**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to maintain an environment that was free from accidents and hazards for 31 (All resident on 100 Hall) of which 5 of 31 (Resident #81,82, 20, 40, and 77) had cognitive decline that could still access their sinks, of 90 residents. -Temperature readings for the public restroom on the 100 hall were 128 degrees Fahrenheit. -The temperature reading in the restroom to Resident room [ROOM NUMBER] on the 100 hall was 128 degrees Fahrenheit. -5 residents on the 100 hall had cognitive decline and could access their sinks. An Immediate Jeopardy to residents' health or safety was identified on 12/21/23. The Immediate Jeopardy template was provided to Administrator on 12/21/23 at 7:23PM. While the Immediate Jeopardy was removed on 12/22/23 at 7:38PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a severity level of a pattern as the facility began lowering water heater temperature for 100 hall, testing water temperatures in resident rooms on the 100 hall and in-servicing staff. These failures placed residents at risk of potential 3rd degree burns. Findings include: In an observation on 12/21 2023 at 12:30 PM, water in the sink of 100 hall public restroom was extremely hot. In an observation and interview on 12/21/2023 at 12:46 PM, the Maintenance Director was observed checking water temperature in 100 hall public restroom. He used 2 plastic cups, one inside of another, and at 1 minute the temperature was observed to be 128 degrees Fahrenheit . The Maintenance Director went to room [ROOM NUMBER] and used 2 plastic cups, one inside of another, and within 1 minute the restroom sink water was observed at a temperature of 128 degrees Fahrenheit. The Maintenance Director said, that's too hot. The Maintenance Director said that water temperature would affect all Resident's on hall 100. He said this water temperature could burn the residents. In an interview on 12/21/2023 at 12:51 PM, the Maintenance Director said they cranked up the hot water on hall 100 due to fluctuation in temperature outside and request from staff for cold showers down hall 100. The Maintenance Director said his thermometer for checking water temperatures was one year old. In an interview on 12/21/2023 at 1:40 PM with both the Maintenance Director and the Maintenance Assistant. The Maintenance Director said he spoke with the Maintenance Assistant and said he had changed the water temperature on 12/18/2023 at approximately 10AM and did not notify the Maintenance Director. The Maintenance Assistant said he did not know the staff's name, but she had requested him to turn water temperatures up on hall 100. The Maintenance Assistant said that travel Staff notified him at approximately 8 AM on 12/18/2023. The Maintenance Assistant said he never notified the Maintenance Director that he had increased the water temperatures by 15 degrees to 130 degrees Fahrenheit. The Maintenance Assistant said he did not check water temperatures before or after changing water temperature. Resident #81 Record review of Resident #81's Quarterly MDS, dated [DATE] revealed an [AGE] year-old male, admitted to the facility on [DATE]. Resident #81 had an active diagnosis of dementia . He had a BIMS score of 8 (moderately impaired). During an observation on 12/19/23 at 3:20pm, Resident #81, who resided on 100 hall, was propelling himself down the hallway in his wheelchair. Resident #82 Record review of Resident #82's Quarterly MDS, dated [DATE] revealed a [AGE] year-old female, admitted to the facility on [DATE]. Resident #82 had an active diagnosis of dementia. She had a BIMS score of 3 (severe impairment). During an observation on 12/19/23 at 3:22pm, Resident #82, who resided on 100 hall, was ambulating herself down the hallway in her wheelchair. Resident #20 Record review of Resident #20's Quarterly MDS, dated [DATE] revealed a [AGE] year-old female, admitted to the facility on [DATE]. Resident #20 had an active diagnosis of dementia. She had a BIMS score of 2 (severe impairment). During an observation on 12/19/23 at 12:46pm, Resident #20, who resided on 100 hall, was sitting in her wheelchair in her room. Resident #40 Record review of Resident #40's Quarterly MDS, dated [DATE] revealed an [AGE] year-old female, admitted to the facility on [DATE]. Resident #40 had an active diagnosis of dementia. She had a BIMS score of 5 (severe impairment). During an observation on 12/19/23 at 3:52pm, revealed Resident #40, who resided on 100 hall, was laying in bed asleep with a Wander Gard on her right foot. Resident #77 Record review of Resident #77's Quarterly MDS, dated [DATE] revealed a [AGE] year-old female, admitted to the facility on [DATE]. Resident #77 had an active diagnosis of dementia. She had a BIMS score of 5 (severe impairment). During an observation on 12/19/23 at 11:00 am, Resident #77, who resided on 100 hall, was sitting up in a chair in her room, stating she had just received a bath. In an observation and interview on 12/21/23 at 1:47 PM, the Maintenance Director checked hot water heater for hall 100 that was inside a locked closet inside the locked medication room. The hot water heater was a dial temperature in which Maintenance Supervisor said he reduced temperature immediately after checking water temperatures earlier. He said the water temperature was 130 degrees Fahrenheit. He said he checked for 1 to 2 minutes regularly when checking temperatures. He said he, starts at beginning of hall and works way to end of halls. The Maintenance Director said he checks random rooms and point of care areas on halls and different rooms each week. He said he knew which rooms to check and said, I just remember from week to week. In an observation and interview on 12/21/23 at 1:48 PM with Charge Nurse F said she does not have a key to the hot water heater closet in the medication room. In an interview on 12/21/2023 at 02:16 PM the Maintenance Director said his expectations were that staff wrote requests in maintenance logbook and water temperature checks would be performed before and after temperature change. He said he had no knowledge of the Temperature change. In an interview with DON on 12/22/2023 at 2:45 PM she said, Only Maintenance has keys to hot water heater closets. Record review of the facility's Maintenance Log from 09/01/23 through 12/21/23 revealed there were no issues noted to hot water, nor that Maintenance had addressed any issues regarding hot water. Record review of facility policy Test Water Temperatures, undated, revealed the following [in part]: It is suggested that you review or watch the TELS Masters Training video that accompanies the task. Test water temperatures . Let the hot water run from 3 to 5 mins. . Insert the stem into the stream of running water, so that the sensor is fully immersed. . As the temperature of the water is taken, hold your hand under the running water at about the same time to assess how the water feels on your skin. 1. Ensure patient room water temperatures are between 105 degrees F. and 115 degrees F. (or as specified by state requirements) . Texas 100 degrees F to 110 degrees F. 5. Common area bathrooms, public bathrooms and any other areas having sinks should be checked and recorded as well. This was determined to be an Immediate Jeopardy on 12/21/23 at 7:23PM. Administrator was notified. Administrator was provided the Immediate Jeopardy template on 12/21/23 at 7:23PM. The following Plan of Removal submitted by the facility was accepted on 12/22/23 at 11:38AM. Timeline: 12/21/23 at 12pm, the Maintenance Director lowered the temperature on the hot water heater. At approximately 3pm, the Maintenance Director checked all the water temperatures from 100 hall and they were all logged at safe range of 110 degrees. At approximately 4pm, the Maintenance Director checked water temperatures in resident rooms in the facility. At 7:38PM, the Maintenance Director checked room [ROOM NUMBER] water temperature and it was within safe range, logged at approximately 110 degrees under running water for 3 minutes. 1. Immediate Response: Water temperatures have been checked on 100 hall and rooms logged a safe water temperature range (see attached log). 31 of 90 residents on hall 100 are not at risk. Skin Assessments completed on all residents on hall 100 with no negative findings. AdHoc meeting with Administrator and DON to review issue and community's response plan implemented. 2. Risk Response: Resident/Residents on hallway 100 that received a shower or used thing sink for hand hygiene may potentially be affected by the alleged deficient practice. o Skin audit (sweep) was conducted by the administrative nurses (DON/ADONS/WCN) on current residents with no significant findings identified. Initial skin audit commenced on the evening of 12/21/23 once the concern was identified prior to the immediacy being implement@ 746PM. o Conducted 100% skin sweep of all active residents on hallway 100. There were no adverse effects identified. See above Date Completed: Initial skin sweeps on: 12/21/23 o ADMINISTRATOR and MAINTENANCE DIRECTOR received re-education on the importance ensuring that temperatures of hot water must be maintained less than 110 degrees and that if water temperatures are adjusted that they must be rechecked before and after doing so. ? Maintenance director were re- educated on running water for 3 minutes prior to any temperature check that is completed as per policy. ? Maintenance director was re-educated on holding the thermometer into the stream of running water so that the sensor is fully immersed and allowing the thermometer to register the correct temperature. o Date Completed: 12/21/23 at 8:30pm. o All management staff received education on the expectation hot water temperatures and that they are to be maintained below 110 degrees and if believed to be too hot to notify the Administrator or maintenance director immediately. Date Commenced: 12/21/23 1. ADMINISTRATOR AND MAINTENANCE DIRECTOR received education prior to exiting the facility. 2. All Management staff received education on the staff received education on the hot water temperatures and that they are to be maintained within safe rage 110-115 degrees and report immediately to Administrator and Maintenance Supervisor while preventing use of hot water until temperatures can be checked for safe temperatures. 3. Reviewing the temperatures and temperature logs to identify elevation or deviation from below 110 during the daily clinical meeting held 5 times weekly as well as random checks on weekends to ensure the temperatures are maintained at the appropriate temperature. 4. IDT will review the system & will update appropriate interventions to address the prevention of hot temperature injury. 5. ADMINISTRATOR and or Designee will conduct weekly rounds to ensure that temperature logs, monitoring logs and QA are being conducted on this system. Date commenced:12/21/23 Date completed: 4. Monitoring Response: The administrator or Designee will make daily temperature checks 5 days per week and then random temperature checks on the weekend to ensure the hot water temperatures are below the 110 degree to validate the compliance. Findings will be reported to the ADMIN and reviewed with the QAPI committee for the next 2-3 months to determine compliance or to identify further education and oversight is needed. Monitoring of the facility's Plan of Removal through observations, interviews, and record reviews from 12/21/2023 at 6:00pm to 12/21/2023 at 7:00pm revealed: In an interview on 12/22/23 at 6:00pm, the Administrator and Maintenance Director said the plumber came at 11:30am on 12/22/23 and looked at all 4 hot water heaters. They were ordering digital regulators that were tamper proof and maintain a continuous temperature. Checked a sample of rooms, 2 on each hallway, and all were within limits with a range of 100-105 degrees. The sample of rooms would be rotated each day and documented. The Administrator said he and only the Maintenance Director had access to hot water heaters. They were the only 2 that can test the water daily. The procedure was for the water to run for 3 minutes and hold the digital thermometer under running water. This will be done daily for 4 weeks, testing different rooms daily, and logging results. In-services started yesterday and were on-going until all staff have been in-serviced. Staff will not be able to pick up their paycheck until they were in-serviced to assure all staff are in-serviced. Record review of Water Temperature Log for 12/22/23 revealed all temperatures on the 100 hall within 100 degrees F to 104.6 degrees F. Record review of In-services started on 12/21/23 revealed: -Hot Water Heater Adjustments and Water Temps are on-going. -Safe Water Temps and Testing by the Administrator and Maintenance Director completed on 12/21/23. Record review of Skin Sweep for Hallway 100 dated 12/21/23 did not reveal any concerns relating to burns from hot water. Record review of AdHoc QAPI meeting completed on 12/21/23 with all required members in attendance. The meeting addressed the facility's POR needs. In interviews on 12/22/23 at 6:00 pm of sample staff from both shifts were completed with 2 RNs, 6 LVNs, 4 CNAs, 1 CMA, Housekeeping Supervisor, Human Resource Director, Medical Records, Dietary Manager and Social Worker. They all stated they had been in-serviced. They all said if the water was too hot, they would notify immediately either the Maintenance Director, Administrator, or the DON. They would also document it in the Maintenance Log that was at the nurse's station. They would protect the residents from being burned by hot water. After the POR and Monitoring, Administrator was informed the Immediate Jeopardy was removed on 12/22/23 at 7:38PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a severity level of a pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure residents had the right to be free from abuse for 2 of 4 residents (Resident #1, Resident #2) reviewed for abuse. 1) The facility failed to ensure a safe environment free from abuse for Resident #1. On 07/22/23 at 11:15p.m, CNA A was observed by LVN B cleaning Resident #1's bleeding ear lobe and denied not knowing what happened. Resident #1 was transferred to the hospital and found to have multiple injuries including left ear laceration, left shoulder abrasion, hematoma on the right and left abdomen, hematoma on the left leg, skin tear on the left forearm and bruise on the foreskin of his penis. According to LVNB she saw Resident #1 less than24 hours back and he did not have these fresh new injuries. 