**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 8 residents reviewed for accidents and hazards. MA A failed to have another staff assist while providing care for Resident #1 in the bed on 1/4/25. Resident #1 rolled out of the bed, fell to the floor, landed on her knees, and fractured both knees. Resident #1 was hospitalized after. An IJ was identified on 1/9/25. The IJ template was provided to the facility on 1/9/25 at 5:09 p.m. While the IJ was removed on 1/10/25 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility needed to monitor the implementation of the plan of removal. The failure placed residents at risk for serious injury, harm, and/or death. The findings included: Record review of Resident #1's admission record, dated 1/8/25, admitted on [DATE] revealed a [AGE] year-old female with diagnoses that included encephalopathy (any brain disorder or disease that affects the brain's structure or function), gastrostomy status (a surgical procedure that creates an opening in the abdomen and into the stomach. A feeding tube, also known as a G-tube, is inserted through the opening to deliver food, fluids, and medications directly to the stomach.), other cerebral palsy (a group of neurological disorders that affect a person's ability to move, maintain balance, and coordinate muscles), muscle weakness, and cognitive communication deficit. Record review of Resident #1's admission MDS, dated [DATE], revealed she had severely impaired cognition for daily decision making. Section GG showed she was dependent (Helper does ALL of the effort - resident does none of the effort to complete the activity - or the assistance of 2 or more helpers is required for the resident to complete the activity) with rolling left and right. Section H for bladder and bowel showed the resident had a indwelling catheter and was always incontinent of bowel and bladder. Record review of Resident #1's care plan, last revised 12/13/24, revealed she had an ADL self-care performance deficit related to cerebral palsy and she required staff participation to reposition and turn in bed. The care plan did not specify if she was a 1 or 2 person assist. Record review of Resident #1's visual/bedside [NAME] report, dated 1/8/25, showed: Transfers BED MOBILITY(ROLL LEFT AND RIGHT, SIT TOLYING, LYING TO SITTING ON SIDE OF BED):Requires staff participation to reposition and turn in bed. Bed Mobility TRANSFER(CHAIR/BED TO CHAIR TRANSFER,TOILET TRANSFER)): Requires staff participation with transfers. Record review of Resident #1's daily skilled progress notes starting on 11/6/24 through 1/4/25 revealed that she was total assist of 2 with ADLs - bed mobility 2+ physical assist; totally dependent. Record review of Resident #1's nursing progress note, dated 1/4/25, written by LVN B stated: -3:59 p.m. resident s/p witnessed fall. Vital signs are stable at this time. No physical injuries or skin tears noted. Some redness to BLE. Resident does complain of pain. Family and NP. aware. New order to Xray BLE. Resident now resting in bed with call light in reach. Bed is in lowest, locked position. Door remains open for additional observation. -5:49 p.m. Sending to ER to rule out any fractures. [Transport Company] ETA 30-45 minutes from this time. -6:47 p.m. [Transport Company] picked up resident at this time. Resident still alert and oriented upon leaving, No nonverbal indicators of pain noted. Report given to [Hospital] [Nurse] ER RN. -1/5/25 9:45 a.m. Called .hospital and spoke with .RN about plan of care. RN stated resident is still pending consultations with hospitalist, cardiologist, and orthopedic physicians for final say, right now we are just managing her pain and nutrition status. Not discharging at this time. Relocated resident bed against wall for fall precaution and floor mat in place. Pending discharge from hospital. Record review of Resident #1's OT evaluation, dated 11/7/24, written by OT E revealed Patient is current total Ax2 with bed mobility . OT provided demonstration and education with our skilled CNAs on bed mobility during changing of brief . Record review of a written statement, dated 1/4/25, written by MA A revealed she provided incontinent care to Resident #1 by herself, and Resident #1 fell off the bed, landing on her knees. Record review of Resident #1's x-ray results, taken 1/4/25, showed acute, traumatic, impacted supracondylar femoral fracture of the right and left knee. Record review of Resident #1's hospital records, printed 1/10/25, stated she was admitted on [DATE] for witnessed fall, hit both knees and side of head with no loss of consciousness. The doctor noted because the resident was non-ambulatory and also had cancer, they would not provide surgical intervention. The Xray of the left and right knee results stated: 1. Osteoporosis (disease in which your bones become weak and are likely to fracture (break)) and multifocal osseous metastatic disease (when cancer from one part of the body spreads to the bones. These metastases can be osteolytic or osteoblastic, causing bone destruction or new bone formation). 