24 and received Tramadol 50mg at 10:54 p.m. Record review of Van Driver D's employee file indicated a hire date of 2/24/23. The file reflected a a competency check-off Orientation Checklist Community Driver-Van-Bus for driving the van, dated 12/4/23 and 2/19/24, and signed by the Administrator and Maintenance Director F as the trainer. The [State name] Depart of Public Safety driver eligibility check revealed Van Driver A was eligible. Record review of Van Driver A's employee file indicated a hire date of 4/29/19. The [State name] Depart of Public Safety driver eligibility check revealed Van Driver A was eligible. The Orientation Checklist Community Driver-Van-Bus dated 8/23/24 indicated a check mark under the trainer's initials with no date listed and signed by the Administrator and Van Driver A. The personnel file did not indicate a job description. Record review of Van Driver B's employee file indicated a hire date of 12/29/21. The [State name] Depart of Public Safety driver eligibility check revealed Van Driver A was eligible. The Orientation Checklist Community Driver-Van-Bus dated 8/23/24 indicated Van Driver A's initials under trainer's initials with no date listed and signed by the Administrator and Van Driver B. The personnel file did not indicate a job description. During an interview on 9/23/24 at 10:56 a.m. Resident #1 said she was facing forward in the van and Van Driver D forgot to strap down her chair in the van and had to break hard causing her to fall out of her chair. She said Van Driver D did put her seat belt on but just didn't strap down her chair so when she hit the brakes her chair moved forward causing her to fall out of the wheelchair. She said she was not hurt, got up and sat on the seat. She said Van Driver D pulled over and was scared she was going to get in trouble and wanted to take her to the hospital, but she was not hurt and didn't want to go. She said she didn't think Van Driver D worked at the facility any longer and said she had not been on any other transports with her . During an attempted a phone interview with Van Driver D on 9/23/24 at 2:49 p.m. a voicemail was left with no return call by the time of surveyor exit. During an observation and interview on 9/24/24 at 10:08 a.m. Van Driver A said he had been the primary van driver for 4 months but had worked at the facility for 6 years. He said he had been trained by the previous van driver before Van Driver D. He said he had not been trained by a maintenance director or anyone from corporate. He said he had only taken papers to the rental van company to be signed and was not trained on the van. Observed a demonstration of loading a resident wheelchair into the van and securing the wheelchair with four straps, one at each corner of the wheelchair. Van Driver A did strap the four corners of the wheelchair appropriately, so the wheelchair was secure and did not move. Van Driver A then latched a seatbelt over the wheelchair and it did not appear to have been done correctly. Surveyor asked Van Driver D to sit down in the wheelchair that was facing forward towards the windshield and attach the seatbelt as if he was a resident. Van Driver A placed the shoulder strap across the chest area and latched it to the lap belt that was attached to the front track of the van. The surveyor was able to reach over and slide the belt off the driver's lap and the driver was not secured in the wheelchair. Van Driver D said he had always strapped the seatbelt that way and did see how it would not hold a resident in the wheelchair if an incident were to occur. During an observation and interview on 9/24/24 at 11:25 a.m. Maintenance Director G said he had worked at the facility for about 1 and ½ months. He said since he had worked at the facility he had not been trained on the van and therefore did not drive the van or do any training with the van drivers. He said he knew there was a vehicle check system in their computer program, but he had not been put in the computer system therefore the vehicle checks had not been done. He said he had a notebook that he kept notes on of anything that he did with the van but did not have any notes of any problems regarding the resident securement system. He said he had worked for the company in the past at a different facility and had knowledge of how a resident should have been properly secured in the van. Observation of a demonstration of how he would secure a resident in the van revealed he moved the lap belt from the front floor track to the back floor track. He said by having the lap belt attached to the front floor track it would not stop a resident's front forward motion. During a telephone interview on 9/24/24 at 11:40 a.m. Maintenance Director H said if a new maintenance director was hired at one of the facility's, then a maintenance director from another facility would come to the facility and train the new maintenance director; then going forward that maintenance director would be responsible for training the van drivers. He said to his knowledge no one had trained Maintenance Director G and he would make sure that Maintenance Director G got trained on the weekly maintenance logs, passenger securement and the transportation policy. During a telephone interview on 9/24/24 at 12:05 p.m. the Rental Van Owner said that he received a call from the facility sometime in February of 2024 asking for him to train the van drivers at the facility. He said the 1st time he scheduled the training no one ever showed up for the training and the 2nd time he walked around the van with an unknown female driver and oriented her to the van. He said to properly secure a resident in the van that was facing forward toward the windshield the lap belt should be secured to the back floor track of the van. He said if the lap belt was secured in the front floor track of the van it would not secure the resident in the chair and the resident would slide out of the chair. During an interview on 9/24/24 at 2:10 p.m. Van Driver B said she had worked as the facility's human resources manager for about 4 months. She said she only transported residents in the van when Van Driver D was not available. She said in the last year she had maybe done 12 transports of an average of about 1 per month. She said she had been trained on the van by Maintenance Director F. She said when she had transported residents in the van the lap belt had usually been attached to the front floor track. She said she did not usually move the lap belt when she transported residents. She said she had not had any incidents while on transport with any residents. Van Driver B said on her Orientation Checklist Community Driver-Van-Bus dated 8/23/24 it was Van Driver A's initials that completed her checklist. During an interview on 9/25/24 at 2:27 p.m. the Administrator said she was not aware that staff were not securing residents in the van properly. She said Van Driver A had been trained by Maintenance Director F . She said if residents were not secured properly in the van and an incident occurred the resident could be significantly injured. Record review of Q'Straint QRT-1 Series user instructions undated indicated: .B. Secure Passenger: 1. A. On the aisle side, attach belt with female buckle to rear tie-down pin connector; ensuring buckle rests on passenger's hip. B. on the window-side, attach belt with male tongue to rear tie-down pin connector and insert into female buckle . 3. Ensure belts are adjusted as firmly as possible, but consistent with user comfort. Warning: 1. Lap and shoulder belt should not be held away from passenger's body by wheelchair components or parts such as the wheelchair's wheels, armrests, panels or frame . 3. Occupant belts should always bear upon the bony structure of passenger's body and be worn low across the front of the pelvis, with the junction between lap and shoulder belts located near passenger's hip . Record review of the facility' policy titled Transportation Policy and Procedure for Center-Based Vehicle dated 11/16/23 with a revision date of 6/27/24 indicated: For our Residents to maintain the highest practical physical, mental, and psychological wellbeing it is the policy of ___(nursing center) to utilize the Facility vehicle for Residents who, because of medical or special needs, require transportation. Maintain a current log notebook to include: Vehicle Maintenance Log, which will include but is not limited to, all recommended routine maintenance as per the vehicle's operating manual, weekly full interior and exterior cleaning and any required non-routine maintenance. Driver Orientation: The authorized driver of the Center's vehicle must be completely oriented as to the transportation policy and procedure as well as successful completion of competency training on all facets of van usage before being permitted by the Center's executive director to drive the Center's vehicle and before being provided with keys to the vehicle. Standard orientation will also need to occur with appropriate verification in personal record. This was determined to be an Immediate Jeopardy (IJ) on 9/24/24 at 4:00 p.m. The facility Administrator, and DON were notified. The Administrator was provided with the IJ template on 9/25/24 at 4:00 p.m. and a plan of removal was requested. The facility's plan of removal was accepted on 9/25/24/24 at 2:32 p.m. and included: 1. Immediate Action Taken A. Resident #1 remains in the facility on 9/24/24. B. The facility's van immediately stopped all van transport on 9/24/2024 at 4:00 pm. C. The Administrator or designee completed the following with the two facilities designated van drivers: In-service education on the Transportation Policy which provides direction on duties of driver, driving of the van, how to operate the wheelchair lift and the wheelchair securement system, use of seat and shoulder harness, and how to transport more than 1 wheelchair. This was completed on 9/24/2024 at 7:00 pm. In-service education on Q'Straint QRT-1 Series User Instructions which provides direction on wheelchair securement, passenger securement and passenger release. This was completed on 9/25/24 at 12:00 pm. In-service education provided to van driver by administrator/designee on weekly maintenance log which includes checking operable seatbelt straps, W/C/ tie down, shoulder strap, floor W/C tie down straps that van driver will complete and provide to administrator/designee weekly. This was completed on 9/24/2024 at 7:00 pm. Sister facility maintenance director completed a skills validation check list on van driver to acknowledge skills competence on how to operate the wheelchair lift and the wheelchair securement system, seatbelts including shoulder harness. The van driver completed a return demonstration. This will be completed on 9/25/2024 at 2:00 pm. The Maintenance Director completed training with sister facility maintenance director on wheelchair securement, passenger securement and passenger release. A skills validation check list was completed on maintenance director to acknowledge skills competence on how to operate the wheelchair lift and the wheelchair securement system, seatbelts including shoulder harness. This will be completed on 9/25/2024 at 2:00 pm. The Maintenance Director completed In-service education on Q'Straint QRT-1 Series User Instructions which provides direction on wheelchair securement, passenger securement and passenger release. This was completed on 9/25/24 at 12:00 pm. The Administrator and/or designee reviewed with van driver, a new signed job description. This was completed on 9/24/2024 at 7:00 pm. 2. Identification of Residents Affected or Likely to be Affected: A. No other residents identified, all scheduled van transports for the remainder of the week will be transported by an outside vendor. This will allow the facility time for training all van drivers, complete skills competencies and return demonstration, with all van drivers. 