2) The Facility failed to ensure a safe environment free from abuse for Resident #2. CNA A was observed on 07/19/23 at 7:06 to 7:18p.m on the video camera physically abusive and aggressive with Resident #2 while trying to provide incontinent care. An IJ was identified on 07/27/23 at 4:05p.m. The IJ template was provided to the facility on [DATE] at 4:05 p.m. While the IJ was removed on 07/28/23 at 4:25p.m, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on effectiveness of the Plan of Removal These failures place residents at risk of physical harm, emotional distress, mental anguish, and death from possible abuse. Findings included: Review of Resident #1's face sheet dated 07/24/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included vascular dementia (impaired blood flow to brain) acute and respiratory failure, chronic obstructive pulmonary disease (breathlessness and cough), personal history of covid-19, bipolar disorder (mental disorder), benign prostatic hyperplasia (enlarged prostate), insomnia (sleep disorder), schizophrenia (mental disorder), osteoarthritis (degenerative joint disease), dysarthria and anarthria (impaired speech) and major depressive disorder (loss of interest). Review of the significant change MDS assessment dated [DATE] for Resident #1 revealed he had a brief interview for mental status score of 1 indicating cognitive severe impairment. Resident has minimum difficulty hearing with unclear speech. He usually understood but with impaired vision. Resident #1 has physical behaviors directed towards others e.g., hitting, kicking, pushing, scratching, and grabbing. Resident #1 had contributing active diagnoses of dementia and schizophrenia. The MDS reflected for skin condition: Resident #1 had only 1 documented pressure ulcers (stage2) or wound on admission. Furthermore, the MDS indicated Resident #1 required extensive assistance with most ADLs and transfer. He was frequently incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 06/28/22 reflected Resident #1 has a behavior problem as evidenced by resisting (activity of daily living) ADL assistance. He hits and curses at staff during ADLs. Goal: The resident will have fewer episodes of resisting ADL assistance and will cooperate with staff. Interventions includes: 1) Explain all procedures to resident before starting and allow the resident (10 minutes) to adjust to changes 2) Minimize potential for the resident's disruptive behaviors by offering task which divert attention 3) Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes 4) If reasonably, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Review of the Braden Scale (predictor of pressure sore risk) dated 06/02/23 revealed Resident #1 had a score of 14 which indicated moderate risk for pressure ulcers. Review of the nurse's notes dated 07/23/23 (the day Resident#1 went to hospital), documented by LVN A reflected, Resident observed to be sitting on left side in upright position, both feet on the floor, alert and oriented to person. Resident presents in brief. Moderately sized lacerations to lower left earlobe, estimated 4cm in length, bleeding, small scratch anterior to lower, left earlobe: two small lacerations present to left anterior shoulder; moderately sized skin tear to left forearm, and a large bruise/swelling assessed to resident's lower extremity. Vitals assessed as follows: T97.6, BP 165/80, 02 97%, P 60 and R 24. As per protocol ADON/DON, Administrator, Resident's family member hospice provider notified of incident. (CNAA) asked to complete a witness statement for incident report. Once witness statement completed, floor CNA was asked to go home for remainder of shift. Review of the hospital admission for Resident #1 dated 07/23/23 reflected, Pt came in via EMS w/c/o laceration on left ear, chin, left shoulder and skin tear to left arm. Altered mental status: Given is confused and not able to provide any information, this information is obtained from emergency department provider as well as from medical records. Patient is a resident at local nursing home and he was found confused and with multiple injuries. Given his status patient is sent to the emergency department for further evaluation. Patient is noted to have multiple superficial bruises over the left ER left forearm, left shoulder and left lower extremity and imaging study showed multiple rib fractures as well as lumbar spine fracture. Patient is also noted to be significantly acidotic (acid condition); he was started on BIPAP and initiated treatment with nebulization and received dose of steroid. After this he is being admitted for further management Further review of the Resident #1's hospital medical records dated 07/23/23 reflected, Pt. was brought to ED via EMS with c/o AMS and potential physical abuse. Is non-verbal. Responsive to pain w/laceration on left ear, skin tear on the left forearm, bruises and lacerations on the left shoulder, bruises and abrasion on the left leg, bruise on the foreskin of the penis and hematoma (localized bleeding) on the right and left upper abdominal area. Observation of Resident #1 on 07/24/23 at 2:52p.m in the hospital revealed Resident #1 was lying with IV tubes connected to him. Resident #1 could speak but was unable to articulate clear thoughts. His nurse RNT did a head-to-toe assessment as this surveyor observed. Resident #1's injuries include a bruised penis, left shoulder lacerations, left ear lobe lacerations, a hematoma to left leg and left abdomen, and multiple rib fractures (per RN T). Resident #1 appeared tired and confused. In an interview with RNT on 07/24/23 at 3:06p.m., he said he is the charge nurse taking care of Resident #1 in the hospital. RNT explained Resident #1 was brought to the Emergency department for treatment of suspected physical abuse in the nursing home where he was residing. Resident #1 sustained multiple lacerations and abrasions consistent with physical abuse. He said paramedics informed them the nursing home refused to give details of what happened to the Resident#1. During interview with LVNA on 07/25/23 at 10:54a.m, she said she was the nurse that transferred Resident #1 to the hospital for evaluation and treatment. She stated on 07/23/23 about 11:00p.m, Resident #1 was found with fresh new bruises, lacerations, and abrasion after changing shift with LVNB. The wounds included left ear lacerations, left shoulder abrasions/lacerations, lacerations on the right and left abdomen, lacerations on the leg, skin tear on the left forearm, and extensive bruising on the foreskin of his penis. LVNA explained the wounds were new on the resident having taking care of him on Friday 07/22/23 a day before the incident. She also said LVNB informed her she saw CNA A cleaning the bleeding earlobe of Resident #1. LVNB asked CNAA what happened and CNAA responded I didn't know. LVNB said she notified the physician and received orders to send resident to the hospital to rule out internal injuries. LVNA explained LVNB on 07/18/23 informed her that she was afraid because CNAA threatened to kidnap, rape, put her in the trunk and throw her in the river. She was shocked and immediately went to HR E. LVNA and HR E walked to the ADM's office and informed him of threat from CNAA. LVNA said she did not hear from ADM or aware of any investigation. The ADM didn't talk to her about the issues and CNAA was still reporting to work as if nothing happened. There was no investigation, suspension, or disciplinary actions. LVNA noted she was very concerned when LVNB informed her CNAA pulled a knife on her in the breakroom few days after the rape threat. She noted LVNB was visibly terrified and said she did understand why ADM had not acted on her complaint regarding CNAA. During interview with LVNB on 07/25/23 at 1:47p.m, she said she was familiar and responsible for Resident #1 and Resident #2 during the night shift. On 07/23/23 at about 11:00p.m she walked into Resident#1's room and observed CNA A wiping blood from laceration on Resident #1's earlobe. She asked what happened and CNAA said I don't know. LVNB assessed Resident #1 and found multiple injuries that was no present a day before. She explained Resident #1 looked like he was on a WWF fight. LVNB immediately notified ADON C, ADON D and DON via text which stated, Hey I need to know what to do for (Resident #1) he's dinged up like he's been in a fight. Do I call ADM or EMS?. She said ADON C called her back and instructed to transfer Resident #1 to the hospital for further evaluation and treatment. During an Interview with ADONC on 07/27/23 at 10:58a.m, she said she was one of the ADONs in the facility. On 07/23/23 at 1:31a.m, LVNB texted her informing Resident #1 was found with multiple injuries including bruises, laceration and abrasions which were fresh and new. LVNB mentioned she saw CNAA cleaning Resident #1's bleeding earlobe in his room. She asked CNAA what happened to the Resident #1?. CNAA repeatedly said he did not know. ADONC told LVNB to transfer Resident #1 to the hospital for further evaluation and treatment. ADONC explained she immediately called ADM on 07/23/23 at 1:39 p.m. and informed him of the reported incident. ADM informed her to call hospice nurse and not call EMS. She stated she had already informed LVNB to transfer Resident #1 to the hospital for evaluation and treatment because of the seriousness of the injury after LVNB texted to her. In an interview with Hos Q on 07/26/23 at 8:27a.m, she said she was the Hospice nurse from the agency. On 07/23/23 at about 2:00a.m, she was called by the facility to come and assess Resident #1 because he was found with multiple injuries. She arrived and saw residents with numerous wounds including laceration and abrasions to left leg, left arm, left ear, bruise to foreskin of his penis and swollen left shin. She said Resident #1 appears to be in pain and was given Tramadol because he was grimacing. Hos Q noted the injuries was new and fresh but the resident could not say how he got the injuries. After assessing Resident #1 she called the doctor and received an order for x-ray to see the extent of his injuries. She treated the wounds and left the facility. 2. Review of Resident #2's face sheet dated 07/25/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses included senile degeneration of the brain, dementia (impaired blood flow to brain), Aphasia (Communication disorder), dysphagia (language disorder), contractures (chronic loss of joint motion), heart failure, seizures), osteoarthritis (degenerative joint disease), and pulmonary embolism (blood clot in the lungs).and depressive disorder (loss of interest). Review of the MDS assessment dated [DATE] for Resident #2 revealed an incomplete brief interview for mental status. Resident has minimum difficulty hearing with unclear speech. He rarely/never understands but with adequate vision. Resident #2 has no documented behavioral issues. Review of nurse's notes dated 07/23/23 reflected, After 10: 00a.m RP resident's family member notified this nurse of watching a man (CNA A) being rough with Resident #2, this nurse told SS and (ADM) notified. Awaiting further instructions at this time Review of hospital admission for Resident #2 dated 07/23/23 reflected, Pt arrived to ED via EMS from facility and was sent by primary care dr. for concerns of internal injuries and to be evaluated for such. Per charge nurse RN, pt. is second individual to arrive today for injuries from the same facility. APS case has been filled for other individual and instructed to file for Pt as well. Pt is at baseline GCS of 14 per EMS. Pt. denies any complaints at this time, pt. is assessed for bruising/injuries, no apparent injuries upon visual assessment. Review of the facility schedule date 07/23/23 revealed CNA A was the only aide assigned to Hall 100 where Resident #1 and Resident #2 were located. Review of three separate video recording of Resident #2 reflected the following: INCIDENT 1 Recording occurred on 07/19/23 from 7:06p.m-7:18pm. The video revealed shows CNA A being physically abusive towards Resident #2, pulling Resident #2 by the arms to flip him over and pulling him by the wrist to not allow Resident#2 to brace himself holding on to the side rails of the bed. Resident #2 tried to fight back but CNAA was relentless in his rough actions towards Resident #2. CNAA grabbed Resident #2 by wrist and pinned him to continue to change him. CNAA aggressively pulled Resident #2's shirt off. INCIDENT 2 Recording occurred on 07/21/23 from 11:44p.m to 11: 48p.m The video revealed CNA A being physically abusive towards Resident #2, pulling him forcefully by the knees to flip the resident unto side and remove his brief. CNAA aggressively pulled the resident by the wrist and pinned wrist and arm under the rail of the bed to continue to change the resident. CNA A removed Resident #2 brief but did not clean resident before putting on new brief. INCIDENT 3 Recording occurred on 07/22/23 from 7:56p.m to 8:05p.m. The video revealed CNA A being physically abusive towards Resident#2, pulling the resident by his knees forcefully flipping him over, grabbing the resident by the wrist to pin him down and flipping him back by forcefully ripping sheets out from under Resident # 2. Approximately at 7:59p.m LVNB entered the room. LVN B stated to CNAA You are being too rough with him in which CNAA replied, I will show you rough. Review of Police report #20230009126 dated 07/23/223 reflected the following: OFFENSE SUMMARY: **************** Injury to Child, Elderly, or Disabled, Serious Bodily Injury CNA A while employed as a CNA at facility Nursing and Rehab and assigned to care for Resident #1, CNA A, intentionally, knowingly, or recklessly caused Resident #1 to have multiple abrasions, severe bruising around the groin, broken ribs on his left side and slipped disc in his spine. Injury to Child, Elderly, or Disabled, Bodily injury CNA A while employed as a CNA at facility Nursing and Rehab and assigned to care for Resident #2, intentionally, knowingly, or recklessly caused Resident #2 to be evaluated for internal injuries from the forceful nature that CNA A treated him with on video. In an attempted interview with CNA A on 07/25/23 at 4:49p.m, he confirmed he was working on hall 100 on 07/23/23 (day of incident). CNA A said he took care of Residents #1 and #2 in the nursing. He was asked if he had a chance to talk to ADM, he said he had not. CNA A ended the call. Several attempts by surveyor to call CNAA back was met with voice message saying the phone was out of services. During interview with Administrator (ADM) on 07/26/23 at 9:54a.m, he confirmed the following: 1) Received video recording from RP showing CNAA physically harming Resident #2 2) LVNB and LVNA notified him of rape threat by CNAA 3) ADON C, LVNA, LVNB notified him of physical abuse of Resident #1 and Resident #2 by CNAA 4) Aware Resident #1 sustain multiple injuries. 5) Did not talk to CNA A about the rape issue or the incidents of physical abuse of Resident #1 and Resident #2 6) Denied not reporting on time. Surveyor tried without success to get some questions answered or timeline on the information during the investigation from ADM. He was reluctant, unwilling, and refused to answer specific question. Review of the facility's undated policy/procedure on abuse/neglect ` reflected: Intent: The facility will develop and operationalized policies and procedure for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property: to include the use f physical or chemical restraint. The purpose is to assure that facility is doing all is within its control to prevent occurrences. Procedure: Prevention: 1) Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution: and provide feedback regarding the concerns that have been expressed. 2) Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. This was determined to be an Immediate Jeopardy (IJ) on 7/27/23 at 4:05 pm. The Administrator and DON were notified. The San [NAME] Nursing and Rehab was provided with the IJ template on 7/27/23 at 4:05 PM. The following Plan of Removal was accepted on 7/28/23 at 4:25 PM and included: Please accept the following Plan of Removal of Immediate Jeopardy-Failure to ensure residents are free from abuse/neglect/exploitation. The facility failed to ensure the residents are free from abuse and neglect. 1. The facility's policies and procedures on abuse and neglect is the following: Ensure the resident is safe and report the event to the abuse coordinator immediately. The Abuse coordinator will conduct a brief investigation and report abuse or neglect to HHSC within two hours. 2. On 7/23/23 at 2:22 AM the employee in question was suspended immediately pending investigation and terminated on 7/23/23 at 8:03 PM after discovering evidence of him committing abuse to a resident. 3. All current staff were in-serviced on abuse and neglect and reporting abuse or neglect policy and procedures on 7/23/23. For those on vacation and cannot be reached, they will not return to work without receiving this in-service. 4. LVN B completed abuse and neglect in-service on 7/23/23. DON will provide 1:1 In-service, written disciplinary actions, and LVN proficiency checkoff prior to LVN B working the floor again. 5. Administrator and Designee received 1:1 in-service from Owner/Operator to cover reporting timeframes. 6. The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect are completed by all staff members. Completion will be reviewed at monthly QAPI meetings. 7. DON/Designee will re-educate the charge nurses on their ability to suspend any employee who is suspected of committing abuse or neglect to a resident or employee will be suspended immediately and escorted out of the building and off the premises pending investigation. This will be completed on 7/28/23. 