2. Age-indeterminate pathologic fracture of the right acetabulum (break in the socket portion of the hip joint) with involvement of the posterior column (the back part of the hip socket). Consider further characterization with CT. 3. Comminuted (a type of bone fracture that is broken in at least two places or multiple fragments) and displaced fractures (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of bilateral distal femoral metaphysis (end of the thigh bone) with intra-articular extension into the knee joint (bone fracture in which the break crosses into the surface of a joint. This always results in damage to the cartilage.) bilaterally. 4. Suspected nondisplaced (bone cracks or breaks but retains its proper alignment and position) bilateral inferior patella (knee cap) fractures. 5. Chronic (old) appearing fractures of the left superior pubic ramus (pelvic area) and left proximal (position in a limb that is nearer to the point of attachment) fibular diaphysis (The fibular diaphysis is the shaft of the fibula, which is one of the two bones of the lower leg. It is situated between the knee and ankle and helps keep the ankle joint stable). Record review of fall report, dated 1/4/25, for resident #1 was completed by LVN B, stated .The Resident was observed on the floor next to her bed, laying on her back CNA. stated she was providing incont/peri care During the process on repositioning the resident the residents' legs slipped of the bed onto the side of the bed in which the resident was initially in a praying position Assessed immediately for pain and injuries No physical injuries or skin tears observed at this time, but redness was noted to lower left knee Resident complains to pain to BLE. Stated her head does not hurt only her legs . The report stated the resident was alert and her mobility was bedridden. It stated the predisposing physiological factor was incontinent. During an interview on 1/8/25 at 4:29 p.m. CNA D stated she worked on 1/4/25 with MA A but was showering another resident at the time MA A dropped Resident #1. CNA D stated she always had a second person assist her with Resident #1 because she was a 2 person assist and also because she was on an air mattress and they could be dangerous when turning a resident in bed. During an interview on 1/9/25 at 1:39 p.m., OT E stated Ax2 with bed mobility meant the resident required 2 persons for a brief change. OT E stated she would have shown the CNAs how to safely roll the resident for incontinent care to prevent injury to the resident or bruising. OT E stated she would use Ax2 for resident would need more physical excursion from the CNA to turn and therefore required a second person to safely turn and position the resident. During an interview on 1/8/25 at 4:50 p.m., MA A stated she normally worked as a medication aide but had picked up a shift as a CNA on 1/4/25. MA A stated she believed the resident was a 1-2 person assist for incontinent care and felt confident she could change the resident by herself. The MA stated the resident was squirming and pulling herself during the care and she asked her to stay still and next thing she knew she fell on to the floor on to her knees. MA stated she thought Resident #1 only need one person to assist with turning in bed. MA A stated she had not had any formal in service or coaching as of 1/8/25 related to Resident #1 falling out of bed during incontinent care. During an interview on 1/8/25 at 6:25 p.m., LVN B stated Resident #1 was a 2 person assist when turning in bed. LVN B stated she was informed by MA A that Resident #1 fell during incontinent care. She stated she asked MA A why she did not come get her to assist with turning the resident and MA A stated she did not know. LVN B stated the resident was returned to bed and was able to communicate that she had pain at her knees. A mobile x-ray was done and found possible fractures. LVN B stated she was sent to the hospital, and she later spoke with the nurse at the hospital who stated she had fractures and were pending a decision if she would be cleared for surgery. During an interview on 1/9/25 at 3:12 p.m., with MDS F stated she updated Resident #1's care plan on 12/13/25 in the mobility section. She stated the electronic medical records system gives prepopulated interventions that could apply, and she chose to check off Requires staff participation to reposition