3.Actions to Prevent Occurrence/Recurrence: A. As of 9/24/2024, any staff member hired for van transports will be provided the following by the facility maintenance supervisor. In-service education on the Transportation Policy which provides direction on duties of driver, driving of the van, how to operate the wheelchair lift and the wheelchair securement system, use of seat and shoulder harness, and how to transport more than 1 wheelchair prior to driving the van. In-service education on Q'Straint QRT-1 Series User Instructions which provides direction on wheelchair securement, passenger securement and passenger release. In-service education on weekly maintenance log which includes checking Operable seatbelt straps, W/C/ tie down, shoulder strap, floor W/C tie down straps that van driver will complete and provides to administrator/designee weekly. Completed a skills validation check list on van driver to acknowledge skills competence on how to operate the wheelchair lift and the wheelchair securement system, seatbelts including shoulder harness, and will complete a return demonstration. Have van driver sign job description duties. B. The weekly maintenance log will be reviewed in the morning meeting by the Administrator or designee. On 9/24/2024 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Accidents/Hazards/Supervision and reviewed plan to sustain compliance Date Facility Asserts Likelihood for Serious Harm No Longer Exists: September 25, 2024 On 9/25/24 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of in-service attendance record with topics Transportation Policy and Weekly Maintenance Vehicle Log dated 9/24/24 indicated Van Driver A, Van Driver B and Maintenance Director G had been educated on duties of driver, driving of the van, how to operate the wheelchair lift and the wheelchair securement system, use of seat and shoulder harness, and how to transport more than 1 wheelchair. Record review of in-service attendance record with topics Orientation securing wheelchair for transport Q'Straint QRT-1 Series dated 9/25/24 at 1:30 p.m. indicated Van Driver A, Van Driver B and Maintenance Director G had been educated on wheelchair securement, passenger securement and passenger release. Record review of in-service attendance record with topics Transportation Policy and Weekly Maintenance Vehicle Log dated 9/24/24 indicated Van Driver A, Van Driver B and Maintenance Director G had been educated on weekly maintenance log which included checking operable seatbelt straps, W/C/ tie down, shoulder strap, floor W/C tie down straps that van driver would complete and provide to administrator/designee weekly. Record review of the Orientation Checklist Community Driver-Van-Bus skills validation check list for Van Driver A and Van Driver B to acknowledge skills competence on how to operate the wheelchair lift and the wheelchair securement system, seatbelts including shoulder harness. Van Driver A and Van Driver B completed a return demonstration. The education was provided to Van Driver A and Van Driver B on 9/25/2024 at 2:00 pm by Maintenance Director H. Record review of in-service attendance record with topics Transportation Policy and Weekly Maintenance Vehicle Log dated 9/24/24 indicated Maintenance Director G had been educated on wheelchair securement, passenger securement and passenger release. A skills validation check list was completed with Maintenance Director G to acknowledge skills competence on how to operate the wheelchair lift and the wheelchair securement system, seatbelts including the shoulder harness. The skills validation was completed on 9/25/2024 at 2:00 pm by Maintenance Director H. Record review of in-service attendance record with topics Orientation securing wheelchair for transport Q'Straint QRT-1 Series dated 9/25/24 indicated Maintenance Director G had been educated on Q'Straint QRT-1 Series User Instructions which provided direction on wheelchair securement, passenger securement and passenger release. Record review of a job description titled: Van Driver dated 9/24/24 signed by Van Driver A, Van Driver B, and Maintenance Director G. Revealed Van Driver A, Van Driver B, and Maintenance Director G were educated on the expectations of transportation. Record review of an Ad Hoc QAPI meeting that was held on 9/24/24 at 5:30 p.m. with the facility's Medical Director, Administrator, DON, and ADON revealed discussion the facility's failed system for adequate training of the facility van drivers and reviewed a plan to sustain compliance. During an interview on 9/25/24 at 3:16 p.m. Maintenance Director G said he was educated on how to properly secure a resident on the van. He said he had received education on the Q'Straint QRT-1 series securement system. He said he had received education on the weekly maintenance log which included checking operable seatbelt straps, wheelchair tie down, shoulder straps, and floor wheelchair tie down straps. He said he had received a job description and was able to verbalize knew what the expectations were for van driving. During an interview on 9/25/24 at 3:36 p.m. Van Driver A said he was educated on how to properly secure a resident on the van. He said he had received education on the Q'Straint QRT-1 series securement system. He said he had received education on the weekly maintenance log which included checking operable seatbelt straps, wheelchair tie down, shoulder straps, and floor wheelchair tie down straps. He said he had received a job description and was able to verbalize knew what the expectations were for van driving. During an interview on 9/25/24 at 3:36 p.m. Van Driver B said she was educated on how to properly secure a resident on the van. He said she had received education on the Q'Straint QRT-1 series securement system. She said she had received education on the weekly maintenance log which included checking operable seatbelt straps, wheelchair tie down, shoulder straps, and floor wheelchair tie down straps. She said she had received a job description and was able to verbalize knew what the expectations were for van driving. During an observation on 9/25/24 at 3:48 p.m. Van Driver A, Van Driver B, and Maintenance Director G were able to demonstrate properly how to secure a resident on the facility van for transport. The Administrator was informed the Immediate Jeopardy was removed on 9/25/24 at 4:30 p.m. 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's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure residents the right to be free from abuse and neglect for 1 (Resident #2) of 10 residents reviewed for abuse and neglect. On 03/25/2023 at 04:39 PM, LVN P grabbed Resident #2 by the face and shoved her back on the couch, then pulled her to a standing position by the arm and turned her around and shoved her in the back pushing her away from LVN P. On 03/25/2023 CNA Q witnessed abuse by LVN P on 03/25/20223 and did not report Abuse and Neglect to the Abuse Coordinator until the day after the incident on 03/26/2023. This failure could place all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. On 07/25/2023 at 6:10 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/27/2023 at 2:50 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: Record review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Dementia (problem in the brain affecting memory), Psychotic disorder (loss of contact with reality), anxiety (feeling of fear, and uneasiness). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, which indicated resident was unable to complete the interview. She required limited to extensive assistance of 1 staff for ADL care. Record review of Resident #2's electronic care plan dated 09/27/2019 revealed she had a history of Depression and received an anti-depressant medication. Interventions were to Approach in calm manner, introduce self and explain procedure/care to be provided, provide validation of feeling by restating concerns/feelings, encourage to focus on positive. Observation of a video taken on 03/25/2023 by the facility cameras revealed LVN P was feeding another resident in the secured unit when she walked over to the couch bent down, grabbed Resident #2's face and pushed her back on the couch. LVN P then picked up Resident #2's hand and pulled Resident #2 into a standing position and turned her and pushed Resident #2 in the back forcing her to walk away from LVN P. LVN P then walked back over to the table and resumed feeding the other resident. The facility DON identified the staff member observed in the video. During an interview on 07/24/2023 at 2:00 p.m. the DON Said CNA Q went to the administrator and reported that LVN P was being mean to the secured unit residents. She said the Administrator pulled the camera, and it showed LVN P shake her finger in her face and then reach up and grab Resident #2 by the face and push her back against the couch. She said LVN P said she did not want Resident #2 to fall and tried to scoot her back in her chair. She said it happened on Sunday 03/26/2023 and CNA Q didn't report the incident until Monday 03/27/2023 morning. During an interview on 07/26/2023 at 01:31 PM CNA Q said she was passing out lunch trays on 3/25/2023. Said she pulled Resident #2's tray off the cart and put it on the table