8. DON/Designee reviewed hall assignments to verify where the CNA and LVN were assigned to and conducted a head-to-toe assessment on all residents they cared for on 7/22/23 and 7/23/23. 9. Complete a resident safe survey on all current residents to ensure they feel safe and free from abuse or neglect by 7/28/23. 10. On 7/27/23, safe surveys were conducted on hall 100 and halls 200,300,400 were completed on 7/28/23. Starting 7/31/23, DON/SW will conduct 10 random safe surveys a week for 3 weeks for the residents to ensure that they continue to feel safe and well taken care of. Findings will be discussed at weekly Committee Meetings and at monthly QAPI Meetings. 11. The residents 1 and 2 who suffered the alleged abuse care plan was not updated or changed due to them discharging and the family placing them in another facility. 12. All possibly affected residents have had care plans updated to reflect potential risk for alteration in mood state and psychosocial well-being related to the alleged incident of abuse in their environment. 13. Prior reportable incidents were reported within the guidelines set forth by HHSC and the Administrator monitored the completion of the investigation. 14. Any staff member suspected of committing abuse/neglect will be suspended immediately and or terminated depending on the outcome of the investigation. 15. Staff who fail to report suspected abuse will be educated on the significance of reporting time and disciplined accordingly. 16. The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect are completed by all staff members. 17. The Administrator/Designee will monitor all reportable incidents and all reportable incidents will be reported to the Corporate Compliance Officer immediately. All reportable will be discussed weekly at our Committee Meeting. 18. Starting 7/28/23 DON/Designee will conduct 10 random quizzes week for 3 weeks for staff to ensure they are retaining the education on abuse and neglect and reporting procedures. Results will be reviewed during the monthly QAPI meetings, and any incorrect answers will be corrected immediately on the spot. Progress will also be monitored during weekly Committee Meetings. 19. The Medical Director is both resident's physician and he is the one who gave the orders to send them to the emergency room for evaluations. 20. On 7/27/23, Administrator conducted an ad-hoc QAPI meeting to discuss the IJ and assign responsibilities. 21. All adverse findings will be discussed at the QAPI meeting and necessary changes will be made at this time. 22. Residents not on 100 hall who may have been provided care by CNA or LVN were given the safe surveys and will be included in the random safe surveys. 23. All residents on 100 halls will be monitored for 72hrs post discovery of the incidents to ensure there is no retaliation or emotional distress. DON will monitor this compliance. 24. Medical Director was alerted of the IJ on 7/27/23 and Administrator personally spoke with him on 7/28/23 to provide more detail. During an interview on 7/28/23 at 3:25 PM Resident #6 stated that an employee came in this morning around 9:15 and did ask her questions about abuse/neglect, if employees are nice to her, etc. She stated she had good things to say for all questions, and it felt nice to have those questions asked to her because they should be asked by staff occasionally. During an interview on 7/28/23 at 3:35 PM Resident #7 stated that a nurse, can't remember who did come in this morning and speak with her and ask her questions on abuse/neglect. She stated it was nice to have that asked to her because that really showed her that they care and want to change things. During an interview on 7/28/23 at 3:45 PM Resident #8 stated that a nurse came in this morning and did ask him about abuse neglect, he has never had any issues here before. He stated it was nice to hear the facility ask these questions. He stated he likes the facility very much and has no issues with any employee or resident. During an interview on 7/28/23 at 3:55 PM Resident #9 stated she did have a nurse come through this morning to check in on her. She stated the nurse asked questions such as has any employee been rude, disrespectful, neglectful etc to you. She stated she said no. She stated she has never really had an issue with any nurse or another resident. She stated that the facility overall seems very good to her. Record review of QAPI meeting notes/in-service regarding IJ conducted on 7/27/23 at 9:30 AM confirmed by AD. She stated that they did have a sit-down meeting to discuss all the IJ templates and a plan of actions, this included abuse neglect in-services, safe surveys, quizzes, monitoring residents, and background checks. Record review of CNAA Corrective action form dated 7/23/23 employee was terminated due to abuse, signed by administrator, and dated as verbal over the phone on 7/23/23 at 8:00 pm. Record review of in-service dated 7/23/23 for all nursing staff, topic abuse and neglect, signed by all staff and stated that no staff could work until complete. Conducted by DON. In-service covered abuse and neglect. Contents of training were: The abuse preventions coordinator is the administrator and I the administrator cannot be reached; the backup contract is the DON. Their names and phone numbers are posted on the board on 200 hall. If you see or suspect abuse or neglect happing, the first response is to stop it and protect the resident. You must then immediately report to the abuse preventionist. The types of abuse include physical, verbal, emotional, sexual, involuntary seclusion, misappropriation of funds, and neglect or abandonment. Please respond to residents needs in an appropriate time manner. Be respectful and talk to residents politely. Remember customer service is a priority. Record review of in-service dated 7/27/23 for all nursing staff, topic abuse and neglect, signed by all staff and stated that no staff could work until complete. Conducted by Administrator and DON. Contents included the fact that abuse or neglect must be reported to the abuse coordinator immediately. They should not wait for someone else to report it. It is their responsibility to protect the residents of this facility. If they are unsure about weather, it was a case of abuse or neglect-report it anyways! Protect your residents! It is your job as the abuse coordinator to start the investigation ASAP-and report to state within 2 hours. Make sure staff is aware that they must contact you directly and immediately. Make sure your number is posted with postings, in the breakroom, at the nurse's station, in therapy, in the kitchen-everywhere. If at any time they cannot reach you, they should be instructed to call the DON. Make yourself heard. During an interview on 7/28/23 at 4:15 PM DON stated multiple Care quizzes have been given to multiple employees who attended both in-services. She stated that she has been reviewing the quizzes and all employees have no missed one question. She stated the Medical Director was contacted on 7/27/23 regarding the incidents that occurred and the IJ being called in the facility. She stated that LVNB completed abuse and neglect in-service on 7/23/23. DON will provide 1:1 In-service, written disciplinary actions, and LVNB proficiency checkoff prior to LVNB working the floor again. DON stated in-service has been completed at 7/23/23 and a write up documentation. LVNB came in 7/27/23 to go over proficiencies. She stated that on 7/27/23 she and the administrator received 1:1 in-service from [NAME], Owner/Operator to cover reporting timeframes. Record review of a completed resident safety survey dated 7/28/23 on all current residents to ensure they feel safe and free from abuse or neglect by 7/28/23. safe surveys were conducted on hall 100 and halls 200, 300, 400 were completed on 7/28/23. Starting 7/31/23, DON/SW will conduct 10 random safe surveys a week for 3 weeks for the residents to ensure that they continue to feel safe and well taken care of. Findings will be discussed at weekly Committee Meetings and at monthly QAPI Meetings. Document included questions such as, have you ever had or felt neglect/abused by any employee or other resident. Record review of Care Quiz revealed all staff that had attended both in-services on 7/28/23 were provided a Care Quiz to complete. Care quiz completed by LVNJ; all answers answered correctly. No issues. Care quiz was created with questions that were from both in-services. Observation three sampled residents (Resident #3, #4 and #5) revealed no signs of pain or abuse. They appear to be carrying their activities of daily living with incident. They said they felt safe and denied abuse staff or other residents. Interviews regarding abuse and neglect training and reporting on 07/28/23 at 3:25p.m through 5: 00p.m revealed no concerns with staff knowledge. Staffs interviewed were representative of various facility shifts. They were able to provide knowledge and participation of training regarding abuse/neglect in-services and training. The following staffs were interviewed on 07/28/23: LVN A, LVNB, ADON C, ADON D, HRE, CNA F, CNA G, CNA H, LVN I, LVN J, LVNK, CNA L, CNA M, Social Worker, and CNA N. They were knowledgeable of types of abuse/neglect and should report any abuse allegations to charge nurse of resident immediately and to the ADM. They all knew Administrator was the Abuse prevention coordinator with DON as the backup if not able to reach ADM. They knew how to get hold of ADM and DON if not in the facility at time. Interview with LVNB (100 hall) on 07/28/23 at 4:30 PM revealed she was in-serviced on 07/25/23 and 07/28/23 on abuse/neglect and reporting. She was asked what she would have done differently looking back at the incident with Resident #1 and Resident#2, and she stated she would follow protocol and nursing judgement and reported the incident immediately. She stated she was terrified on what CNAA could have done to her for reporting her observation. On 07/28/23 at 4:25p.m, the Administrator was notified the IJ was removed. While the IJ was removed on 7/28/23, the facility remained out of compliance at a severity level of actual harm with the potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, for 2 of 4 residents (Resident #1 and #2) reviewed for neglect. 1) LVN B failed to report physical abuse of Resident #1 after witnessing CNA A 's rough actions with the resident during incontinent. Resident #1 was transferred to the hospital with diagnosis of left ear lacerations, left shoulder abrasion and laceration, a hematoma (localized bleeding) on the right and left abdomen, hematoma (localized bleeding) on the left leg, skin tear on the left forearm and a bruise on the foreskin of his penis. 2) The ADM failed to report serious and multiple injuries on Resident #1 to Police or State Agency. ADON C notified the ADM on 07/23/23 at 1:39a.m. The ADM did not report the incident until 11:28p.m which was more than 9 hours later. 3) The ADM failed to report to the Police, State agency physical abuse of Resident #2 after he was made aware of the incident. LVN A notified the ADM on 07/23/23 at 1:00a.m. The ADM did not report the incident until 12:03 more than 10 hours later. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 07/27/23 at 4:05p.m. While the IJ was removed on 07/28/23 at 4:25p.m, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. These failures could place all the residents, who resided in the facility, at risk for abuse and mental anguish. Findings included: Review of Resident #1's face sheet dated 07/24/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses included vascular dementia (impaired blood flow to brain) acute and respiratory failure, chronic obstructive pulmonary disease (breathlessness and cough), personal history of covid-19, bipolar disorder (mental disorder), benign prostatic hyperplasia (enlarged prostate), and insomnia (sleep disorder), schizophrenia (mental disorder), osteoarthritis (degenerative joint disease), dysarthria and anarthria (impaired speech) and major depressive disorder (loss of interest). Review of the MDS assessment dated [DATE] for Resident #1 revealed he has a brief interview for mental status (BIMS) score of 1 indicating cognitive severe impairment. Resident has minimum difficulty hearing with unclear speech. He usually understands but with impaired vision. Resident #1 required extensive assistance with most ADLs and transfer. He was frequently incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 06/28/22 reflected Resident #1 has a communication problem related vascular dementia and schizophrenia. His speech is unclear and very soft spoken. The goal will be able to make basic needs known on daily basis through review. Interventions includes the following: 1) Allow adequate time to respond. Repeat as necessary. Do not rush. Request clarification from resident to ensure understanding. Face when speaking. Make eye contact. Turn off TV/radio to reduce environmental noise. Ask yes/no questions if appropriate. Use simple, brief, consistent words/cues. Use alternative communication tools as needed. 2) Monitor/document for physical/nonverbal indicators of discomfort and distress and follow up as needed. 3) Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on words or phrase that make sense or responds to the feeling resident is trying to express. Record review of the hospital records for Resident #1 dated 07/23/23 reflected, Pt. was brought to ED via EMS w/c/o (with complain) AMS (altered mental status) and potential physical abuse. Is non-verbal. Responsive to pain. W/(with) lacerations on left ear, skin tear on the left forearm, bruises and lacerations on the left shoulder, bruises and abrasions on the left leg, bruises on the foreskin of the penis and hematoma on the right and left upper abdominal area Per EMS, staff member(s) from the patient's nursing home refused to provide details regarding the patient's condition. They did state the patient did not fall, and internal injuries had to be ruled out. Of note, two other patients from the same nursing home were also brought to the same ED today, at least one to rule out internal injury as well. Review of nurse's notes dated 07/22/23 documented by LVN A reflected, upon entering the resident's room, the resident presented laying in a supine position with eyes open, alert, and oriented to person. Resident #1 was looking up at floor CNA, CNA A, who was clearing off the resident's ear with a wipe. The resident's ear was noticeable bleeding from moderately sized cut on lower left earlobe. This nurse asked the floor CNA, what happened? CNA A responded, I don't know. During an interview with LVNB on 07/25/23 at 1:47p.m, she said she was working on hall 100 where Resident #1 and Resident #2 were residing. On 07/18/23, she was working with CNA A who threatened her. She explained CNA A told her, he was going to kidnap her, put chloroform on her face, take her to secluded place, rape, dismember her, put her in a car trunk and throw her in the River. LVN B stated she was scared to death because of the tone and his look when he was talking. She immediately informed LVN A who was changing shift with her. LVN B said LVNA was just as scared and notified the ADM immediately. She explained the ADM did not take any action. He did not talk to her or LVNA after the report. The ADM did not investigate, suspend, or terminate CNA A employment. CNA A was still on schedule working with her. A few days after his threat, LVNB said CNAA pulled a knife in the break room on her. She screamed but nobody heard her. She was convinced CNA A was going to hurt or kill her and her 2 kids. She was terrified and looking over her shoulders with sleepiness nights looking to see if CNA A would come to attack knowing he knew where she lives. On 07/23/23 at about 11:00p.m, she walked into Resident #1's room and saw CNA A cleaning the resident's bleeding earlobe. She asked him what happened. CNAA responded I don't know. LVNB stated Resident #1 looked like he was in WWF fight. She said Resident #1's wounds were new and fresh because she took care of him less than 24 hours earlier. She was horrified and terrified of CNA A and did not immediately report the incident. She told LVNA what she saw. LVNB notified the ADON C who instructed her to transfer