and turn in bed for bed mobility because some of the CNA could change Resident #1's brief on their own and some of the CNA's needed assistance and could not change the resident's brief alone. MDS F stated although the MDS section GG noted the resident was dependent for bed mobility it did not mean she required 2 staff because hygiene was also dependent but did not require 2 staff to help her brush her teeth. During an interview on 1/8/25 at 5:39 p.m., the DON stated she received a call from LVN B on 1/4/25 about the fall Resident #1 had. She stated they did not understand the initial x-ray results, so they sent the resident to the hospital. The DON stated they had nothing conclusive from the hospital yet to know if she had fractures. The DON stated the [NAME], or care plan showed the resident required 1 or 2 staff for assistance but upon looking further neither showed how many staff the resident required to assist and this could cause accidents. The DON stated going forward Resident #1 would be a 2 person assist and all residents with pressure reducing mattresses would require 2 staff to assist with turning to prevent falls. The DON stated she did not report the injury to HHSC because it was a witnessed fall. The DON stated she began in servicing staff on Monday 1/6/25 and in serviced MA A after her interview with surveyors on 1/8/25. Record review of facility policy titled Fall Management System. Dated 12/2023, stated It is the policy of this facility to provide an environment that remains as free of accident hazards as possible. It is also the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs . 2. Residents with high risk factors identified on the Fall Risk Evaluation will have an individualized care plan developed that includes measurable objectives and timeframes. a. The care plan interventions will be developed to prevent falls by addressing the risk factors and will consider the particular elements of the evaluation that put the resident at risk . An Immediate Jeopardy was identified on 1/9/25 The Administrator and the DON were notified of the Immediate Jeopardy on 1/9/25 at 5:09 p.m. and were given a copy of the IJ template and a Plan of Removal (POR) was requested. The facility's Plan of Removal for the Immediate Jeopardy was accepted on 1/10/25 at 12:30 p.m. and reflected the following: [Nursing Home] Plan of Removal 1/9/25 Per IJ Template F689- Incidents/Accidents Immediate Action o Medical Director notified of Immediate Jeopardy on 1/9/25 @ 1811 (6:11 p.m.). o Resident RP .was notified of Immediate Jeopardy on 1/9/25 @2002 (8:02 p.m.) o Resident #1 was sent to [Hospital] on 1/4/25 and is no longer in the facility. o The following in-services were conducted: Abuse and Neglect at 100% for all staff, Review of [NAME] to determine who is a 2 person assist with ADL-bed mobility to all licensed nurses, CNA's and CMA' at 100%, OT and PT were in-serviced at 100% on evaluating new admissions to determine ADL-bed mobility status, and all licensed nurses were in-serviced at 100% to refer to special instructions in resident's care profile to ensure ADL-bed mobility documentation is accurate, starting on 1/9/25 and completed on 1/10/25 by 1 pm. Any employee not receiving in-services will not be allowed to work their shift until in-services have been received. In-services will be in person or via phone. o An audit of resident ADL's- bed mobility to identify residents who require 2 persons assist completed at 100% by nursing and therapy services to be completed on 1/10/25 by 1 pm. o Any resident's identified as 2 persons assist for ADL's-bed mobility will be added to the [NAME]/Careplan and Special Instructions in the resident's care profile to be completed on 1/10/25 by 1 pm. o CNA A (CNA A is the same person as MA A) was in-serviced 1:1 on 2 persons assist for ADLs- bed mobility and referring to [NAME] for ADL- bed mobility status to be completed on 1/10/25 by 1pm. o Residents safe surveys were starting on 1/9/25 and to be completed on 1/10/25 by 1pm. o Residents safe surveys were starting on 1/9/25 and to be completed on 1/10/25 by 1pm. Identification of Others Affected All residents who require 2 persons assist with ADLs-bed mobility have the potential to be affected by this alleged deficient practice. Systemic Change to Prevent Re-occurrence. 1. DON/ADON started in-services on Abuse and Neglect at 100% for all staff, Review of [NAME] to determine who is a 2 person assist with ADL-bed mobility to all licensed nurses, CNA's and CMA's at 100%, all licensed nurses were in-serviced at 100% to refer to special instructions in resident's care profile to ensure ADL-bed mobility documentation is accurate to be completed on 1/10/25 by 1pm. Any employee not receiving inservices will not be allowed to work their shift until in-services have been received. In-services will be in person or via phone. 