and told Resident #2 to come to the table. Said she went back to the cart to finish delivering trays to the table and Resident #2 sat up and started laughing, then LVN P turned around and grabbed Resident #2 by the face and said something to her then grabbed Resident #2 by the arm stood her up and pushed her towards the table. CNA Q said she went and told the med aide. The med aide then told LVN P what she had said, and LVN P came up to CNA Q in an aggressive manner and said just to let you know, I don't abuse my residents and I don't appreciate you talking about me in that tone. CNA Q said she did not report it to the administrator until the next day because she did not have phone numbers saved in her phone and due to her being from out of state, they had a different reporting system where she was from. CNA Q said at her old facility they just filled out a paper and turned it in. CNA Q said it happened on the weekend and there was not much staff to ask what she should do. She said she did not know anyone else's name so she did not ask any other staff what she should do. She said she does not remember being trained on how she was supposed to report abuse that she can remember. CNA Q said the next day she texted the DON and asked what she should do and was advised to talk with the Administrator. She said she texted the Administrator on 03/26/2023 and asked for her to call her and after reporting what happened, the Administrator came to the facility and had her write out a statement of what happened. After that she said later the Administrator told her she had gotten it on camera so she has fired the nurse and would be contacting the state. Record review of LVN P's Notice of Employee Separation dated 03/27/2023 revealed she was involuntarily terminated due to resident abuse. Record review of the facility's Inservice meeting dated 03/26/2023 revealed staff were trained on abuse and neglect, exploitation, what is abuse and neglect and who to report abuse and neglect to. The in-service was conducted by the Administrator, and DON. In an attempted interview on 07/25/2023 at 11:23 a.m. LVN P did not answer the phone call. This Surveyor left a voicemail and provided the state cell number. Record Review of 13 safe surveys dated 07/26/2023 conducted by the facility social worker did not reveal any additional concerns. In an interview on 07/27/23 at 11:50 a.m. the Administrator said she conducted a swift and thorough investigation immediately. She notified the police. LVN P was immediately terminated. Abuse and neglect in-services were given to staff, and they were educated on reporting abuse and neglect. She said no other residents were abused by LVN P. Record review of the facility's Abuse policy dated 02/01/2021 read in part, .Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. B. Each covered, individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. C. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. The DON was informed on 07/25/2023 at 6:10 pm that an Immediate Jeopardy (IJ) existed on 07/25/2023, and a copy of the IJ Template was provided. The following Plan of Removal was accepted on 07/26/23 at 02:56 PM: Immediate Action: On 3/27/2023 DON/Designee immediately suspended staff member pending outcome of investigation (and was subsequently terminated) On 3/26/2023 DON/Designee reported incident to the local police department. On 3/26/2023 Administrator reported Incident to Health and Human Services Department. On 3/26/2023 and 3/27/2023 DON/Designee obtained witness statements from witnesses involved in the incident. On 3/26/2023 Administrator reviewed video surveillance of incident on facility camera. On 3/27/2023 DON/Designee started education on the facilities Abuse and Neglect Compliance Policy to all staff (which included: Signage of what and when to report abuse, Reporting Abuse guidelines, Resident Rights policy) On 7/26/2023 at 1:30 pm the Regional Nurse Consultant will provide 1:1 education to the facility's CNA Q who failed to notify the Administrator/DON immediately of the witnessed abuse on 3/25/2023. On 7/26/2023 at 1:00 pm the Regional Nurse Consultant provided 1:1 education to the Administrator and DON on the facility's abuse policy which included: o Definition of Abuse/Neglect, Explanation and compliance guidelines, Components of Abuse prohibition, Prevention of abuse/neglect, Identification of abuse neglect, investigating abuse/neglect, Resident protection, reporting timely abuse and neglect and QAPI. On 7/26/2023 the Business Office Manager completed 100% audit of all employee's personal files to validate that all required staff had required backgrounds checks completed on hire. This will be completed by 6:00 pm on 7/26/2023. Identification of Residents Affected or Likely to be Affected: On 3/27/2023 Social Services/Designee completed alert resident interview to validate that all resident felt safe. On 3/27/2023 Administrator reviewed video surveillance cameras to validate that no other residents were affected by the actions of this staff member. On 7/26/2023 Social Worker/Designee completed interviews with alert resident to validate all residents feel safe. This will be completed by 6:00 pm on 7/26/2023. The DON verbalized that she did not assess residents in the secure unit on 3/26/2023 to validated that no resident had any signs or symptoms of physical or emotional distress. DON was provided 1:1 education by the Regional Nurse Consultant on 7/26/2023 on identifying like residents when an abuse incident occurs. Actions to Prevent Occurrence/Recurrence: On 3/27/2023 DON/Designee started education with all staff on the facilities Abuse and Neglect Compliance Policy (which included: Signage of what and when to report abuse, and reporting abuse to the abuse coordinator, Reporting Abuse guidelines, Resident Rights policy) On 7/26/2023 the DON/Designee started education with staff on the facility's abuse policy which included: o Definition of Abuse/Neglect, Explanation and compliance guidelines, Components of Abuse prohibition, Prevention of abuse/neglect, Identification of abuse neglect, investigating abuse/neglect, Resident protection, reporting timely abuse and neglect, and reporting abuse to the abuse coordinator, and QAPI This was completed on 7/26/2023 at 12:00 pm, and no staff will be allowed to work after this date and time until they receive this education. Monitoring: Social Services/Designee will complete weekly alert resident interviews x 4 weeks to validate that all residents feel safe and free from abuse. The DON/designee will validate with daily rounds that cognitively impaired residents are free from signs of abuse. On 7/25/2023 at 7:30 pm the DON notified the facility's medical director regarding the Immediate Jeopardy the facility received related to abuse and neglect. On 7/26/2023 at 1:30 pm the facility will conduct an Ad Hoc QAPI meeting to discuss the cite related to abuse, and on plan to sustain compliance. On 07/27/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of provider investigation report confirmed LVN P was terminated on 03/27/2023. The local police department, Texas Board of Nursing and Health and Human services was notified of the incident. Witness statements and video surveillance of incident reviewed. Record review of 1:1 education provided to CNA Q dated 07/26/2023 regarding abuse/neglect, and to notify administrator immediately of witnessed or suspected abuse. Record review of 1:1 education provided to the Administrator and DON on 07/26/2023 regarding abuse/neglect policy including: 1. Definition of abuse/neglect. 2. Explanation and compliance guidelines. 3. Components of abuse prohibition. 4. Prevention of abuse and neglect. 5. Identification of abuse and neglect. 6. Investigating abuse and neglect. 7. Resident protection. 8. Reporting timely abuse and neglect and QAPI. Record review of required staff background checks completed on 07/26/2023. Record review of 26 resident interviews to validate all residents feel safe completed by the social worker on 07/26/2023. Record review of 1:1 education provided to the DON by the Regional Consultant regarding identifying like residents when an abuse incident occurs completed on 07/26/2023. Record review of all staff in-service dated 07/26/2023, titled: Abuse and Neglect Policy with Post Test with 33 staff signatures. Record review of Ad Hoc QAPI completed on 07/26/2023 at 01:30 PM. The meeting was to discuss the cite related to abuse, and on a plan to sustain compliance. During staff interviews on 07/27/2023 from 10:00 a.m. to 2:50 p.m. the following clinical staff were interviewed (MA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, LVN J, CNA K, CNA L, CNA M, LVN N, and Housekeeper) During these interviews LVN's, CNAs and MAs said they had been in-serviced over the abuse/neglect policy. All staff interviewed were able to verbalize types of abuse and notifying the Administrator immediately of witnessed of suspected abuse. On 07/25/2023 at 6:10 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/27/2023 at 2:50 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 10 residents (Resident #2) reviewed for develop and implement abuse policies. The facility failed to implement their policies and procedures related to reporting allegations of allegations of abuse when CNA Q failed to report abuse, she witnessed on 03/25/2023 until 03/26/2023 to the abuse coordinator. This failure could place residents at risk of abuse which could lead to further abuse and neglect of other residents. On 07/25/2023 at 6:10 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/27/2023 at 2:50 PM, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings include: Record review of Resident #2's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Her diagnoses included Dementia (problem in the brain affecting memory), Psychotic disorder (loss of contact with reality), anxiety (feeling of fear, and uneasiness). Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99, which indicated resident was unable to complete the interview. She required limited to extensive assistance of 1 staff for ADL care. Record review of Resident #2's care plan revealed she had a history of Depression and receive an anti-depressant medication. Interventions were to Approach in calm manner, introduce self and explain procedure/care to be provided, provide validation of feeling by restating concerns/feelings, encourage to focus on positive. Observation of a video taken on 03/25/2023 by the facility camera's revealed LVN P was feeding another resident in the secured unit when she walked over to the couch bent down, grabbed Resident #2's face and pushed her back on the couch. LVN P then picked up Resident #2's hand and pulled Resident #2 into a standing position and turned her and pushed Resident #2 in the back forcing her to walk away from LVN P. LVN P then walked back over to the table and resumed feeding the other resident. During an interview on 07/24/2023 at 2:00 p.m. the DON Said CNA Q went to the administrator and reported that LVN P was being mean to the secured unit residents. She said the Administrator pulled the camera, and it showed LVN P shake her finger in her face and then reach up and grab Resident #2 by the face and push her back against the couch. She said LVN P said she didn't want Resident #2 to fall and tried to scoot her back in her chair. She said it happened on Sunday and CNA Q didn't report the incident until Monday morning. During an interview on 07/26/2023 at 01:31 PM CNA Q said she was passing out lunch trays on 3/25/2023. Said she pulled Resident #2's tray off the cart and put it on the table and told Resident #2 to come to the table. Said she went back to the cart to finish delivering trays to the table and Resident #2 sat up and started laughing, then LVN P turned around and grabbed Resident #2 by the face and said something to her then grabbed Resident #2 by the arm stood her up and pushed her towards the table. CNA Q said she went and told the med aid. The med aide then told LVN P what she had said, and LVN P came up to CNA Q in an aggressive manner and said just to let you know, I don't abuse my residents and I don't appreciate you talking about me in that tone. CNA Q said she didn't report it to the administrator until the next day because she did not have phone numbers saved in her phone and due to her being from out of state, they had a different reporting system where she was from. CNA Q said at her old facility they just filled out a paper and turned it in. CNA Q said it happened on the weekend and there was not much staff to ask what she should do. She said she didn't know anyone else's name so she did not ask any other staff what she should do. She said she does not remember being trained on how she was supposed to report abuse that she can remember. CNA Q said the next day she texted the DON and asked what she should do and was advised to talk with the Administrator. She said she texted the Administrator on 03/26/2023 and asked for her to call her and after reporting what happened, the Administrator came to the facility and had her write out a statement of what happened. After that she said later the Administrator told her she had gotten it on camera so she has fired the nurse and would be contacting state. Record review of LVN P's Notice of Employee Separation dated 03/27/2023 revealed she was involuntarily terminated due to resident abuse. Record review of the facility's Inservice meeting dated 03/26/2023 revealed staff were trained on abuse and neglect, exploitation, what is abuse and neglect and who to report abuse and neglect to. The in-service was conducted by the Administrator, and DON. In an attempted interview on 07/25/2023 at 11:23 a.m. LVN P did not answer the phone call. This Surveyor left a voicemail and provided the state cell number. Record Review of 13 safe surveys conducted by the facility social worker did not reveal any additional concerns. In an interview on 07/27/23 at 11:50 a.m. the Administrator said she conducted a swift and thorough investigation immediately. She notified the police. LVN P was immediately terminated. Abuse and neglect in-services were given to staff, and they were educated on reporting abuse and neglect. She said no other residents were abused by LVN P. Record review of the facility's Abuse policy dated 02/01/20221 read in part, .Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. B. Each covered, individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. C. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. The DON was informed on 07/25/2023 at 6:10 pm that an Immediate Jeopardy (IJ) existed on 07/25/2023, and a copy of the IJ Template was provided.

**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 remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 10 (Resident #4) residents reviewed for supervision. The facility failed to respond to door alarm that resulted in Resident #4 elopement on 06/14/2023. Resident #4, who had dementia and a history of previous attempts of elopement, left the facility through an alarmed door on 06/14/2023 at 04:30 AM while wearing a wander guard. The resident wandered 0.3 miles in a wheelchair down the street and was intercepted by a passerby who returned Resident #4 to the facility. An IJ was identified on 07/25/2023. The IJ template was provided to the facility on [DATE] at 06:10 PM. While the IJ was removed on 07/27/2023 the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the need for the facility to monitor its corrective action for effectiveness. This failure could place residents at risk of not being properly supervised which could result in injury or death. Findings included: Record review of Resident #4's facilities electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnosis include dementia with history of psychotic disturbance (problem with thinking and delusions), epilepsy (seizures), paranoid schizophrenia (delusions and hallucinations). Record review of Resident #4's quarterly MDS assessment dated [DATE] revealed a BIMS score of 07, indicating he had severe cognitive impairment. He required supervision to limited assistance with one person assist for dressing, toilet use and personal hygiene, and required supervision with locomotion. Record review of Resident #4's care plan dated 02/21/2022 (day created) revealed Resident #4 is an elopement risk/wanderer as evidenced by Impaired safety awareness and leaving facility grounds with interventions that included wander guard to wrist or ankle for safety, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Record review of Resident #4's quarterly elopement risk assessment dated [DATE] revealed he was at risk to elope and should be placed on the elopement risk protocol. A care plan for elopement is indicated. Record review of nursing progress note dated 02/23/2023 at 11:38 AM revealed Resident #4 found outside in parking lot on property per staff, was redirected and educated on facility set parameters while outside. Resident #4 stated understanding and denies attempted elopement. NP aware, wander guard to right ankle. Will continue to monitor. Written by LVN R. Record review of nursing progress note dated 06/14/2023 at 06:14 AM revealed Resident #4 did exit his room moments later alarm sounded. After staff searched for resident in rooms, on the front porch, behind and the facility. Resident was spotted by a motorist who then notified staff. DON notified and received orders to place resident on secured hall. Written by LVN S. Record review of Resident #4's incident report dated 06/21/2023 revealed incident description: Summary reveals that resident left facility via front door. Wander guard alarms sounded alerting staff who immediately went to door and began facility search. Resident found outside near facility grounds. Facility confirmed that door alarm activated and alerted to potential elopement when wander guard device was near door. All other doors assessed to assure that alarm activated when wander guard device was near. Investigation is confirmed that resident left building unwitnessed. Facility immediately notified 911, the resident's family, facility personnel and MD. Due to elopement, the resident was relocated to the secured unit. Resident interviewed and reported was going to get cigarettes. Doors alarmed alerting staff to potential elopement. There are no other residents with wander guard. Facility assessed the door and it noted to sound when alarm comes in contact with it as it should. Assessments completed on all other residents to ensure of any elopement potential identified. During an observation and interview on 07/24/2023 at 09:45 AM, Resident #4 was observed lying in bed in his room inside of the secured unit. When asked about the elopement on 06/14/2023, Resident #4 said he remembered the incident then said, I did what I did and I don't want to talk about it. During an interview on 07/24/2023 at 1:38 PM, LVN A said she has worked at the facility through agency for about 1 year. She said she works all over the building and is not always assigned to the secured unit. She said she had not seen Resident #4 attempt to get out of the secured unit. During an interview on 07/24/2023 at 1:48 PM CNA B said she had worked at the facility for about 2 months and had not seen Resident #4 attempt to get out of the secured unit. During an Interview on 07/24/23 at 2:00 PM the DON said she was notified by LVN S that Resident #4 had eloped on 06/14/2023 at around 04:30 AM. She said he had a wander guard on the right ankle. She said he ran out of cigarettes that night and was going to the store to get some. She said the wander guard starts alarming and locks the door if a resident gets within 3 feet of a door, however the resident was somehow able to push through the door. She said LVN S and passerby caught him and brought him back to the facility. She said he made it to the 2nd stop sign before the highway. She said they called 911 and there were no injuries at the time and resident refused treatment. She said there was a previous 1st elopement on the day his family member took him to a family reunion then the next day he went outside on 02/23/2023. She said her administrator told her it did not have to be reported if the resident did not leave the property. She said she feels like the CNA caused the first elopement with Resident #4 because she was arguing with him and said staff was with him at the time. The DON said when Resident #4 was brought back he was assessed by LVN S and placed in the secure unit on 06/14/2023. The DON said LVN S reported no injuries were noted during his assessment. The DON said an elopement risk assessment was completed at that time. The DON said she started in-service on Head Count Guidelines and Elopement. Observation on 07/24/2023 at 5:54 PM surveyor took wander guard and pushed all hallway exit doors (100 hall, 200 hall, 300 hall, 400 hall) and 2 entrance doors, they were all locked. No concerns. Record review of the facilities Missing Residents policy dated 10/24/2022 revealed This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. 