the resident to the hospital. LVNB explained ADM was notified. The ADM informed them not to send Resident #1 to the hospital but to call Hospice nurse to do an assessment. LVNB said she took the advice of ADON C and transferred Resident #1 to hospital for evaluation and treatment because Resident #1's wound was serious. She noted CNA A was asked to write a statement and sent home. LVNB stated CNA A continued to say he didn't know what happened. She believed CNA A did something to the resident because he was the only aide assigned to that hall. Meanwhile, she went to the police to report the threat on her life by CNA A since ADM was not doing anything. The police wanted to come to the facility that night to watch the videos but the ADM told them wait till the morning because it was too late at night for him. During interview with ADON C on 07/27/23 at 10:58a.m. she said she notified the ADM on 07/23/23 at 1:39 a.m. that Resident #1 was found with serious injury. ADON C explained the ADM wanted her to notify hospice agency and not send Resident #1 to the hospital. She exercised nursing judgement and instructed LVNB to transfer Resident#1 to the hospital because of his serious injury including a bleeding earlobe. She noted the picture of the earlobe was sent to her by LVNB. In another interview with LVNB on 07/27/23 at 10:05a.m she stated on 07/22/23 at 11: 15p.m LVNB entered Resident #1's room. LVN B saw CNA A cleaning Resident #1's bleeding earlobe. LVNB stated when asked multiple times to CNA A what happened. CNA A would only reply, I don't know. LVNB stated CNA A was the only aide assigned to that hall all night and the wounds look fresh. LVNB asked Resident #1 what happened, Resident #1 made a motion with hands, like he got into a fight. LVN B asked Resident #1 who he got in a fight with, he pointed to CNA A In an Interview with HR E on 07/26/23 at 9:30a.m, she said she was the Human Services Director and has been employed in the facility for 8 months. On 07/18/23, she was notified by LVNA that CNA A threaten to rape and throw LVNB in the river. HR E explained she went with LVNA to ADM office to talk to him about the incident. She said she was not aware if ADM talked to LVNB or CNA A. Surveyor asked the facility protocol when an employee threaten another.HR E stated she informed ADM and did not talk to LVNB or CNA A. She went on to say she did not know if ADM investigated or reported the incident. Review of Resident #2's face sheet dated 07/25/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses included senile degeneration of the brain, dementia (impaired blood flow to brain), Aphasia (Communication disorder), dysphagia (language disorder), contractures (chronic loss of joint motion), heart failure, seizures), osteoarthritis (degenerative joint disease), and pulmonary embolism (blood clot in the lungs).and depressive disorder (loss of interest). Review of the MDS assessment dated [DATE] for Resident #2 revealed an incomplete brief interview for mental status (BIMS). Resident has minimum difficulty hearing with unclear speech. He rarely/never understands but with adequate vision. Resident #1 has no documented behavioral issues. In an interview with the RP on 07/25/23 at 11:05a.m, she said she was the family member to Resident #2. She explained she had videos where a staff member was physically abusing her Resident #2. She said she wanted to send me a statement to include I my report to ensure all areas of Resident #2's experienced was covered. Surveyor said it was ok. The following was her statement: My name is RP, (Resident #2) is a resident at (facility) nursing & rehab nursing home. On July 23rd I watched the video from the camera that I have currently in his room at the facility. The camera showed that a CNA A that works there is being rough with Resident #2 assaulting him while he's changing him and changing his sheets being very mean to him also fighting with the nurse that was in there. Her name was (LVN B). She's an RN. She tells him he needs to he's going to get fired. He said they won't get fired. He holds Resident #2 down putting pressure on his arms as well as while he's changing him, he throws him around back-and-forth on the bed. Resident #2 hit his head on the rail of the bed twice Resident #2 is resisting as he's doing this .but he doesn't speak much he is mostly nonverbal. After I see this video, I call the nursing facility and speak to the nurse LVN B and ask her to check Resident #2 out and assess him to make sure that he didn't have any sores. She finds bruises on him on his forearms and his wrists as well as spot on his arm that was bleeding, they sent him to the ER to be fully checked out once he gets to the hospital, they call me and say that they can keep him until we find another place for him to go. I do not want him going back to facility Nursing in Rehab because this is the second time that he's been assaulted by a CNA in the three years that he's been there. The nurse tells me the ADM phone number and I give him a call. His name is ADM. He answers the phone and he's mad that I have his personal number and rude to me on the phone and downplayed the situation as if it wasn't that big of a deal said that he already complained to the state And tells me I guess you can call the cops if you want. I called the police they come to my house and they watched the video and then another cop comes and then they watch the video and other cop comes so they seem to think it was serious what the guy was doing to my Resident #2. They have an open investigation against this guy and I learned that another family had the exact experience as well with their family member at the nursing home. I'm not sure of their names but there's another family that had their family member go to the hospital too. Last night I began looking at the tape from the last couple weeks at the nursing home of the nights that this guy CNA A worked, and there's more videos.he has done us to Resident #2 several times several different occasions several different nights. In another video that I found he wedges Resident #2 's whole arm in between the mattress and the rail of the bed and puts his knee on it so that Resident #2 can't get it out and proceeds to keep changing Resident #2 pamper. Resident #2 is fighting him and resisting at the same time, he also is antagonizing him verbally as he's doing all this ripping the sheets off at one point, he puts the sheets over Resident #2 's face. Resident #2 seems so scared and confused in the video. You can see Resident #2 's hand shaking he's so scared. I have turned in the rest of the videos into the police and hopefully they complete their investigation soon. I had emailed the local Ombudsman here in San [NAME] and he just called me this morning and told me to write this all out in an email and send it to y'all. This nursing home needs to be investigated. I wonder what type of screening they do before they hire people especially CNA 's. This is the second time that this is happened in three years that my Resident #2 has been there, and it is uncalled for and inappropriate on all levels. The videos might be too long for me to email to you as an attachment but I will send a few screenshots of some of the videos. Please feel free to contact me if you have any questions Resident 32 is currently at the hospital staying there until I figure out what nursing home, I'm going to have to switch him to, this is very unfortunate that I have to move him because of what another person caused. He has dementia & is disabled and it's very hard for him to adjust when you move him. The guy ADM is a fill in ADM from when old ADM quit .he doesn't do a whole lot. There are multiple videos I submitted to the police for evidence this is just a few. Record review of the Police report #2023009117 dated 07/23/23 by OFFZ reflected, I, Officer [NAME], D65 was dispatched to hospital for an assault. Upon arriving, I located the charge nurse, RN R, who had called dispatch. RN R stated that she had received three patients from (facility) Nursing and Rehab today. Two patients Resident #1 and Resident #2 who had come in with minimal information as to cause of injuries being told to Paramedics to relay to the ER for further medical care. RN R stated that Resident #! had a broken back and broken ribs discovered from x-rays in addition to other injuries. RN R stated that Resident #1 was admitted due to the extent of injuries. RN R did not have much information about Resident #2 other than the (Facility} Nursing and Rehab had sent him to get checked out for internal injuries due to Resident #2 having a feed tube in his side. I was also provided information for Resident #3 that RN R believed to be related to the incidents with Resident #1 and Resident #2. I gathered RN R's information and the which medics transported Resident #1, Resident #2 and Resident #3. I then called Sgt. PO S with what I had gathered so far to get advise on how to proceed. I then went to Station 2 to speak with Medic 2 Crew. Medic 2 paramedics stated that staff mentioned incidents but did not go into detail. The Paramedics stated that they did not believe that Resident #3 was involved in the incidents. As she had been to the ER the prior night for a broken arm and was not discharged till later in the morning from what they had told as she had overdosed on her medication. I then went to Station 7 to speak with Medic 7 crew who transported both Resident #1 and Resident #2 nursing facility to the hospital. When I arrived and talked with the paramedics one stated that while he was trying to gather information on how the injuries had occurred for Resident #1 that staff did not want to say due to legal reasons telling him to label it as internal injuries. The paramedic then stated that for Resident #1 when they arrived the staff was not open to discussing how Resident #1 was injured as they would typically tell the paramedics if the residents had been combative or had fought another resident but that this was the case this time. After speaking with the crew of Medic 7 I called PO S again to inform him of what the paramedics had told me before heading to facility Nursing and Rehab at the address. After arriving, I spoke with staff who gave me the phone numbers for the DON Staff also stated that Resident #3 was not related to the incidents as she was in a separate hall. I then went out to my vehicle to call (DON) as she was not present the facility. DON stated that she was aware of two incidents that had occurred in the early hours of 07/24/2023 but did not have a lot of the details as she had been notified by the ADM. I gathered her information while she informed me that one of the family members had video of one incident that occurred. DON directed me to talk ADM as he had was going to investigate the incidents. I then went back inside the nursing facility and got the phone number for ADM before returning to my vehicle to call ADM. ADM stated that he had been notified by staff somewhere between 0200 to 0245 in which a CNA A was placed on suspension pending termination from employment. I gathered the information that ADM had on file for CNA A. I then asked ADM what their policy or procedure was for incidents like this and why did they not call the Police or other agency in regard to the incidents to this point. ADM stated that it was up to staff to contact authorities. I finished speaking with ADM when a priority called drop close by in which I cleared from the call to return to service . I then went inside were Officer PO U was talking to LVNB about threats that CNA A had made to her, Case 20230009126. i then went back outside and began to type my report watching in case CNA A decided to return to the facility as LVN B was afraid of retaliation from CNA A. Once Det. PO V arrived, I assisted him by telling him details that I had been told before he began to interview staff that was present in the facility at the time of the incidents. A staff member showed us Resident #1's and Resident #2's rooms which I took photos of starting from the hall working my way inside to where their beds are located. I then attempted to located Resident #1 dirty linens from that night but they had already been washed and did not have any visible stains remaining on his shirt or sheets. I then attempted to locate disposable wipes that LVN B had seen CNA A use to clean up blood from Resident #1 in the dumpster but was unsuccessful. I then waited near Det. PO V and Det. PO X till they had interviewed all the staff present. I then cleared from the call and returned to service. I later uploaded photos taken to [NAME] Database at a later time. In an attempted interview with CNA A on 07/25/23 at 4:49p.m, he confirmed he was working on hall 100. CNA A said he took care of Residents #1 and #2 on hall 100. He was asked if he had a chance to talk to ADM, he said he had not. CNA A hanged up the phone. Several attempts to reconnect with CNA A came with voice message that the phone was out of service. During interview with Administrator (ADM) on 07/26/23 at 9:54a.m, he confirmed the following: 1) Received video recording from RP showing CNA A physically harming Resident #2 2) LVNB and LVNA notified him of rape threat by CNA A 3) ADON C, LVNA, LVNB notified him of physical abuse of Resident #1 and Resident #2 by CNA A 4) Aware Resident #1 sustain multiple injuries. 5) Did not talk to CNA A about the rape issue or the incidents of physical abuse of Resident #1 and Resident #2 6) Denied not reporting on time. Surveyor tried without success to get some questions answered or timeline on the information during the investigation from ADM. He was reluctant, unwilling, and refused to answer specific question. Review of intake investigation worksheet dated 07/23/23 referencing Resident #1 incident was received and created at 11:28a.m about 9 hours after the Incident was reported to ADM. Review of the facility's policy/procedure on abuse/neglect undated reflected: Intent: The facility will develop and operationalized policies and procedure for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property: to include the use f physical or chemical restraint. The purpose is to assure that facility is doing all is within its control to prevent occurrences. Procedure: Reporting/Response: 1) Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the result of the investigation 2) Report to State nurse aide registry or licensing authorities any knowledge I has of any actions by a court of law which would indicate an employee is unfit foe service . This was determined to be an Immediate Jeopardy (IJ) on 7/27/23 at 4:05 pm. The Administrator and DON were notified and were provided with the IJ template on 7/27/23 at 4:05 PM. The following Plan of Removal was accepted on 7/28/23 at 4:25 PM and included: Please accept the following Plan of Removal of Immediate Jeopardy-Failure to ensure residents are free from abuse/neglect/exploitation. The facility failed to ensure the residents are free from abuse and neglect. 1. The facility's policies and procedures on abuse and neglect is the following: Ensure the resident is safe and report the event to the abuse coordinator immediately. The Abuse coordinator will conduct a brief investigation and report abuse or neglect to HHSC within two hours. 2. On 7/23/23 at 0222 the employee in question was suspended immediately pending investigation and terminated on 7/23/23 at 8:03 after discovering evidence of him committing abuse to a resident. 3. All current staff were in-serviced on abuse and neglect and reporting abuse or neglect policy and procedures on 7/23/23. For those on vacation and cannot be reached, they will not return to work without receiving this in-service. 4. LVN B completed abuse and neglect in-service on 7-23-23. DON will provide 1:1 In-service, written disciplinary actions, and LVN proficiency checkoff prior to LVN B working the floor again. 5. Administrator and Designee received 1:1 in-service from [name], Owner/Operator to cover reporting timeframes. 6. The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect are completed by all staff members. Completion will be reviewed at monthly QAPI meetings. 