2. Starting on 1/9/25 an audit of resident ADL's- bed mobility to identify residents who require 2 persons assist completed at 100% by nursing and therapy services to be completed on 1/10/25 by 1 pm. 3. Starting on 1/9/25 any resident's identified as 2 persons assist for ADL's-bed mobility will be added to the [NAME]/Careplan and Special Instructions in the resident's care profile. 4. Starting 1/9/25 any new residents will be evaluated by therapy services to determine if a resident requires 2 persons assist with ADL-bed mobility and will ensure it is added to [NAME]/Care Plan and to special instructions in resident's care profile. 5. Starting 1/9/25 any new hires, licensed and certified will receive all in-services before working their assigned shift. 6. Two MDS nurses will verify that all new assessments careplan and [NAME] corelate with the plan of care. A log with 2 verification signatures will be in place starting 01/10/25 and will be on-going. 7. All nurses CNAS and CMAS will complete a Bed mobility competency prior to working the floor. The competencies will be completed by 1-10-25 by 1:00pm. 8. All new hires will receive a bed mobility competency prior to working the floor. Monitoring to ensure on-going compliance. 1. DON/Designee will ensure any resident requiring 2 persons assist with ADL-bed mobility is added to care plan/[NAME] and special instructions of resident's care profile. Starting 1/9/25 and will continue for 90 days to ensure compliance and continued to be reviewed monthly during QAPI. 2. DON/Designee will review new admissions to ensure if a resident requiring 2 persons assist with ADL bed mobility it is added to the [NAME]/Care Plan and special instructions of resident's care profile starting 1/9/24 and will continue for 90 days to ensure on going compliance and continued to be reviewed monthly during QAPI. 3. The plan will be reviewed with all nurse managers who will monitor staff when making rounds to ensure the plan is being followed. The managers will be in-serviced and in-service will be completed on 1-10-25. 4. The DON /Administrator will observe 10 staff members a week for verification of proper use of care plans and [NAME]. A tracking log will be in place showing verification of proper use and which employee was observed this will begin 1-10-25 and will be on going, until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 5. The DON/ ADON will verify MDS verification log is accurate by reviewing the log weekly. This process will start on 1-10-2025 and will be on going until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 6. DON/designee will observe 5 nursing staff weekly complete proper bed mobility, starting 1-10-25 and will be on going until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 7. Summary of IJ and corrective action to be reviewed by QAPI monthly until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. The facility's POR Verification was as follows: Record review of POR binder note stated Medical Director was notified of Immediate Jeopardy on 1/9/25 at 6:11 PM. Interview on 1/10/25 at 4:19 p.m., the Medical Director stated she had not spoken to the facility about an IJ, and it may have been in her call log. The Medical Director stated there are several reasons a resident might need more assistance with bed mobility and was based on the ability of the patient. She stated for example weight issues could require the resident to need more assistance. She stated the type of assistance needed was dependent on the residents needs and abilities. Interview on 1/10/25 at 7:00 p.m., the DON she left a message on 1/9/25 for the Medical Director. The DON showed her call log and a call lasting 46 seconds at 6:11 p.m. was on the call log. Interview on 1/8/25 at 3:00 PM, Resident #1's RP was interviewed and stated another emergency contact had more information about what happened to the resident the day of the fall and referred the surveyors to speak to that contact. Review of EHR progress notes of Resident #1 stated RP was notified of Immediate Jeopardy on 1/9/25 at 8:02 PM. Interview on 1/10/25 at 7:00 p.m., the DON stated she told the RP what happened and because of what happened and an IJ was called. The RP stated she would pass the message onto the emergency contact #2. Record review of Resident #1's EHR progress notes dated 1/4/25 at 6:47 p.m. stated resident was transferred to [hospital] via EMS. During an Observation on 1/9/25 at 8:53 a.m. Resident #1 was at the hospital. Resident #1 was asleep in bed and non-interviewable. The hospital Case Worker stated the resident