4: monitoring and managing residents at risk for elopement or unsafe wandering: A- residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. The DON was informed on 07/25/2023 at 6:10 pm that an Immediate Jeopardy (IJ) existed on 07/25/2023, and a copy of the IJ Template was provided. The following Plan of Removal was accepted on 07/26/23 at 02:56 PM: 1. Immediate Action: On 6/14/2023 resident # 4 was placed on the secure unit to prevent further attempts for elopement and to keep resident safe. Family and physician were notified. On 6/14/2023 a new elopement assessment was completed for resident # 4 by DON/designee. On 6/14/2023 an assessment of resident # 4 was completed by DON/designee with no signs of distress or injury. On 7/26/2023 all doors were checked by Maintenance Director/Designee to validate that all are secure and functional with either a wander guard system or a mag-lock system 2. Identification of Residents Affected or Likely to be Affected: On 6/14/2023 a head count was completed by DON/designee to validate that all other residents were in the facility and accounted for. On 6/16/2023 an elopement assessment was completed on all 44 other residents in the facility by DON/Designee. No other residents in the general population were identified as elopement risk per the elopement assessment. On 7/26/2023 at 9:30 am DON/Designee identified only 1 resident who had a Wander guard on in the facility. This resident was evaluated by the DON to determine Elopement risk. Based on elopement risk assessment, this resident was moved to the secure unit with notification to physician and family. No other residents in the facility are wearing a wander guard bracelet. 3. Actions to Prevent Occurrence/Recurrence: On 6/14/2023 DON/Designee educated staff on Safety Training (that included Missing resident guidelines and head count guidelines) This education provides information on: (1) missing resident guidelines what do if a resident is missing, (2) how to conduct a head count to ensure no other residents have left the facility, (3) article on Nursing home abuse, center's missing patient guideline regarding investigation and root cause analysis. On 7/26/2023 DON/Designee began education with staff on Elopement/Wandering/Missing resident Policy which entails: (1) definitions, (2) Explanation and compliance guidance, (3) Process for locating a missing resident, (4) procedure post elopement. Head Count Clinical Practice Guidelines which entail: (1) process for conducting a head count when a resident is missing, (2) explanation and compliance guidance. This will be completed at 12:00 pm on 7/26/2023, and no staff will be allowed to work after this date and time until they have completed this education. On 7/26/2023 at 2:00 pm DON/Designee will conduct a missing resident drill on the Am shift to validate staff's knowledge on response to an elopement. On 7/26/2023 DON/Designee will conduct a missing resident drill at the beginning of the evening and the night shift before staff start work, to validate staff's knowledge on response to an elopement. Beginning on 7/26/2023, any new or readmit resident will have an elopement assessment completed upon admission to determine the resident's risk for elopement. Any resident with a risk of elopement will be evaluated for placement on the secure unit with order from physician and family notification. The DON/designee will be responsible for this evaluate for placement on the secure unit based on the elopement risk assessment. As of 7/26/2023 the center will not use the Wander guard bracelets in the center. 4. On 7/25/2023 the DON/Designee notified the facility's Medical Director of the Immediate Jeopardy that facility was cited for at 7:30 pm. On 7/26/2023 the facility will conduct an Ad Hoc QAPI meeting to discuss the Immediate Jeopardy related to Accidents/Hazards and on sustaining compliance. On 07/27/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on 07/26/2023 at 10:40 AM all doors were checked by surveyor to validate that all are secure and functional with either a wander guard system or a mag-lock system. During an observation on 07/26/2023 at 10:45 AM surveyor confirmed all residents with a wander guard system were moved to the secured unit. No other residents in the facility were wearing a wander guard bracelet. During an observation on 07/26/2023 at 02:20 PM, surveyor elopement drill completed. Record Review of in-services dated 07/26/2023 titled Missing Person/Elopement Risk Policy with 31 employee signatures. Record review of Ad Hoc QAPI dated 07/26/2023, (2) provide adequate supervision to prevent Resident #4's elopement after previous attempts at elopement. During staff interviews on 07/27/2023 from 10:00 a.m. to 2:50 p.m. the following clinical staff were interviewed (MA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, LVN J, CNA K, CNA L, CNA M, LVN N, and Housekeeper) During these interviews LVN's, CNAs and MAs said they had been in-serviced over the missing person, elopement risk, and head count policies. All staff interviewed were able to verbalize procedures for any missing residents and notifying the Administrator immediately of any missing residents. On 07/25/2023 at 6:10 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/27/2023 at 2:50 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain a temperature range of 71°F to 81°F for 10 of 10 residents (Resident #'s 2, 4, 7, 8, 9, 10, 11, 12, 13, and 14) reviewed for exposure to high temperatures in the facility. The facility air conditioning system had not been working adequately for at least 4 days. The temperature of a common area (dining room) used by the residents was above 81°F. The temperature of a common area of the secured unit (dining area/TV room) used by the residents was above 81°F. The temperature of a common area (lobby/TV room) used by the residents was above 81°F. An Immediate Jeopardy (IJ) was identified on 07/24/2023. The IJ template was provided to the facility on [DATE] at 6:10 PM While the IJ was removed on 07/27/2023, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. This failure placed all residents at risk for dehydration and hyperthermia (elevated body temperature that could result in stroke or death). Findings Included: Observation on 07/24/2023 at 11:40 a.m. revealed uncomfortable temperatures while walking through the main dining room, lobby, and secured unit. Upon approaching the secured unit section of the skilled nursing facility, the temperature in the hallway was noticeably warmer. On the secured unit there was a water-cooled fan at the beginning of the hallway and a water-cooled fan at the end of the hallway. The thermostat on the wall read 83°F in the middle of the secured unit hallway. During an interview on 07/24/2023 at 11:42 a.m. LVN A said the air conditioning system on the secured unit had been broken for three to four weeks. She said she had not reported to the Maintenance Man that the air conditioning was broken. She said they were not doing anything differently in assessing residents or providing additional hydration due to the air conditioner being broken. She said she works at the facility through agency and had been coming to the facility for about a year. During an interview on 07/24/2023 at 11:44 a.m. CNA B said the air conditioning system had been broken on the secured unit for two to three weeks. She said she had not reported to the Maintenance Man that the air conditioner was broken. She said they were not doing anything differently in assessing residents or providing additional hydration due to the air conditioner being broken. She said she has worked full time at the facility for about 2 months. During an interview 07/24/2023 at 01:50 p.m., the Maintenance Man said it was reported to him that morning (07/24/2023) that the air conditioning system was not working on the secured unit. He said he was working on the air conditioning and should have it up and running again as soon as he could. In an interview 07/24/2023 at 02:00 p.m. with the DON, she said the air conditioning problem on the secured unit was reported to the Maintenance Man and Administrator on Friday 07/21/2023 at 08:33 p.m. She said no residents had been relocated to an area where the air conditioning was functioning. The DON said she would get the facility's emergency plan to the surveyor as soon as someone got it to her. The DON said she did not know how long the air conditioning system had been down in the main dining room or the lobby but that it had been a while, as in more than a month. Record review of text messages provided by the DON revealed on 07/21/2023 at 08:33 PM the Maintenance Man and Administrator were notified the air conditioning system was not working on the secured unit and the temperature was 87 degrees. Observation on 07/24/2023 at 05:00 p.m. revealed a water-cooled fan at the beginning of the secured unit hallway and at the end of the secured unit hallway. The thermostat on the wall read 85°F. The following room temperatures were taken with a Performance Tool W89721 laser infrared temperature gun: Secured unit front of hallway-76.8°F room [ROOM NUMBER]-74.2°F room [ROOM NUMBER]-78.1°F Secured unit middle of the hallway- 83°F room [ROOM NUMBER]-83.9°F room [ROOM NUMBER]-83.5°F room [ROOM NUMBER]-85°F Secured unit end of hallway- 84°F During an interview on 07/24/2023 at 05:10 p.m. the Maintenance Man said he was having a hard time finding a repair man that would come to the facility due to not having the funds to pay for the service call and previous unpaid bills. During an interview on 07/24/2023 at 06:10 p.m. the DON said she could put wander guards on all residents and put one staff member to each room and move all residents off the secured unit to the end of 100-hall. Observation on 07/24/2023 at 06:45 p.m. revealed residents were being transferred to the end of 100-hall where the air conditioning was functioning by facility direct care staff. Observation and interview on 07/25/2023 at 08:30 a.m., the Maintenance Man A revealed he had contacted a repair man and he should be at the facility at 9:30 a.m. The thermostat on the wall read 83°F. During the coolest part of the day (morning) the following temperatures were obtained by the surveyor using a Performance Tool W89721 laser infrared temperature gun: Secured unit front of hallway-74.5°F room [ROOM NUMBER]-72.3°F room [ROOM NUMBER]-74.3°F Secured unit middle of the hallway- 78.8°F room [ROOM NUMBER]-80°F room [ROOM NUMBER]-79.4°F room [ROOM NUMBER]-79.7°F Secured unit end of hallway- 81°F During an observation and interview on 07/25/2023 at 8:45 a.m. revealed additional