7. DON/Designee will re-educate the charge nurses on their ability to suspend any employee who is suspected of committing abuse or neglect to a resident or employee will be suspended immediately and escorted out of the building and off the premises pending investigation. This will be completed on 7/28/23. 8. DON/Designee reviewed hall assignments to verify where the CNA and LVN were assigned to and conducted a head-to-toe assessment on all residents they cared for on 7/22/23 and 7/23/23. 9. Complete a resident safe survey on all current residents to ensure they feel safe and free from abuse or neglect by 7/28/23. 10. On 7/27/23, safe surveys were conducted on hall 100 and halls 200,300,400 were completed on 7/28/23. Starting 7/31/23, DON/SW will conduct 10 random safe surveys a week for 3 weeks for the residents to ensure that they continue to feel safe and well taken care of. Findings will be discussed at weekly Committee Meetings and at monthly QAPI Meetings. 11. The residents 1 and 2 who suffered the alleged abuse care plan was not updated or changed due to them discharging and the family placing them in another facility. 12. All possibly affected residents have had care plans updated to reflect potential risk for alteration in mood state and psychosocial well-being related to the alleged incident of abuse in their environment. 13. Prior reportable incidents were reported within the guidelines set forth by HHSC and the Administrator monitored the completion of the investigation. 14. Any staff member suspected of committing abuse/neglect will be suspended immediately and or terminated depending on the outcome of the investigation. 15. Staff who fail to report suspected abuse will be educated on the significance of reporting time and disciplined accordingly. 16. The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect are completed by all staff members. 17. The Administrator/Designee will monitor all reportable incidents and all reportable incidents will be reported to the Corporate Compliance Officer immediately. All reportable will be discussed weekly at our Committee Meeting. 18. Starting 7/28/23 DON/Designee will conduct 10 random quizzes week for 3 weeks for staff to ensure they are retaining the education on abuse and neglect and reporting procedures. Results will be reviewed during the monthly QAPI meetings, and any incorrect answers will be corrected immediately on the spot. Progress will also be monitored during weekly Committee Meetings. 19. The Medical Director is both resident's physician and he is the one who gave the orders to send them to the emergency room for evaluations. 20. On 7/27/23, Administrator conducted an ad-hoc QAPI meeting to discuss the IJ and assign responsibilities. 21. All adverse findings will be discussed at the QAPI meeting and necessary changes will be made at this time. 22. Residents not on 100 hall who may have been provided care by CNA or LVN were given the safe surveys and will be included in the random safe surveys. 23. All residents on 100 halls will be monitored for 72hrs post discovery of the incidents to ensure there is no retaliation or emotional distress. DON will monitor this compliance. 24. Medical Director was alerted of the IJ on 7/27/23 and Administrator personally spoke with him on 7/28/23 to provide more detail. Monitoring of the facility's Plan of Removal through observation, interview and record from 07/28/23 at 2: 52p.m to 07/28/23 at 5: 15p.m revealed no concerns. During an interview on 7/28/23 at 3:25 PM Resident #6 stated that an employee came in this morning around 9:15 and did ask her questions about abuse/neglect, if employees are nice to her, etc. She stated she had good things to say for all questions, and it felt nice to have those questions asked to her because they should be asked by staff occasionally. During an interview on 7/28/23 at 3:35 PM Resident #7 stated that a nurse, can't remember who did come in this morning and speak with her and ask her questions on abuse/neglect. She stated it was nice to have that asked to her because that really showed her that they care and want to change things. During an interview on 7/28/23 at 3:45 PM Resident #8 stated that a nurse came in this morning and did ask him about abuse neglect, he has never had any issues here before. He stated it was nice to hear the facility ask these questions. He stated he likes the facility very much and has no issues with any employee or resident. During an interview on 7/28/23 at 3:55 PM Resident #9 stated she did have a nurse come through this morning to check in on her. She stated the nurse asked questions such as has any employee been rude, disrespectful, neglectful etc to you. She stated she said no. She stated she has never really had an issue with any nurse or another resident. She stated that the facility overall seems very good to her. Record review of QAPI meeting notes/in-service regarding IJ conducted on 7/27/23 at 9:30 AM confirmed by AD. She stated that they did have a sit-down meeting to discuss all the IJ templates and a plan of actions, this included abuse neglect in-services, safe surveys, quizzes, monitoring residents, and background checks. Record review of CNA A Corrective action form dated 7/23/23 employee was terminated due to abuse, signed by administrator, and dated as verbal over the phone on 7/23/23 at 8:00 pm. Record review of in-service dated 7/23/23 for all nursing staff, topic abuse and neglect, signed by all staff and stated that no staff could work until complete. Conducted by DON. In-service covered abuse and neglect. Contents of training were: The abuse preventions coordinator is the administrator and I the administrator cannot be reached; the backup contract is the DON. Their names and phone numbers are posted on the board on 200 hall. If you see or suspect abuse or neglect happing, the first response is to stop it and protect the resident. You must then immediately report to the abuse preventionist. The types of abuse include physical, verbal, emotional, sexual, involuntary seclusion, misappropriation of funds, and neglect or abandonment. Please respond to residents needs in an appropriate time manner. Be respectful and talk to residents politely. Remember customer service is a priority. Record review of in-service dated 7/27/23 for all nursing staff, topic abuse and neglect, signed by all staff and stated that no staff could work until complete. Conducted by Administrator and DON. Contents included the fact that abuse or neglect must be reported to the abuse coordinator immediately. They should not wait for someone else to report it. It is their responsibility to protect the residents of this facility. If they are unsure about weather, it was a case of abuse or neglect-report it anyways! Protect your residents! It is your job as the abuse coordinator to start the investigation ASAP-and report to state within 2 hours. Make sure staff is aware that they must contact you directly and immediately. Make sure your number is posted with postings, in the breakroom, at the nurse's station, in therapy, in the kitchen-everywhere. If at any time they cannot reach you, they should be instructed to call the DON. Make yourself heard. During an interview on 7/28/23 at 4:15 PM DON stated multiple Care quizzes have been given to multiple employees who attended both in-services. She stated that she has been reviewing the quizzes and all employees have no missed one question. She stated the Medical Director was contacted on 7/27/23 regarding the incidents that occurred and the IJ being called in the facility. She stated that LVNB completed abuse and neglect in-service on 7/23/23. DON will provide 1:1 In-service, written disciplinary actions, and LVNB proficiency checkoff prior to LVN B working the floor again. DON stated in-service has been completed at 7/23/23 and a write up documentation. LVNB came in 7/27/23 to go over proficiencies. She stated that on 7/27/23 she and the administrator received 1:1 in-service from Owner/Operator to cover reporting timeframes. Record review of a completed resident safety survey dated 7/28/23 on all current residents to ensure they feel safe and free from abuse or neglect by 7/28/23. safe surveys were conducted on hall 100 and halls 200, 300, 400 were completed on 7/28/23. Starting 7/31/23, DON/SW will conduct 10 random safe surveys a week for 3 weeks for the residents to ensure that they continue to feel safe and well taken care of. Findings will be discussed at weekly Committee Meetings and at monthly QAPI Meetings. Document included questions such as, have you ever had or felt neglect/abused by any employee or other resident. Record review of Care Quiz revealed all staff that had attended both in-services on 7/28/23 were provided a Care Quiz[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review revealed the facility failed to, in response to allegations of abuse, thoroughly investigate the alleged abuse for one (Residents #1) of 4 residents reviewed for resident abuse. 1) The facility failed to thoroughly investigate an incident of physical abuse of Resident #1 when LVN B observed rough action by CNA A while providing incontinent care to o Resident #1. 2) The facility failed to thoroughly investigate an incident of physical abuse of Resident #2 by CNA A. On 07/23/23 at 10:00a.m, ADM was informed by LVNB and RP of video recording of physical abuse of Resident #2. There was no call to police, State agency, no safe surveys/assessment/interviews with residents/staffs until IJ was called. 3) The facility failed to thorough investigate an incident of abuse of Resident #1 by CNA A. On 07/23/23 at 1:39a.m, ADM was informed by ADON C of Resident #1 injuries. CNA was not suspended until 2:22a.m and not terminated until 8:00p.m. The ADM did not call police and did not want Resident #1 sent out to the hospital, but wanted the hospice nurse called instead. The other residents were not assessed or interviewed. This was determined to be an Immediate Jeopardy (IJ) on 7/27/23 at 2:30pm. The Administrator and DON were notified and were provided with the IJ template on 7/27/23 at 2:30 PM. On 07/28/23 at 4:25p.m, the Administrator was notified the IJ was removed. While the IJ was removed on 7/28/23, the facility remained out of compliance at a severity level of actual harm with the potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal. The failures could place residents involved in abuse incidents at risk of continued abuse, further injury, pain, and physical and emotional distress. Findings included: Review of Resident #1's face sheet dated 07/24/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses included personal history of covid-19, bipolar disorder (mental disorder), benign prostatic hyperplasia (enlarged prostate), and insomnia (sleep disorder), schizophrenia (mental disorder), osteoarthritis (degenerative joint disease), dysarthria and anarthria (impaired speech) and major depressive disorder (loss of interest), vascular dementia (impaired blood flow to brain) acute and respiratory failure, chronic obstructive pulmonary disease (breathlessness and cough) and depressive disorder (loss of interest). Review of Resident #1's Significant MDS assessment dated [DATE] reflected Resident #1 had a BIMS of 1 indicating severe cognitive impairment. Resident #1 required extensive assistance with most ADLs except personal hygiene. Resident #1 was frequently incontinent of bowel and bladder. Review of Resident #1's undated comprehensive care plan reflected Resident #1's ADL self- care performance deficit related to confusion, dementia, severe cognitive impairment, physical mobility, muscle wasting and atrophy, unawareness of needs. He uses wheelchair for mobility on and off the unit. Interventions included to encourage the resident to participate to the fullest extent possible with each interaction. Review of hospital records for Resident #1 dated 07/23/23 reflected, This nurse spoke with (facility), they stated that patient is brought in due to PHY's request due to potential abuse allegations, and the need to check for internal bleeding. They stated that patient prior to is a X2 assist to his wheelchair, but can freely move himself in the wheelchair, can feed himself (mechanical soft diet) and take his medications. Pt. uses 3 liters of oxygen via NC. Pt. has multiple wounds in various stages of healing, however, new ones per nursing home nurse include left shin, left chest, left ear, and left forearm. According to them, pt. did not fall or have any signs of being combative. Hospice provider is following as patient is a patient of them for heart failure. Pt. is known to be aphasic at times. Here pt. presents non-verbal, contracture, and with bipap present. Family member, pt. MPOA notified of patient being in hospital. Family member states pt. does not have any family in town, and her last visit with him was about a month ago. Care resuming. Review of Police report #20230009126 reflected, Officer [NAME], D65 was dispatched to hospital for an assault. Upon arriving, I located the charge nurse, (RN R), who had called dispatch. RN R stated that she had received three patients from facility Nursing and Rehab today. Two patients (Resident #1 and Resident #2) who had come in with minimal information as to cause of injuries being told to Paramedics to relay to the ER for further medical care . After speaking with the crew of Medic 7 I called Sgt. PO S again to inform him of what the paramedics had told me before heading to facility at facility address. After arriving, I spoke with staff who gave me the phone numbers for the DON. Staff also stated that RN R was not related to the incidents as she was in a separate hall. I then went out to my vehicle to call (DON) she was not present the facility. (DON) stated that she was aware of two incidents that had occurred in the early hours of 07/24/2023 but did not have a lot of the details as she had been notified by the ADM. I gathered her information while she informed me that one of the family members had video of one incident that occurred. DON directed me to talk ADM as he had was going to investigate the incidents. I then went back inside the nursing facility and got the phone number for ADM before returning to my vehicle to call ADM. (ADM) stated that he had been notified by staff somewhere between 0200 to 0245 in which a CNA, CNA A was placed on suspension pending termination from employment. I gathered the information that ADM had on file for CNA A. I then asked ADM what their policy or procedure for incidents like this was and why did they not call the Police or other agency in regards to the incidents to this point. ADM stated that it was up to staff to contact authorities. I finished speaking with ADM when a priority called drop close by in which I cleared from the call to return to service. During interview with LVNA on 07/25/23 at 10:54a.m, she said she received video recording from RP showing physical abuse of Resident #2 by CNA A. She immediately notified ADM. She explained ADM did not tell her to call police or notified them himself. She felt there was no urgency on ADM's part to investigate or notify police considering the seriousness of the abuse and what the video recording showed. LVNA noted ADM had the same altitude of indifference when she reported to him that CNA A threaten to rape LVNB and throw her in the river. He did not investigate or suspend or terminate CNA A employment. LVNA said CNA A continued to work which led to physical abuse of Resident #1 and Resident #2 about 1 week later. In an attempted interview with CNA A on 07/25/23 at 4:49p.m, he confirmed he was working on hall 100. CNA A said he took care of Residents #1 and #2 in the nursing. He was asked if he had a chance to talk to ADM, he said he had not. CNA A hanged up the phone. Several attempts to reconnect came with voice message that the phone was out of services. During interview with LVNB on 07/26/23 at 10:45a.m, she said she was working with CNA A on 07/18/23 when he threatens to rape her and throw in [NAME] River. She informed LVNA. She stated she and LVNA reported the incident to ADM. She believes if ADM has investigated the incident, CNA A could not have physically abuse Resident #1 on 07/22/23 and 07/22/23 about 1 week latter. On 07/22/23 at about 11:15p.m, she entered Resident #1's room. She saw CNA A cleaning Resident #1 earlobe because it was bleeding. LVNB stated that when asked multiple times to CNA A what happened, CNA A would only reply, I don't know. LVNB stated CNA A was the only CNA on that hallway all night and the wounds were fresh. LVNB asked Resident #1 what happened, Resident #1 made a motion with his hands, like he got into a fight. LVNB asked Resident #1 who he got in a fight with, and Resident #1 pointed at CNA A. LVNB explained on 07/23/23, Resident #1 was found with left ear lacerations, left shoulder abrasion and laceration, a hematoma on the right and left abdomen, hematoma on the left leg, skin tear on the left forearm and a bruise on the foreskin of his penis. LVNB said ADM was the abuse coordinator and should have investigated, suspended, or terminated CNA A employment to prevent his subsequent actions on Resident #1. During interview with Administrator (ADM) on 07/26/23 at 9:54a.m, he confirmed the following: 1) ADON C, LVNA, LVNB notified him of physical abuse of Resident #1 and Resident #2 by CNA A 2) Aware Resident #1 sustain multiple injuries. 