had broken bones in her legs and was not a candidate for surgery. The Case Worker stated they were just making the resident comfortable and she would most likely discharge home as the family wanted. Record review of in-service titled Abuse, Neglect, and Exploitation, dated 1/9/25 contained 143 of 143 scheduled staff signatures present in plan of removal binder. Record review of in-service titled 2 Person Assist for ADL/Bed Mobility with Review of [NAME] conducted on 1/9/25 with scheduled staff signatures present (89 total, 56 of 56 CNAs, CMAs, or HA signed the in-service, and 33 Licensed Nurses). Record review of in-service titled [NAME] and Bed Mobility, dated 1/10/25, showed PT, OT, and ST with 25 of 25 scheduled staff signatures present. During an interview on 1/10/25 at 7:00 p.m., the DON stated she participated in training for staff by demonstrating to staff where to locate the [NAME], special instructions, POC, and care plans. During an interview on 1/10/25 at 2:23 p.m., the DON stated they gathered input from rehab department for any residents they had prior PT, OT, ST, evaluations done on, and CNAs input to compile a list of residents who needed +2 assistance with bed mobility. Record review of active resident list was used to audit 115 residents and showed an updated list of residents with clarification of the type of mobility assistance they required. On 1/10/25 a random sample from taken from the Resident audit list. The [NAME] was reviewed of each resident and were updated with ADL-bed mobility status for bed mobility and transfers the following sampled residents: Resident #2 +2, +2 Resident #3 +1, +1 Resident #4 +2, +2 Resident #5 +2, +1 Resident #6 +2, +2 Resident #7 +2, +2 Resident #8 +1, +1 Resident #9 +2, +2 Resident #10 +2, +1 Resident #11 +1, +1. During an interview on 1/10/25 at 7:00 p.m., the DON stated every resident care plan was updated to state how many persons are required for assistance with bed mobility and transfers. Record review of in-service titled 2 Person Assist for ADL/Bed Mobility with Review of [NAME] conducted on 1/9/25 contained MA A's signature. Interview on 1/10/25 with MA A at 6:17 p.m., she said LVN H did the in service with her 1 to 1, and another nurse watched her to the ADL portion. During an interview on 1/10/25 at 7:00 p.m. the DON stated she re-iterated to MA A she should ask for assistance with a resident if she was unsure of the type of assistance the resident required. The DON stated MA A normally worked as a medication aide and may not have been as familiar with the type of assistance the resident needed with mobility. . Record review of POR binder on 1/10/25 revealed 20 resident safe surveys were completed and no concerns were noted. During an interview on 1/10/25 at 7:00 p.m. the DON stated the AITs and DONs came into help complete the safe surveys. Nothing was reported of concern. Record review of POR binder revealed a document, dated 1/10/25, for an Off Cycle QAPI with staff signatures present. Record review on 1/10/25 a sample of residents' EHR [NAME] for Resident #12, Resident #13, Resident #14, Resident #15, and Resident #16 were updated for 2 persons assist for transfers and bed mobility. Previously their [NAME] and care plans had not stated the number of staff needed for transfers. Interview on 1/10/25 at 6:55 p.m., . MDS F stated the facility will determine new admissions mobility needs and document them for staff to reference by looking at the last 3 days of assessment documentation from the nurse after a resident is admitted . MDS F stated the nurse does the documentation for 3 days under the GG assessment then they compared it with therapy assessments. MDS F stated the DOR did a verbal with them during daily meetings and would review the PT and OT documentation. They would verify it is accurate and matches the nurse and PT assessments. MDS F stated typically, PT, OT, or ST would try to see the Resident next day after admission for an assessment or if they were admitted early enough they could complete the assessment the same day. During an interview on 1/10/25 at 7:00 p.m., the DON stated they would verify with MDS new admissions, the DOR will give them updates, and discuss anyone she had done an assessment on and require a 2 person assist. Record review on 1/10/25 showed a log with one upcoming new hire notated to be trained at first shift so far. During an interview on 1/10/25 at 7:00 p.m. the DON stated they had called in mostly everyone who was new to complete the in-service and training. The DON stated any new hires after that would train with HR to do the sit-down orientation. During an interview on 1/10/25 at 6:48 p.m. with MDS F said they started a log with new admissions from 1/9/25. They