water-cooled fans were brought to the facility by a sister facility Maintenance Man B. Maintenance Man B said he had contacted an air conditioning repair man who should be at the facility by 10:00 a.m. During an Observation on 07/25/2023 at 6:00 p.m. the following temperatures were obtained by the surveyor using a Performance Tool W89721 laser infrared temperature gun: Secured unit front of hallway-79.6°F room [ROOM NUMBER]-81.5°F room [ROOM NUMBER]-82.3°F Secured unit middle of the hallway- 82.8°F room [ROOM NUMBER]-85.2°F room [ROOM NUMBER]-86.3°F room [ROOM NUMBER]-85.8°F Secured unit end of hallway- 86.8°F Lobby- 83°F Middle of main dining room- 84.6°F During an interview 07/26/2023 at 8:05 a.m. The Maintenance Man A said the air conditioning system on the secured unit had been repaired and staff were going to move the residents back to the secured unit. During an observation on 07/26/2023 at 08:10 a.m. revealed residents were being transferred back to the secured unit by facility direct care staff from the end of 100-hall. The following temperatures were obtained by the surveyor using a Performance Tool W89721 laser infrared temperature gun: Secured unit front of hallway-71.2°F room [ROOM NUMBER]-65.7°F room [ROOM NUMBER]-69.7°F Secured unit middle of the hallway- 71.7°F room [ROOM NUMBER]-69.7°F room [ROOM NUMBER]-72.2°F room [ROOM NUMBER]-66.9°F Secured unit end of hallway- 72.1°F Lobby- 77.1°F Middle of main dining room- 78.2°F During an Observation on 07/26/2023 at 1:00 p.m. the following temperatures were obtained by the surveyor using a Performance Tool W89721 laser infrared temperature gun: Secured unit front of hallway-74.4°F room [ROOM NUMBER]-68.2°F room [ROOM NUMBER]-73.5°F Secured unit middle of the hallway- 76.6°F room [ROOM NUMBER]-73.3°F room [ROOM NUMBER]-74.3°F room [ROOM NUMBER]-71.1°F Secured unit end of hallway- 75.3°F Lobby- 80.6°F Middle of main dining room- 79.9°F During an interview 07/26/2023 at 1:15 p.m. The Maintenance Man said the air conditioning system in the lobby and in the main dining room went down within an hour that morning. He said the repair man should be back at the facility that afternoon between 2:00-3:00 p.m. He said the air should be blowing 69°F- 70°F at the air vent. During an Observation on 07/26/2023 at 2:20 p.m. the following temperatures were obtained by the surveyor at the vent using a Performance Tool W89721 laser infrared temperature gun: Lobby: Vent #1-77.7°F Vent #2-77.5°F Vent #3-75.5°F Vent #4-76.1°F Main Dining Room: Vent #1-78.6°F Vent #2-77.8°F Vent #3-74.8°F Vent #4-73.7°F Vent #5-73.3°F Vent #6-74.5°F Vent #7-74.3°F Vent #8-74.5°F During an interview on 07/26/2023 at 3:00 p.m. The BOM said the air conditioning system in the kitchen, lobby and dining room has been down since before the beginning of summer. She said she thinks it was somewhere around April 2023 when the air conditioning system went out. She said she called a friend of hers that owns a repair service on 7/25/23 and told them the situation and was able to have the air conditioning repair man come out that day. She said since the CHOW on 06/01/2023 she is no longer handling the accounts payable, so she does not know why they have not had a repair man come out at this time. She said before 06/01/2023 she did not have a problem with getting the funds to pay a repair man. She said she would have a check ready for the repair man by the time the repair man had finished the job that day. During an Observation on 07/26/2023 at 04:30 p.m. multiple residents observed being served the dinner meal in the main dining room. Residents in the main dining room do not appear to be in distress. the following temperatures were obtained by the surveyor using a Performance Tool W89721 laser infrared temperature gun: Main Dining Room- 86.3°F Lobby- 80.1°F During an interview 07/26/2023 at 05:00 p.m. The Maintenance Man said the air conditioning system in the Lobby and Main Dining room are working properly. He said the air is blowing 69°F- 70°F at the air vent and that is how the temperature was supposed to be measured. He said he did not know what he was expected to do since it is over a hundred degrees outside, and the air conditioner was functioning properly. During an observation and interview on 07/27/2023 at 09:20 a.m. the Sister Facility Maintenance Man said he was not happy with the Maintenance Man. He said he had told the Maintenance Man to clean the coils on the condenser of the outside air conditioning unit and the Maintenance Man had not done so. He said the correct temperature the air should have been blowing at the air vents was 50°F- 60°F for the room temperature to be comfortable. The Sister Facility Maintenance Man said the AC units worked better if they were serviced twice a year. He said he could not determine if the facility air conditioning units had been serviced in a while. He said those things probably contributed to the air conditioning system failure. Record review of the facility maintenance logs revealed the air conditioning being broken had not been reported using the maintenance log. Record review of the local area weather dated 07/27/2023 located at: <https://weather.com/weather/monthly/l/80702542c8a914a6b950390ce10301ca35c038784e8ba155d80cd24e459fb2f0> read in part the high temperatures from 07/24/2023 to 07/27/2023 in [NAME], Texas ranged from 98 °F to 99 °F, with the average high temperature being 99 °F. Record Review of the Extreme Weather-Heat or Cold policy of the facilities emergency preparedness manual section 5-8 provided on 07/27/2023 revealed: The priority of this facility to minimize the stress our residents could experience from extreme temperatures related to weather events. To mitigate this risk, we rigorously maintain our systems of heating, ventilation and air conditioning and generator. In the event of a disruption to these systems during extreme weather we will initiate the following actions: 1. Activate the facility's extreme weather heat P&P and appoint a facility incident commander if warranted. 2. Assess residents for signs of distress and/or discomfort. 4. Consider re-locating residents to a cooler part of the facility. 7. Provide cool washcloths and cooling fans for air circulation. 8. Encourage residents to drink fluids to maintain hydration. 10. Notify the HHSC to report an unusual occurrence and activation of facility's EOP. The facility DON was notified that an immediate jeaopardy IJ had been identified on 07/24/2023 at 06:10 PM and the IJ template was provided. The facility's plan of removal was accepted on 07/27/2023 at 08:18 AM and included: Immediate action taken: On 7/24/2023 the 10 residents on the Secure Unit were move to other beds throughout the facility at 6:15 pm. All windows were checked by maintenance director, and all were locked. On 7/25/2023 facility will increase staff back to 7 staff members on this unit from 3:00 pm until wireless audible window alarms can be placed on windows on this unit. On 7/24/2023 there were 7 staff members (6 nurse assistants and 1 licensed nurse) assigned to the unit that housed these 10 residents. On 07/25/2023 there would be 2 staff members that would be assigned to door monitor for both doors that leave the unit. These 2 staff will sit inside the unit monitoring the closed door that exits out into the facility, and the end door that exits out of the facility 24 hours a day ensuring that no residents leave the unit, until residents can be moved back to the secure unit. These 2 monitors will have no other duties but monitor the door and ensure the safety of the residents. During break periods, these 2 monitors will be relieved by staff from other areas of the building. Each monitor will document times of duties/responsibilities for each shift covered. This went into effect 7/25/2023 at 6:30 pm. On 7/25/2023 there will be 1 licensed nurse, and 2 nurse assistants assigned to provide direct care to the 10 residents on this unit. This went into effect 7/25/2023 at 6:30 pm. On 7/24/2023 the DON/Designee completed an assessment on the 10 residents on the secure unit for signs/symptoms of dehydration, heat exhaustion and heat stroke. The physician will be notified if any resident has any symptoms of dehydration, heat exhaustion, or heat stroke. This was completed 7/24/2023. On 7/24/2023 An air conditioner company was notified of the need for air conditioning repair in the facility. On 7/25/2023 Regional Nurse consultant provided 1:1 education to the facility/maintenance director related to scheduling repairs when any system malfunctions. On 7/25/2023 the air conditioner company is in the center working on the air conditioner units that are not working. The air conditioner in the kitchen has been repaired. The air conditioner for the lobby and the secured unit will be repaired by 5:00 pm 7/25/2023. The air conditioner for the lobby and for the secure unit has been repaired, operating, and working. 2. Identification of Residents Affected or Likely to be Affected: Maintenance Director/Designee completed rounds on 7/24/2023 to validate that all other air conditioners were operational. On 7/25/2023, air conditioner in the kitchen has been repaired. The air conditioner for the lobby and the secured unit will be repaired by 5:00 pm 7/25/2023. The air conditioner for the lobby and for the secure unit has been repaired, operating, and working. On 7/26/2023 the air conditioner unit in the Dining room went down about an hour ago. The Maintenance Director will place two refrigerated window units in the Dining Room today 7/26/2023 to ensure that the temperature in the Dining Rooms remains at 80 degrees or cooler until the Air Conditioner Unit can be repaired. The lobby air conditioner is operational. On 7/26/2023 the air conditioner in the lobby is not maintaining temperatures at a comfortable level. All residents were removed from the lobby area at this time, and the center will place Evaporated units in the lobby areas to maintain the temperature at or below 80 degrees. Laundry Supervisor will be taking temperatures in the lobby and Dining area this evening and tonight to validate temperature is at 80 or below. Resident will be encouraged to not sit in these areas and will be removed from lobby and Dining Rooms if temperature is not maintained. 