3) Denied not reporting on time. Surveyor tried without success to get some questions answered or timeline on the information during the investigation from ADM. He was reluctant, unwilling, and refused to answer specific question. In an Interview with HR E on 07/26/23 at 9:30a.m, she said she was the Human Services Director and has been employed in the facility for 8 months. On 07/18/23, she was notified by LVNA that CNA A threaten to rape and throw LVNB in the river. HR E explained she went with LVNA to ADM office to talk to him about the incident. She said she was not aware if ADM talked to LVNB or CNA A. Surveyor asked the facility protocol when an employee threaten another.HR E stated she informed ADM and did not talk to LVNB or CNA A. She went on to say she did not know if ADM investigated or reported the incident. During interview with DON on 07/26/23 at 9:06a.m, she said she was informed by LVNA that CNA A threaten to rape LVNB and throw her to the river. She explained the ADM was informed by LVNA and HR E about the incident before she was aware of the incident. The DON stated she assumed the ADM was investigating the incident. She said she was aware that ADM did not talk to CNA A about the rape incident. The DON stated the facility protocol was to investigate and talk to the parties involved. Remove the staff if necessary and in-serviced is conducted. She said the ADM should have called CNA A and talk to him and write a report and call Police when it was brought to his attention. Review of Resident #2's face sheet dated 07/25/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses included senile degeneration of the brain, dementia (impaired blood flow to brain), Aphasia (Communication disorder), dysphagia (language disorder), contractures (chronic loss of joint motion), heart failure, seizures), osteoarthritis (degenerative joint disease), and pulmonary embolism (blood clot in the lungs).and depressive disorder (loss of interest). Review of the MDS assessment dated [DATE] for Resident #2 revealed an incomplete brief interview for mental status (BIMS). Resident has minimum difficulty hearing with unclear speech. He rarely/never understands but with adequate vision. Resident #1 has no documented behavioral issues. In an interview with the RP on 07/25/23 at 11:05a.m, she said she was the Responsible party for Resident #2. RP explained on 07/23/23, she watched video recording in the facility of CAN A physically abusing her Resident #2 over several days (on 07/19/23 from 7: 06p.m-7: 18p.m, on 07/21/23 from 11: 44p.m-11: 48p.m, on 07/22/23 from 7: 56p.m to 8:05p.m.). RP stated, the video recording revealed CNA A physically abusing Resident #2 multiple times while providing incontinent care. She immediately notified LVNB and ADM. RP explained ADM was rude and answered how she got his number and seems unconcerned with the welfare of Resident #2. The ADM did not call Police or investigate her legitimate concerns about Resident #2 condition. RP said she reported the incident of Resident #2 abuse to the police. The RP noted Resident #2 was found with bruises by LVNB and transferred to the hospital for check of internal injuries. Review of the facility's policy/procedure on abuse/neglect undated reflected: Intent: The facility will develop and operationalized policies and procedure for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property: to include the use f physical or chemical restraint. The purpose is to assure that facility is doing all is within its control to prevent occurrences. Investigation: Investigate different types of incidents; and identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities. An Immediate Jeopardy (IJ) was identified on 07/28/23 at 4:25 p.m. While the IJ was removed on 07/28/23, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. This was determined to be an Immediate Jeopardy (IJ) on 7/27/23 at 2:30pm. The Administrator and DON were notified and were provided with the IJ template on 7/27/23 at 2:30 PM. The following Plan of Removal was accepted on 7/28/23 at 3:05 PM and included: Please accept the following Plan of Removal of Immediate Jeopardy-Failure to ensure residents are free from abuse/neglect/exploitation. The facility failed to ensure the residents are free from abuse and neglect. 1. The facility's policies and procedures on abuse and neglect is the following: Ensure the resident is safe and report the event to the abuse coordinator immediately. The Abuse coordinator will conduct a brief investigation and report abuse or neglect to HHSC within two hours. 2. On 7/23/23 at 0222 the employee in question was suspended immediately pending investigation and terminated on 7/23/23 at 2003 after discovering evidence of him committing abuse to a resident. 3. All current staff were in-serviced on abuse and neglect and reporting abuse or neglect policy and procedures on 7/23/23. For those on vacation and cannot be reached, they will not return to work without receiving this in-service. 4. LVN B completed abuse and neglect in-service on 7-23-23. DON will provide 1:1 In-service, written disciplinary actions, and LVN proficiency checkoff prior to LVN B working the floor again. 5. Administrator and Designee received 1:1 in-service from [name], Owner/Operator to cover reporting timeframes. 6. The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect are completed by all staff members. Completion will be reviewed at monthly QAPI meetings. 7. DON/Designee will re-educate the charge nurses on their ability to suspend any employee who is suspected of committing abuse or neglect to a resident or employee will be suspended immediately and escorted out of the building and off the premises pending investigation. This will be completed on 7/28/23. 8. DON/Designee reviewed hall assignments to verify where the CNA and LVN were assigned to and conducted a head-to-toe assessment on all residents they cared for on 7/22/23 and 7/23/23. 9. Complete a resident safe survey on all current residents to ensure they feel safe and free from abuse or neglect by 7/28/23. 10. On 7/27/23, safe surveys were conducted on hall 100 and halls 200,300,400 were completed on 7/28/23. Starting 7/31/23, DON/SW will conduct 10 random safe surveys a week for 3 weeks for the residents to ensure that they continue to feel safe and well taken care of. Findings will be discussed at weekly Committee Meetings and at monthly QAPI Meetings. 11. The residents 1 and 2 who suffered the alleged abuse care plan was not updated or changed due to them discharging and the family placing them in another facility. 12. All possibly affected residents have had care plans updated to reflect potential risk for alteration in mood state and psychosocial well-being related to the alleged incident of abuse in their environment. 13. Prior reportable incidents were reported within the guidelines set forth by HHSC and the Administrator monitored the completion of the investigation. 14. Any staff member suspected of committing abuse/neglect will be suspended immediately and or terminated depending on the outcome of the investigation. 15. Staff who fail to report suspected abuse will be educated on the significance of reporting time and disciplined accordingly. 16. The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect are completed by all staff members. 17. The Administrator/Designee will monitor all reportable incidents and all reportable incidents will be reported to the Corporate Compliance Officer immediately. All reportable will be discussed weekly at our Committee Meeting. 18. Starting 7/28/23 DON/Designee will conduct 10 random quizzes week for 3 weeks for staff to ensure they are retaining the education on abuse and neglect and reporting procedures. Results will be reviewed during the monthly QAPI meetings, and any incorrect answers will be corrected immediately on the spot. Progress will also be monitored during weekly Committee Meetings. 19. The Medical Director is both resident's physician and he is the one who gave the orders to send them to the emergency room for evaluations. 20. On 7/27/23, Administrator conducted an ad-hoc QAPI meeting to discuss the IJ and assign responsibilities. 21. All adverse findings will be discussed at the QAPI meeting and necessary changes will be made at this time. 22. Residents not on 100 hall who may have been provided care by CNA or LVN were given the safe surveys and will be included in the random safe surveys. 23. All residents on 100 halls will be monitored for 72hrs post discovery of the incidents to ensure there is no retaliation or emotional distress. DON will monitor this compliance. 24. Medical Director was alerted of the IJ on 7/27/23 and Administrator personally spoke with him on 7/28/23 to provide more detail. Monitoring of the facility's Plan of Removal through observation, interview and record from 07/28/23 at 2:52p.m to 07/28/23 at 5:15p.m revealed no concerns. During an interview on 7/28/23 at 3:25 PM Resident #6 stated that an employee came in this morning around 9:15 and did ask her questions about abuse/neglect, if employees are nice to her, etc. She stated she had good things to say for all questions, and it felt nice to have those questions asked to her because they should be asked by staff occasionally. During an interview on 7/28/23 at 3:35 PM Resident #7 stated that a nurse, can't remember who did come in this morning and speak with her and ask her questions on abuse/neglect. She stated it was nice to have that asked to her because that really showed her that they care and want to change things. During an interview on 7/28/23 at 3:45 PM Resident #8 stated that a nurse came in this morning and did ask him about abuse neglect, he has never had any issues here before. He stated it was nice to hear the facility ask these questions. He stated he likes the facility very much and has no issues with any employee or resident. During an interview on 7/28/23 at 3:55 PM Resident #9 stated she did have a nurse come through this morning to check in on her. She stated the nurse asked questions such as has any employee been rude, disrespectful, neglectful etc to you. She stated she said no. She stated she has never really had an issue with any nurse or another resident. She stated that the facility overall seems very good to her. Record review of QAPI meeting notes/in-service regarding IJ conducted on 7/27/23 at 9:30 AM confirmed by AD. She stated that they did have a sit-down meeting to discuss all the IJ templates and a plan of actions, this included abuse neglect in-services, safe surveys, quizzes, monitoring residents, and background checks. Record review of CNAA Corrective action form dated 7/23/23 employee was terminated due to abuse, signed by administrator, and dated as verbal over the phone on 7/23/23 at 8:00 pm. Record review of in-service dated 7/23/23 for all nursing staff, topic abuse and neglect, signed by all staff and stated that no staff could work until complete. Conducted by DON. In-service covered abuse and neglect. Contents of training were: The abuse preventions coordinator is the administrator and I the administrator cannot be reached; the backup contract is the DON. Their names and phone numbers are posted on the board on 200 hall. If you see or suspect abuse or neglect happing, the first response is to stop it and protect the resident. You must then immediately report to the abuse preventionist. The types of abuse include physical, verbal, emotional, sexual, involuntary seclusion, misappropriation of funds, and neglect or abandonment. Please respond to residents needs in an appropriate time manner. Be respectful and talk to residents politely. Remember customer service is a priority. Record review of in-service dated 7/27/23 for all nursing staff, topic abuse and neglect, signed by all staff and stated that no staff could work until complete. Conducted by Administrator and DON. Contents included the fact that abuse or neglect must be reported to the abuse coordinator immediately. They should not wait for someone else to report it. It is their responsibility to protect the residents of this facility. If they are unsure about weather, it was a case of abuse or neglect-report it anyways! Protect your residents! It is your job as the abuse coordinator to start the investigation ASAP-and report to state within 2 hours. Make sure staff is aware that they must contact you directly and immediately. Make sure your number is posted with postings, in the breakroom, at the nurse's station, in therapy, in the kitchen-everywhere. If at any time they cannot reach you, they should be instructed to call the DON. Make yourself heard. During an interview on 7/28/23 at 4:15 PM DON stated multiple Care quizzes have been given to multiple employees who attended both in-services. She stated that she has been reviewing the quizzes and all employees have no missed one question. She stated the Medical Director was contacted on 7/27/23 regarding the incidents that occurred and the IJ being called in the facility. She stated that LVNB completed abuse and neglect in-service on 7/23/23. DON will provide 1:1 In-service, written disciplinary actions, and LVNB proficiency checkoff prior to LVNB working the floor again. DON stated in-service has been completed at 7/23/23 and a write up documentation. LVNB came in 7/27/23 to go over proficiencies. She stated that on 7/27/23 she and the administrator received 1:1 in-service from Owner/Operator to cover reporting timeframes. Record review of a completed resident safety survey dated 7/28/23 on all current residents to ensure they feel safe and free from abuse or neglect by 7/28/23. safe surveys were conducted on hall 100 and halls 200, 300, 400 were completed on 7/28/23. Starting 7/31/23, DON/SW will conduct 10 random safe surveys a week for 3 weeks for the residents to ensure that they continue to feel safe and well taken care of. Findings will be discussed at weekly Committee Meetings and at monthly QAPI Meetings. Document included questions such as, have you ever had or felt neglect/abused by any employee or other resident. Record review of Care Quiz revealed all staff that had attended both in-services on 7/28/23 were provided a Care Quiz to complete. Care quiz completed by LVNJ; all answers answered correctly. No issues. Care quiz was created with questions that were from both in-services. Observation three sampled residents (Resident #3, #4 and #5) revealed no signs of pain or abuse. They appear to be carrying their activities of daily living with incident. They said they felt safe and denied abuse staff or other residents. Interviews regarding abuse and neglect training and reporting on 07/28/23 at 3:25p.m through 5: 00p.m revealed no concerns with staff knowledge. Staffs interviewed were representative of various facility shifts. They were able to provide knowledge and participation of training regarding abuse/neglect in-services and training. The following staffs were interviewed on 07/28/23: LVN A, LVNB, ADON C, ADON D, HRE, CNA F, CNA G, CNA H, LVN I, LVN J, LVNK, CNA L, CNA M, Social Worker, and CNA N. They were knowledgeable of types of abuse/neglect and should report any abuse allegations to charge nurse of resident immediately and to the ADM. They all knew Administrator was the Abuse prevention coordinator with DON as the backup if not able to reach ADM. They knew how to get hold of ADM and DON if not in the facility at time. Interview with LVNB (100 hall) on 07/28/23 at 4:30 PM revealed she was in-serviced on 07/25/23 and 07/28/23 on abuse/neglect and reporting. She was asked what she would have done differently looking back at the incident with Resident #1 and Resident#2, and she stated she would follow protocol and nursing judgement and reported the incident immediately. She stated she was terrified on what CNAA could have done to her for reporting her observation. On 07/28/23 at 4:25p.m, the Administrator was notified the IJ was removed. While the IJ was removed on 7/28/23, the facility remained out of compliance at a severity level of actual harm with the potential for more than minimal harm that is not immediate jeopardy, and a scope of pattern because the facility had not had the opportunity to monitor the effectiveness of the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, which included tracheostomy care and tracheal suctioning, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for respiratory and tracheostomy care. On [DATE], the facility failed to ensure that suction supplies were readily available at Resident #1's bedside and on the crash cart when she required suctioning and experienced sudden decreased oxygen saturation. Due to the rapid deterioration in her condition, she was transferred to the emergency room by ambulance where she later died with diagnoses of a collapsed right lung and cardiac arrest. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:19 PM. While the IJ was removed on [DATE] at 6:40 PM, the facility remained out of compliance at a scope of isolated with a severity of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could affect residents with a tracheostomy by placing them at risk of a delay in receiving life-saving treatment which could result in serious injury including death. The findings included: Review of Resident #1's admission Record dated [DATE] revealed she was a [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dysphagia (difficulty swallowing), and tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube and is commonly done in an operating room under general anesthesia) status. Review of Resident #1's Five-day MDS Assessment, dated [DATE] revealed: She did not speak but was able to understand and make herself understood. Her mental status exam scored a 15 of 15 (indicating she was cognitively intact). She needed limited assistance for ADLs including eating. Review of Resident #1's Care Plan, initiated [DATE] revealed: Issue: Resident is at risk for aspiration due to presences of tracheal stoma and neck trauma related to esophageal cancer. Goals: Resident will maintain patent airway and risk for aspirations will decrease as a result of ongoing assessments. Interventions included: Auscultate bowel sounds to evaluate bowel motility; Keep suction setup at bedside at all times; Maintain upright position 30-45 minutes after meals; Notify MD immediately of noted decrease in cough and/or gag reflex or difficulty swallowing. Resident #1's Initial Care Plan, dated [DATE] revealed she had a cuffless Tracheostomy at 6 mm. Review of Resident #1's Order Summary Report, dated [DATE], revealed: Order dated [DATE] Trach care every shift and as needed. Order dated [DATE] Suction trach every shift and as needed. Order dated [DATE] oxygen at 2 liters per minute as needed. Order dated [DATE] albuterol sulfate via nebulizer (breathing treatment) every 4 hours as needed. Review of Resident #1's Nurse's Notes , revealed the following: Nurse's Notes [DATE] at 4:56 p.m. LVN J wrote: Received this [AGE] year-old female to facility. Resident was awake, alert, with even and non-labored respirations to room air. Resident has Tracheostomy, no Tracheal Tube in place. Stoma (opening) is bruised, with no drainage noted. Lung sounds are diminished. Has order for antibiotic for five days for bronchitis. Alert, oriented, no speech understands what is being said to her, writes down answer to questions answered. Nurse's Note dated [DATE] at 11:35 p.m. LVN L wrote : Nurse attempted to install current Tracheostomy tube in resident's stoma. Resident #1 refused due to size of tube. Resident #1 said that the tracheostomy tube we have is way too big. She said that her doctor ordered her size and that will arrive tomorrow. Nurse's Note dated [DATE] at 4:24 a.m. LVN L wrote: Resident knocking on her bedside table to get nurse's attention. Upon entering her room, writer noted Resident #1 showing signs of shortness of breath. Nurse asked her if she wanted to go to the hospital and she nodded her head yes. Nurse contacted EMS and attempted to call her family. Resident sent to emergency room via ambulance. Nurse's Note dated [DATE] at 2:40 p.m. LVN M wrote: Resident arrived at the facility via facility van, alert and oriented and no complications at this time. Oxygen saturation at 96%. Nurses Note dated [DATE] at 3:43p.m. DON wrote: went to welcome and assess new resident with charge nurse. Resident was alert and oriented. Resident was sitting in a 60-degree angle without her trach mask on. Oxygen saturation at 94% on room air. Resident educated on keeping her trach mask on with oxygen on and to not pick at her stoma on her neck. Resident wrote on a piece of paper I know and smiled. Nurse's Note dated [DATE] at 11:12 a.m. DON wrote: Resident noted lying in bed with head of bed at 45-degree angle. Trach mask was not on resident. It was noted to be hanging on the side rail. New Tubing placed and educated resident on keeping the trach mask on. Resident smiled and mouthed I know. Nurse's Note dated [DATE] at 8:11 a.m. DON wrote: Resident noted lying in bed with head of bed less than 30 degrees and trach mask on bed rail. Educated resident to keep head of bed more than 30 degrees and to wear the trach mask. Resident mouthed I know and sat up slowly to side of bed. Nurse's Note [DATE] at 11:18 a.m. DON wrote: Resident noted lying in bed without trach mask on. Oxygen 94% on room air. Doctor notified of noncompliance of mask with resident. Continuous oxygen changed to oxygen as needed. Resident notified and smiled and mouthed I know. She wrote on paper that she really did not use it at home either. Resident educated on pressing the call light button for assistance if she feels short of breath or in any distress. Resident mouthed I will. Nurse's Note dated [DATE] at 1:45 p.m. LVN D wrote: CNA notified nurse of resident having difficulty breathing. Upon entering room, Resident #1's oxygen mask was not on. It was hanging on the bed and head of bed was less than 30 degrees. Patient education had been implemented of the importance of keeping oxygen in place and keeping head of bed above 90-degree angle. This nurse placed oxygen mask back over trachea and raised head of bed and assessed oxygen level which read at 75% upon assessment, resident was noted in distress. Nurse asked resident if she could breathe at all and she used a hand gesture motioning so/so. Called for assistance, oxygen dropped to 35% with oxygen in place, (nurse) left room to grab crash cart. Ambulance called. Oxygen was dropping but pulse still present reading at 77 and pulse was palpable. Attempted to suction with little success. EMT arrived, assessed resident, and took over care, used ambu-bag. Resident aspirated and EMT placed her on stretcher to transfer her to ER for evaluation. Review of Resident #1's hospital records revealed the following: Resident #1 was admitted [DATE] and discharged [DATE]. HPI: Chief Complaint Patient Presents with: Cardiac Arrest; Respiratory Distress Patient is a [AGE] year-old with past medical history listed below who presents to the emergency department via EMS in cardiac arrest (her heart stopped beating). Upon arrival to the emergency department, patient did not have her tracheostomy device in place. The patient was being bag-valve-masked (mask placed over a patient's mouth to forcibly push air into the lungs when they are unable to breathe on their own) orally upon arrival. CPR was in progress via [NAME] device (machine that did CPR compressions). ACLS (Advanced Cardiac Life Support interventions including CPR, medications and defibrillating or shocking a patient to restart their heart) was then taken over by me. PEA (pulseless electrical activity - condition in which the patient's pulse could not be felt but the cardiac monitor continued to register some electrical activity) on the monitor during first pulse check. Patient was subsequently intubated (breathing tube inserted into the windpipe) through her tracheostomy stoma with a ETT (endotracheal tube or breathing tube) over a [NAME] (device used to help guide the insertion of a breathing tube). Patient had ROSC (return of spontaneous circulation - the restart of a sustained heart rhythm after cardiac arrest) after two rounds of ACLS. Patient went into asystole approximately 10 minutes later and ACLS was initiated. Patient had return of spontaneous circulation after two rounds. CT angiogram (an imaging test that looks at the arteries that supply blood to the heart) of the chest performed on [DATE] showed moderate right pneumothorax (collapsed lung) and mild pneumomediastinum (air in the space between the lungs and around the heart). Troponin I (protein found in the muscles of the heart not normally found in the blood, when the heart is damaged, troponin is sent into the blood stream) was 177.3 pg/ml (normal range is between 0 and 0.04 pg/ml) indicating a heart attack. Assessment: 67 y.o. female .recently in hospital for pneumonia then sent after skilled nursing facility p/w cardiac arrest with prolonged code (medical emergency in which a patient requires resuscitation) and anoxic (without oxygen) brain injury. Problem List: Right Pneumothorax POA: Yes Plan: Cardiac Arrest: With possible anoxic injury, patient was a DNR by her request prior to the event. Given her multiple medical comorbidities (two or more diseases or medical conditions) and declined health and her DNR family wanted to move forward in withdrawing care. Patient to be placed on palliative (form of medical care focused on relieving symptoms without dealing with the cause of the condition) orders and extubated (breathing tube removed). Patient was extubated by day RT at an unknown time. Call placed to hospitalist (doctor employed by the hospital) on [DATE] at 2:16 AM for notification of patient expiration (death). At the time of death Resident #1's diagnosis was right pneumothorax and cardiac arrest. Interview on [DATE] at 5:04 p.m. LVN D confirmed she was Resident #1's nurse on the day shift of [DATE]. LVN D described Resident #1 as noncompliant with her oxygen and would frequently lower the head of her bed; she said Resident #1 was non-verbal but could communicate with notes or mouthing the words. LVN D reported Resident #1 was supposed to be on continuous oxygen. LVN D stated CNA C came to her (LVN D) around 1:30 p.m. and reported Resident #1 could not breathe and needed to be suctioned. LVN D said she went to check on Resident #1. LVN D stated the last time she worked with Resident #1 there was suctioning equipment available in her nightstand drawer. LVN D said she checked the drawer, where the suction catheters were usually stored, and the suction catheter was not there. LVN D reported she sat Resident #1 up, put her oxygen on her and hoped it would help but it did not. LVN D stated she checked the drawers, the closets and there was no suction catheter available. LVN D said she called 911 at 1:45 p.m. on her personal phone while she checked the supply closet for suction catheters, then she went to the nurse's station to print Resident #1's face sheet and physician orders. LVN D recalled she returned down the hallway with the crash cart (cart all facilities have for emergency supplies if someone who is a full code needed emergency services). LVN D stated that she was unable to locate a suction catheter on the crash cart after she got to Resident #1's room with the cart. LVN D stated she called her chain of command but no one on answered. She said all the other clinical staff were also looking for the suction catheters. LVN D said while she was doing this, she tried to call everyone she could think of, but no one answered until finally ADON G answered the phone. LVN D stated by the time ADON G answered Resident #1 was not breathing and turning blue. LVN D stated the other nurses found a tube to suction Resident #1 with. LVN D said the tube was thick. LVN D stated LVN E found whatever tubing was used to suction Resident #1 on the crash cart and she was not sure what it was. During the interview on [DATE] at 5:04 p.m. , LVN D said after Resident #1 was taken by EMS, she sat down at the nurses' station and found the bag of suctioning supplies, but it was not labeled and not put up. LVN D stated the only thing that was significant about [DATE] was the facility was short of nurses and ADON F was on call but would not answer the phone, but the night nurse from the previous evening stayed until noon to help cover the additional hall. She said the weekend RN had called in sick to work that day. LVN D said she never worked with a resident with a Tracheostomy before Resident #1 was admitted to the facility. LVN D said she was not comfortable with the situation but did not say that at the beginning of the shift. She said the other nurses were as new as she was. LVN D said she worked with Resident #1 two days prior and there were plenty of supplies (suction catheters). She said this was her first resident code as a nurse. During the interview on [DATE] at 5:04 p.m., LVN D said the facility had a respiratory therapist come in [DATE] to give an in-service, but that was it. LVN D said she asked the DON for a refresher after Resident #1 was admitted , but all the DON did was give her the handout from the presentation. LVN D stated she messaged ADON G about it and ADON G walked her through it on [DATE]. LVN D said she did not know what she would do differently since no one was answering the phone and she did not know what to do. She said she had not been in those situations before and all she knew was to call her bosses. She said she wished she was more aware of her surroundings to know the supplies were at the nurse's station. LVN D stated she wished she insisted on getting the additional training. At that time, LVN D said the night nurse suctioned Resident #1 the night before but did not communicate the facility was running low on supplies. LVN D said this was her first job as an LVN and her orientation at the facility was three days of training. She recalled the first day she watched the RN do everything; the second day the RN watched her do everything she could do; and the third day she was just watched. LVN D confirmed she was oriented to where the supplies were. She said she thought the nurse who signed for the suctioning equipment got busy and forgot about it . LVN D said she did not know who was responsible for putting up equipment, she assumed whichever nurse signed for it. LVN D stated she was informed of changes of condition on the residents by the 24-hour report or could get on the facility's documentation program. Interview on [DATE] at 5:54 p.m. LVN E confirmed she worked on the day shift on [DATE] . She stated she was working on the 200-hall when she heard LVN D needed help suctioning Resident #1. LVN E said she overheard the staff say they could not find a suctioning catheter and she (LVN E) went to check the storage room. LVN E stated she found aides in there also looking for the suctioning catheters. LVN E stated she knew what the catheter equipment looked like, so she checked and there were not any in the storage room, Resident #1's closet, Resident #1's drawer, or in the equipment bag over Resident #1's head. LVN E stated she tried to tell the aides what the suctioning equipment looked like. LVN E