3. Actions to Prevent Occurrence/Recurrence: On 7/24/2023 the Regional Nurse Consultant provided education to the Director of Nurses, and the Maintenance Director on the center's Extreme Weather Policy including assessing resident for any signs/symptoms of distress or discomfort, re-locating resident to a cooler part of the facility if temperature go above 81 degrees, providing cool cloths and fan for circulation, encourage hydration and notification to the Regional Nurse Consultant or Regional Director of Operations if applicable. This was completed at 8:00 pm 7/24/2023. On 7/25/2023 hydration rounds were increased for all residents in the center to 4 times a day (not including meal times) On 7/24/2023 the Regional Director of Operations will provide education to the Administrator via Telephone on the center's Extreme Weather Policy including assessing resident for any signs/symptoms of distress or discomfort, to re-locating resident to a cooler part of the facility if temperature go above 81 degrees, providing cool cloths and fan for circulation, encourage hydration and notification to the Regional Nurse Consultant or Regional Director of Operations if applicable. The education also covered reportable events (loss of HVAC system in an emergency and need to report). This was completed at 8:00pm on 7/24/2023. On 7/24/2023 the DON/designee will provide education to all staff currently in the center on Extreme Weather Policy including assessing resident for any signs/symptoms of distress or discomfort, re-locating resident to a cooler part of the facility if temperature go above 81 degrees, providing cool cloths and fan for circulation, encourage hydration and notification to the Regional Nurse Consultant or Regional Director of Operations if applicable. This was completed at 8:00 pm 7/24/2023. No staff will be allowed to work until they have completed this education. On 7/25/2023 hydration rounds were increased for all residents in the center to 4 times a day (not including mealtimes) On 7/24/2023 the DON/designee will provide education to all staff currently in the center on Abuse and Neglect Policy as a refresher of what could constitute abuse. This was completed at 8:00 pm 7/24/2023. No staff will be allowed to work until they have completed this education. On 7/25/2023 the DON/designee will provide education to all staff currently in the center on signs and symptoms of heat exhaustion to observes for and report to include a. Heavy sweating b. Cold/tiredness c. Cool/clammy skin d. Fast weak pulse, dizziness e. Nausea/vomiting f. Headache This will be completed on 7/25/2023 by 2:00 pm, and no staff will be allowed to work until they have completed this education. 4. Monitoring: The Administrator/Designee will monitor temperatures on all hallways and common areas throughout the center and record twice daily for 30 days The DON notified the center's Medical Director of the Immediate Jeopardy on 7/24/2023 at 8:00 pm. An Ad Hoc QAPI meeting will be conducted to review the issues resulting in an Immediate Jeopardy and plan of sustaining compliance. On 07/27/2023 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: The arrival of the air conditioning repair man at the facility was observed by the surveyors on 07/25/2023 at approximately 05:30 p.m. The system was up, and running and resident rooms were spot checked for cool air coming out of the vents and falling temperatures were verified by surveyors before exiting the building on 07/25/23 at approximately 06:15 p.m. During Observations on 07/27/2023 from 10:15 a.m. to 2:50 p.m., surveyors continued to monitor temperatures in the facility. Initially, elevated temperatures were obtained in the facility secured unit of 72.3-86.8 degrees. After the air conditioning was repaired the temperature ranged 69.7- 76.2. All resident occupied areas and rooms checked were found to be between 69-75 degrees Fahrenheit. In-service sign in sheets dated 07/24/2023 and 07/25/2023 over signs and symptoms of dehydration and signs and symptoms of heat exhaustion were reviewed. The In-service sign in sheet for the Administrator, DON and Maintenance Man in-service over Emergency preparedness was reviewed. The Maintenance rounds sheets reviewed to ensure all other air conditioning systems were operational. The Ad Hoc QAPI meeting held 07/26/2023 addressing the air conditioning system. Record review revealed the DON/Designee completed an assessment on the 10 residents on the secure unit for signs/symptoms of dehydration, heat exhaustion and heat stroke. The physician will be notified if any resident has any symptoms of dehydration, heat exhaustion, or heat stroke. During staff interviews on 07/27/2023 from 10:00 a.m. to 2:50 p.m. the following clinical staff were interviewed (MA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, LVN J, CNA K, CNA L, CNA M, LVN N, and Housekeeper) During these interviews LVN's, CNAs and MAs said they had been in-serviced over signs and symptoms of dehydration (feeling thirsty, Lightheaded, tiredness, dry mouth, dark colored or strong smelling urine, decreased urination) signs and symptoms of heat exhaustion elevated body temperature, hot, red, dry or damp skin, headache, dizziness, nausea, confusion, heavy sweating, cold pale or clammy skin, elevated heart rate, muscle cramps), abuse and neglect. The nurses said if they observed, or it was reported to them that any residents had s/s of heat exhaustion or dehydration they would immediately notify the physician and DON. During an interview on 7/27/23 at 2:30 p.m., the Administrator correctly listed s/s of heat exhaustion and dehydration (elevated body temperature, hot, red, dry or damp skin, headache, dizziness, nausea, confusion, heavy sweating, cold pale or clammy skin, elevated heart rate, muscle cramps/ feeling thirsty, Lightheaded, tiredness, dry mouth, dark colored or strong-smelling urine, decreased urination). She said she will monitor temperatures on all hallways and common areas throughout the center and record twice daily for 30 days ensure temperatures are maintained. The Administrator said he had been given 1 on 1 In-service over emergency preparedness/ procedures, the center's Extreme Weather Policy and immediate reporting by the Regional Director of Operations. Record Review on 07/27/2023 reveal the facility was monitoring the temperatures on all common hallways twice daily. On 07/24/2023 at 6:10 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 07/27/2023 at 2:50 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of Pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to be adequately equipped to allow resident to call for assistance for 2 of 10 residents (Residents #5 and Resident #6) reviewed for accommodation of needs. The facility failed to be adequately equipped to allow residents to call for staff assistance when needing help due to call light malfunction. The facility failed to ensure Residents #5 and #6 had a working call light. The facility failed to ensure all residents on the secured unit had a working call light. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. This failure could place the residents at risk of injury and not being able to obtain assistance or care as needed. Findings included: 1.Record review of Resident #5's electronic Face Sheet, dated [DATE], revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident #5 had diagnosis which included the following: Atherosclerotic heart disease (a buildup of fats in the artery walls), venous insufficiency (veins have problems moving blood back to the heart), Hyperlipidemia (high cholesterol). Record review of Resident #5's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 10, which indicated Resident #5's cognition was moderately impaired. The MDS revealed Resident #5 required limited assistance of one person assistance for the following ADLs: transferring, toilet use, and personal hygiene. Further review of the MDS revealed Resident #1 was occasionally incontinent of urine, and continent of bowel and needed assistance for toileting hygiene. Record review of Resident #5's care plan, last revised on [DATE], revealed Resident #5 was at risk for falling due to unsteady gait, decreased balance, medications, and poor safety awareness. The interventions included Call light in reach in room and answered promptly. Encourage and remind him to use call light to ask for assistance. Record review of incident report dated [DATE] revealed Resident #5 had a fall resulting in a laceration requiring staples to laceration while taking a shower. Record review of progress note dated [DATE] at 04:53 PM revealed Resident #5 returned from emergency room with 5 staples in the back of his head. Clear CT scan but complaints of head pain. DON notified. 2.Record review of Resident #6's electronic face sheet dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #6 had diagnosis which included the following: end stage renal disease (kidney failure), metabolic encephalopathy (problem in the brain), dialysis dependent (removes extra fluid and waste from the blood), type 2 diabetes (affects the way the body processes blood sugar), legal blindness (unable to see). Record review of Resident #6's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 15, which indicated Resident #6's cognition was intact. The MDS revealed Resident #6 required limited assistance of one person assistance for the following ADLs: transferring, locomotion, bed mobility and personal hygiene. Resident #6 required extensive assistance of one person for walking, dressing and toilet use. Further review of the MDS revealed Resident #6 was occasionally incontinent of urine, and frequently incontinent of bowel and needed assistance for toileting hygiene. Record review of Resident #6's care plan, last revised on [DATE], revealed Resident #6 has the potential for falls. The interventions included place the resident's call light is within reach and encourage the resident to use it for assistance as needed. During an interview and observation on [DATE] at 09:20 AM, Resident #5 said he has not had a call light for 2-3 weeks. He said he had a call light, and it broke 2-3 weeks ago, and the facility was supposed to order him a new one. He said he had not heard why it was taking so long to get a new one. When asked how he calls for help, he said he sticks his head out of his door and yells down the hallway. Resident #5 said he had fallen in the shower and sustained a laceration to the back of his head that had required staples. Resident #5's bathroom observed with no call light in place. During an interview on [DATE] at 10:00 AM, LVN O said that not all residents have a call light. She said Resident #5 and Resident #6 do not have a call light on 100 hall. She said that it was caught on camera that staff was unplugging the call light system and putting it in a drawer so that no one's call light was working. She said they had a meeting with the administrator and was told that anyone caught unplugging the call light system would be immediately terminated. She said it has gotten a lot better ever since. She said Resident #5 did have a call light, but it had broken a few weeks ago and had not yet been replaced. She said Resident #6 had not had a call light since admission. She said the main call light box sits at the nurse's station and it could be unplugged, and no one's call light will work. She said you can turn the volume up or down on the main call light box. She said she thought the facility had ordered the call light system online. She said some residents have a button that hangs on a lanyard and each resident is assigned a number. She said when the number lights up on the main box staff has to look at the key taped at the nurses' station to determine which resident was using the call light. She said once it is determined which resident has pushed the call button then staff just has to know what room that resident is in. She said the light on the outside of the room does not light up. During an interview and observation on [DATE] at 10:15 AM, Resident #6 stated she has never had a call light since the day she admitted to the facility. She said if she needs something she asks her roommate to push her call light. She said she does not know why she does not have a call light. Observation of Resident #6's bathroom revealed there was not a call light in place. During an interview [DATE] at 02:00 PM, the DON said she had stopped working for the facility for about 6 months and had returned to working for the facility in October of 2021. She said that when she returned in 2021 the current call light system was in place. She said she was told it was approximately 30 thousand dollars to fix the call light system so as a work around the owners had ordered the current call light system online. She said that it became her duty to issue out a call light button when there was a new admission. She said Resident #5 has had about 3 call lights, but no one reported to her that he currently did not have one. She said she was not sure why Resident #6 had been missed and not issued a call light when she admitted to the facility on [DATE]. She said had she been aware that those 2 residents did not have a call button she would have issued them one because she has 5 extra call buttons in her desk drawer. She said it was the maintenance man's responsibility to mount the call lights in the bathroom when residents admitted to the facility. She said she was aware that the residents on the secured unit did not have call buttons at this time, because they had initially been issued one but that most of them had been lost or thrown away or possibly stuck in drawers due to the resident's cognition. The DON said LVN T and CNA U had been given a notice of disciplinary action on [DATE] and [DATE] due to unplugging the main call light box at the nurse's station. She said after LVN T and CNA U were disciplined for unplugging the main call light box, the facility implemented the End of Shift Round Sheet. During interviews on [DATE] between 01:30 PM to 02:30 PM the following staff members were asked about the End of Shift Round Sheet: 1. CNA V said she did not know what the end of shift round sheet was. 2. CNA B said she had never used the end of shift round sheet and does all her documentation online in their chart. 3. CNA X said she knew what an end of shift round sheet is, she said it is completed at the end of the shift and turned in to the nurse. 4. LVN A said she knew what an end of shift round sheet is but had never used one at this facility. 5. CNA Y said she did not know what the end of shift round sheet was. 6. CNA Z said she knew what an end of shift round sheet is but had never used one at this facility. 7. LVN O said yes, she knew what an end of shift round sheet was but said they had not used them in a while. During an observation on [DATE] at 05:30pm with the DON all resident bathrooms on 100 and 200 halls were observed for call lights with 4 observed and 0 working at that time. Resident #5 and Resident #6's bathroom did not have call lights. Record review of disciplinary action dated [DATE] for CNA U revealed make sure call light stays on top of desk. Record review of disciplinary action dated [DATE] for LVN T revealed this staff removed call light from desk and placed it into drawer this is unacceptable. This staff will return on [DATE] on a 90-day probationary period, any write ups during this time will result in her termination from the facility. Record review of End of Shift Round Sheets form revealed the following information should be filled out at the end of the shift: 1. Date 2. Staff name completing the sheet (off going and on coming). 3. Charge nurse signatures (off going and on coming). 4. Please make sure all-round sheets are placed at the front of the focus binders to be checked the next day in the morning focus meeting by DON/ADON. 5. DON/ADON signatures. A record review of the facility's policy titled Call light Response, dated [DATE], revealed The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. 5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. 6. Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied. (Examples include: replace call light, provide a bell or whistle, increase frequency of rounding, etc.). The DON was informed on [DATE] at 6:10 pm that an Immediate Jeopardy (IJ) existed on [DATE], and a copy of the IJ Template was provided. The following Plan of Removal was accepted on [DATE] at 04:59 PM: 1. Immediate Action Taken: Resident # 5 was given a new call button. Resident # 6 was given a Med. Alert call button. DON/Designee completed rounds for all residents on [DATE] at 7:00 pm and validated that there were 7 residents who did not have a call light system. These residents were given bells to use as audible alarms and instructions on their use on [DATE]. DON/Designee completed rounds for all residents on [DATE] at 7:00 pm and validated that there were 23 residents that do not have a visual call light system (16 of these do have a Med. Alert call system). Staff will check all Med. Alert devices every shift to ensure they are working, batteries are working, and that alarm can be heard with the door closed, and there is no signal interruption when doors are closed and that they are not broken or misplaced. This will be documented, and the documentation will be retained in the DON office. A staff member on each shift will be responsible to complete the rounds on each shift to check the Med. Alert devices and document on the Med. Alert monitoring tool. The DON or designee will be responsible to collect and review the Med. Alert monitoring tool daily. On [DATE] at 7:00 pm Staff will start every 1-hour visual check of the 23 residents that do not have a visual call light system with documentation. This will remain in effect until the call light system can be repaired. This documentation will be retained in the DON office. A staff member on each shift will be responsible to complete the rounds on each shift to check residents that do not have a visual call light and document on Every 1-hour monitoring tool. The DON or designee will be responsible to collect and review Every 1-hour monitoring tool daily. On [DATE] The Regional Director of Operations will contact a Call Light Systems Company to come onsite to provide a bid for repair. The center has contacted a company to come to the facility to provide a bid to repair the call light system on [DATE]. 2. Identification of Residents Affected or Likely to be Affected: DON/Designee completed rounds for all residents on [DATE] at 7:00 pm to validate that no resident needed emergency assistance. On [DATE] going forward, all new or readmit resident will have a call light system upon admission. This will be validated daily on rounds by DON or designee. 3. Actions to Prevent Occurrence/Recurrence: On [DATE] DON/Designee started education on Resident call light Policy for all staff. This education was completed on [DATE] at 10:00 pm, and no staff will be allowed to work until this education has been completed. On [DATE] DON/Designee started education on Monitoring tool that will be used every 1 hour to monitor residents without a visual call light. This education was completed on [DATE] at 10:00 pm, and no staff will be allowed to work until this education has been completed. This documentation will be retained in the DON office. Staff will check all Med. Alert devices every shift to ensure they are working, batteries are working, and that alarm can be heard with the door closed, and there is no signal interruption when doors are closed and that they are not broken or misplaced. This will be documented, and the documentation will be retained in the DON office 4. Monitoring On [DATE] at 7:00 pm the facility staff will use the Resident Monitoring tool to round on residents with no visual function call system every 1 hour until the call system can be repaired. 5. On [DATE] at 7:30 pm the DON notified the Medical Director of the Immediate Jeopardy the facility received on [DATE]. On [DATE] at 1:00 pm the facility will conduct an Ad Hoc QAPI meeting to discuss the Resident call light system and plan for sustaining compliance. On [DATE] the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on [DATE] at 11:30 AM on 100 hall and the secured unit all residents had a call button or were given bells to use as audible alarms and had been given instructions on their use. During an observation on [DATE] at 11:45 AM staff were using the med alert monitoring tool and the Q 1-hour rounds on non-visual working call lights monitoring tool. Record review of an email dated [DATE] at 01:56 PM revealed the Regional Director of Operations had contacted a call light systems company to onsite to provide a bid for repair on [DATE]. During staff interviews on [DATE] from 10:00 a.m. to 2:50 p.m. the following clinical staff were interviewed (MA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, LVN J, CNA K, CNA L, CNA M, LVN N, and Housekeeper) During these interviews LVN's, CNAs and MAs said they had been in-serviced over the Q 1 hour rounds on non-visual working call lights and the med alert monitoring tool. All staff interviewed were able to verbalize procedures for any non-working call lights and notifying the Administrator immediately of any call light related issues. On [DATE] at 6:10 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE] at 2:50 PM, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.