stated she sat Resident #1 up a little higher to see if that would help her breathe a little bit. LVN E disclosed that no one found the suctioning equipment, but she could not remember who said to use a different type of tubing. LVN E described the tubing as having a cover to keep it sterile, but it was not the suctioning catheter. LVN E said the nurse (LVN D) started suctioning Resident #1 and it was working and then the EMTs arrived. LVN E said she remembered Resident #1 oxygen saturations dropped to 30%. LVN E said Resident's #1's oxygen dopped really quick and Resident #1 turned purple as time went on. LVN E said Resident #1 was not coherent or responsive. LVN E said she could not remember anything else because it was traumatizing to watch someone go from walking to essentially suffocating. During the interview on [DATE] at 5:54 p.m., LVN E stated she knew that there was correct suctioning equipment in the building, but no one had communicated with the nurses on duty as to where it was. She stated the correct suctioning catheter looked skinny or thin and was covered by plastic to keep it sterile and had numbers on it. She stated in the packaging it was approximately 6 inches by three inches and when taken out of the bag it was long. LVN E explained there was a thumb hole on the tubing and a wider part that attached to the machine. LVN E stated she was comfortable taking care of residents with tracheostomies because she did so in her previous job. LVN E said the suction catheters were supposed to be stored in the storage room with the rest of the suctioning supplies, but it was at the nurse's station, and no one told them. LVN E stated she thought it should be at the Resident's bed side and not just a catheter. She stated I thought we were supposed to have the catheter on the crash cart at all times for emergencies and I found it weird that it wasn't available. LVN E stated she did not receive any in-services on taking care of tracheostomy residents before Resident #1 was admitted to the facility. She said she did not know where the facility policy was about taking care of residents with tracheostomies. LVN E said there's probably a book somewhere but she was not made aware of where it was. She said she did not know what was expected of her, but she did her best to provide the care she could. During the same interview, LVN E said the only other thing unusual about [DATE] was they were short staffed, so all the nurses had to take an additional ten residents each. She said they called all the management, and no one would come in because they were all out of town. LVN E said the DON came in after 4 p.m. after everything happened. During the interview with LVN E on [DATE] at 5:54 p.m., LVN E stated the only way to know about changes of conditions in residents was to check the 24-hour report book. She said the nurse on the off-going shift was supposed to have written down any new change and it was in the computer. LVN E said she felt it was effective for the most part. Interview on [DATE] at 9:12 a.m. LVN D stated she used what LVN E told her to use to suction out Resident #1. She said she did not know what kind of tubing was used but it was some kind of catheter. LVN D shared it was on the crash cart and was a clear tube. Interview on [DATE] at 9:15 a.m. LVN E said she was not sure what kind of tubing was used to suction Resident #1 because she never got the name of it. She stated the staff had to cut something off the top and it looked like it could go on a breathing treatment or something like that. LVN E said she could not recall whose idea it was to cut off the tip because everything was just so chaotic. LVN E stated she believed the tubing was found in Resident #1's room but it was not the correct suctioning catheter Resident #1 needed. LVN E repeated she did not remember, but it had the protective thing covering the tubing, so it did not fit the suctioning machine. LVN E stated the tubing did not fit on the suctioning machine and the staff had hold it with their hands to create the suction needed. LVN E said when the staff held the tubing on, it did create suction. Interview on [DATE] at 3:01 p.m. CNA A confirmed she worked the day shift on [DATE] . She said she came in from outside around 1:30 PM and the housekeeper said everyone was on Hall 4 and the nurse was worried. CNA A stated she went to Resident #1's room. CNA A said the nurse called 911 and started looking for something small and got something and got the crash cart. CNA A said she heard that Resident #1 needed to be suctioned and she (CNA A) and LVN D went to find the right suctioning piece. CNA A stated common sense says the suctioning piece should have been there; the night nurse told the day shift she suctioned Resident #1. CNA stated we (the staff) tried to find a suction piece and could not. CNA A stated that she looked in both supply rooms and in the closet in Resident #1's room for the suction catheter. CNA A stated LVN D brought the crash cart to Resident #1's room when Resident #1's saturation started dropping. She stated the ambulance had already been called and she went to the door to wait on them. CNA A reported when the EMTs arrived at the facility she let them in and told them they needed to hurry. CNA A shared she sat with LVN D after and the LVN was pissed off because the suctioning equipment should have been in the room and LVN D later found it at the nurse's station. CNA A said the suctioning supplies were not labeled and it just looked like a bag of basic medical supplies CNA A stated she thought the suctioning supplies came in on [DATE]. CNA A stated it was a high adrenaline situation so something things were not as clear as others. CNA A stated she did not see the nurses suction Resident #1 during the incident and she was not able to describe the tubing that was used. Interview on [DATE] at 3:57 p.m. CNA B confirmed she worked the day shift on [DATE] and she was one of the aides assigned to Resident #1's hall. CNA B stated Resident #1 had been in the facility for a week. CNA B said Resident #1 was capable of using the call light and since Resident #1's roommate was a high fall-risk, the aides checked the room often. CNA B revealed Resident #1 was independent with ADLs. CNA B stated on [DATE] around 1:30 p.m. Resident #1 activated her call light and CNA B and CNA C went into Resident #1's room. CNA B said CNA C asked Resident #1 what she needed, and Resident #1 pointed at her throat indicating she wanted her trach suctioned. CNA B stated Resident #1 seemed fine. CNA B said she informed LVN D and LVN D came to the room. CNA B said LVN D put the pulse oximeter on Resident #1's finger and tried to get the suction machine ready. CNA B said the suctioning machine and equipment was on the bedside table but the suction catheter was not. CNA B stated LVN D checked the nightstand drawer and the closet, but the suction catheter was not there. CNA B reported she (CNA B) and LVN D noticed Resident #1's oxygen saturations dropping on the pulse oximeter so LVN D called the ambulance and went out of the room to look for the suction catheter. She said as soon as Resident #1's oxygen saturation dropped to 45%, she (CNA B) started hollering she needed a nurse because she did not know if Resident #1 would run out of oxygen. CNA B said the lowest Resident #1's oxygen saturations got was 30%. CNA B said LVN D asked the other nurses for help. CNA B reported she stayed in the room with Resident #1 and was holding the pulse oximeter on her finger to keep track of her oxygen levels and was holding the oxygen mask to Resident #1's tracheostomy hole so it would help her breathe but the oxygen saturations kept dropping. CNA B said while LVN D called report into the EMT, she believed the other nurses continued to look for the equipment . CNA B said LVN D called everyone and finally got ahold of someone. CNA B said LVN D returned with the crash cart and was told to use a catheter tube as a suction, and they cut it to make it work. CNA B stated then the EMTs arrived, and the staff stepped back. CNA B said she did not know why the suction catheter was not available - if the nurse blanked or what . CNA B said as an aide she monitored for build up for fluid; she said the aides had received some training on tracheotomy care but did not remember when. CNA B clarified that LVN D called 911 as soon as something went wrong. CNA B said the nurses were able to find the piece for suctioning the mouth (yankauer) but could not find what Resident #1 needed and on call told them to use a catheter and it worked. Interview on [DATE] at 4:23 p.m. CNA C confirmed she worked the day shift on [DATE] on Resident #1's hallway. CNA C stated Resident #1 ate in her room and after the meal she was fine, and her color was good. CNA C remembered after lunch trays were picked up Resident #1 activated the call light and tapped her chest communicating that she needed to be suctioned. CNA C said she asked Resident #1 if she needed to be suctioned and Resident #1 nodded 'yes'. CNA C reported at that time, Resident #1 looked normal and was not in distress . CNA C said she told the nurse (LVN D). CNA C said LVN D went into the room and checked the oxygen saturation, and she believed it was at 87%. CNA C said she sat next to Resident #1 and rubbed her back to comfort her and Resident #1's oxygen saturation went down to 77%. CNA C said every time she looked at the oximeter, Resident #1's oxygen saturations went down. CNA C stated LVN D checked the drawer, and the suction end was not in there, she said she (CNA C) went and checked the supply room but did not find anything. CNA C reported she told the 'other nurses present' that LVN D needed help while she was looking for the hose. CNA C said LVN D got the crash cart, and she (CNA C) still could not find the piece she needed. CNA C said LVN D said she found something that worked a little bit about the time the EMTs showed up. CNA C stated she did not know why the equipment was not in the room. CNA C shared she never worked with anyone with a tracheostomy and the staff were reluctant to work with her. Interview on [DATE] at 10:22 a.m. the NP stated she was informed on [DATE] by the DON that Resident #1 started getting hypoxic with her oxygen saturations dropping, the nurse called EMS, and the resident passed in the ER. The NP answered the expectation for tracheostomy care was the DON called in an RT to come do an in-service with the staff. The NP said she was responsible for Resident #1's care. The NP stated she saw Resident #1 the week prior to [DATE] and Resident #1 was alert and calm. The NP stated Resident #1 communicated with a board and was stable, stubborn, and noncompliant with care by constantly sticking her (Resident #1's) finger in the ostomy (hole in Resident #1's throat). The NP said she did not know if there was a specific protocol for tracheostomy care. She stated the expectation for supplies was it was supposed to be at bedside. The NP explained Resident #1's tracheostomy equipment looked different than what the facility normally saw. The NP said Resident #1 only used her breathing treatments and humidified air. The NP stated Resident #1 refused to wear a tracheotomy cuff. The NP stated the facility asked her (the NP) to double check Resident #1's equipment because it was different than what was usually used. The NP stated there should be suctioning cannula always at bedside and she thought Resident #1 did her own suctioning. The NP said she never saw Resident #1 do her own suctioning. The NP said it was hard to say if the missing suctioning cannula contributed to Resident #1's death because Resident #1 had a recent respiratory infection. She said there was nothing else to her knowledge that staff could have used to safely suction Resident #1 . The NP said she did not know if the proper suctioning materials would be expected to be on the crash cart or not, she thought for a minute and said not really because it was not something the facility dealt with. The NP said Resident #1 being hypoxic would have happened regardless and there was no way to tell if suctioning would have prevented the hypoxic episode. Interview on [DATE] at 10:53 a.m. the DON confirmed she was aware of Resident #1 and her care. The DON said Resident #1 asked her (the DON) if she could do her own suctioning and the DON told Resident #1 that the nurses had to do it. The DON said the nurses performed suctioning for Resident #1 and they provided breathing treatments. The DON said Resident #1 would not wear an inner cannula and was non-complaint with her oxygen use because Resident #1 did not wear it all the time at home . The DON said the facility felt they were able to meet Resident #1's care needs. The DON stated ADON F was on-call and there was an RN scheduled to be in the building, so she went out of town. She stated on [DATE] when the facility was short staffed, the nurses called ADON F who could not come into work. The DON said the nurses called all the other nurses they knew to come in and help; she said the nurses called multiple people and no one was available to cover. The DON stated she started calling people mid-morning of [DATE]. The DON said during the day shift, the facility liked to run four nurses plus two medication aides to assist with medications. The DON said she was unable to find coverage, so she started driving to the facility, but she was a few hours away. The DON said the RN had not come in yet. The DON said there was a rotation for the on-call nurse, for the nurse managers and the expectation was if someone called in sick the on-call nurse was to cover the spot. She said her expectation was if the facility called the on-call nurse, that the on-call nurse was to get into the building. During the interview with the DON on [DATE] at 10:53 a.m., she said she was on the phone with ADON G when LVN D called. The DON checked her phone records and said it was 1:43 p.m. on [DATE] when LVN D called. The DON stated she asked ADON G what was wrong and ADON G told her she was not sure; the DON asked ADON G if the ambulance was called, and she (ADON G) said yes. The DON reported LVN D was frantic and hung up on them (the DON and ADON G). The DON stated LVN D mentioned that there was no suctioning equipment available; the DON told LVN D that it was in the drawer. The DON said they (ADON G and the DON) after everything calmed down and LVN D told them she (LVN D) was unable to find anything. The DON said her expectation for tracheostomy care was the nurses checked the drawer for tubing and to replace what they used. The DON informed surveyor there was no one staff specifically designated to check and re-fill the suctioning catheters. The DON said that practice did not work very well on [DATE] because LVN D was unable to find anything. The DON guessed that the night staff did not replace the catheters used. The DON said the drawer was full on [DATE] and there were at least five suctioning kits available. The DON said the catheters were supposed to be used once and thrown away. The DON said the Administrator ordered the right catheters from someone local to make sure the facility had some available and there were ten kits delivered on [DATE] or [DATE]. The DON stated she was not sure where they went after they were delivered. The DON said the staffing coordinator was responsible for ordering equipment but not putting it up because we all help each other. The DON said there was a list of equipment that was supposed to be in the supply room, and it needed to be checked at least once a week. During the interview with the DON on [DATE] at 10:53 a.m. she said typically a yankauer catheter was available to suctioning on the crash cart. (A yankauer catheter is a hard, inflexible tube used to suction fluids from the mouth). The DON said the staff did not use a yaunker catheter. The DON said she was still trying to figure out what the staff used to suctioning Resident #1. The DON said the crash cart was checked for suctioning equipment once weekly by one of the ADONs and the night staff completed a nightly audit. At that time, the DON said training given to the staff about tracheostomy care was a Respiratory Therapist came in [DATE]. T[TRUNCATED]