looked at them to make sure their ADLs were checked, the nurse completed the assessments until therapy was able to evaluate them. All 3 new admission residents had the assessments done. MDS F stated they planned to fill out the audit log weekly. MDS F stated they corrected all the care plans, [NAME], and special instructions to specify if the resident needed one or two people to assist. Record review of report dated 1/9/25, showed a new admission and discharge of residents in the facility with 3 residents on it for new admissions. Record review of document titled new assessment/care plan/[NAME] log, dated January 2025, showed 2 MDS nurses and the DON signed that they looked at the 3 new resident admissions. Interview on 01/10/25 at 4:07 p.m. ADON J stated the bed mobility competency were done by her LVN K, LVN H, and LVN L, and maybe LVN M. ADON J stated they watched staff they were training perform perineal care and would guide them on the correct way as needed. Record review of documents titled Persons Needing Assistance with Bed Mobility, dated 1/9/25-1/10/25, showed 70 direct care staff (LVNs, RNs, CNAs, MAs, and HAs) completed skills check off for this competency on 1/9/25 though 1/10/25. 12 staff from the staff list did not have competency check offs because they were either no longer working at the facility or were PRN staff that were not scheduled to work till after 1/10/25. Interviews conducted on 1/10/25 between 3:49 p.m. to 7:44 p.m. with 20 staff (MA I, CNA S, CNA T, OT U, CNA V, CNA W, CNA Q, CNA Z, CNA D, CNA AA, CNA BB, CNA P, CNA CC, MA A, CNA Y, LVN K, LVN DD, and LVN C) from various shifts who all stated they received the in service and hands on training for residents who needed assistance with mobility and how to locate the information in the medical records. During an interview on 1/10/25 at 7:00 p.m., the DON stated nurse managers will oversee training new hires, but they also planned to hire a staffing developer with a start date of 2.4.25 to assist with training. The DON stated she would review any resident requiring 2 persons assist with ADL-bed mobility was added to care plan/[NAME] and special instructions of resident's care profile and review this in QUAPI meetings. Record review of POR binder with in-services of nurse managers on 01/10/25 given by DON. All topics on the POR were reviewed. 8 staff signed the in service. Record review of document titled verification of care plan and [NAME] log had 4 staff names, 2 staff with additional required teachings, and signed off by the DON. Record review of document titled verification log new assessment/careplan/[NAME] showed a log with the resident, date, and signature for both MDS and DON who verified it. During an interview on 1/10/25 at 7:00 p.m. the DON stated verification of proper bed mobility log was completed by MDS G who observed two CNAs on 1/10/25. The log was filled out with this information and placed in the POR binder. During an interview on 1/10/25 at 7:00 p.m. the DON stated they had an off cycle QAPI and discussed how they were going to move forward. The DON stated they had the meeting on 1/10/25 and a log of this was placed in the POR binder. On 1/10/25 at 8:55 p.m., the Administrator was notified the IJ was removed. While the IJ was removed on 1/10/25 at 8:50 p.m. the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy because of the facility's need to monitor the implementation of the plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 57 Residents (Resident #1) reviewed for psychosocial concerns, in that: The facility failed to put interventions in place or promptly arrange for psychiatric services for Resident #1 after he displayed increased signs of depression on [DATE]. On the evening of [DATE], Resident #1 committed suicide by a firearm. This failure resulted in the identification of an Immediate Jeopardy (IJ) on [DATE] at 5:05 p.m. While the IJ was removed on [DATE] at 3:20 p.m., the facility remained out of compliance at a level of potential harm with a scope identified as isolated until interventions were put in place to ensure residents with signs and/or symptoms of psychiatric illnesses were promptly evaluated for psychiatric treatment. This failure could place residents who need psychiatric services at risk of diminished quality of life, decline in mental health, and self-harm. The findings were: Record review of Resident #1's face sheet, dated [DATE], revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of encounter for other orthopedic [referring to the musculoskeletal system] aftercare, unspecified protein-calorie malnutrition, insomnia, hypotension, unspecified, and acute respiratory failure with hypoxia [low oxygen levels in the blood]. There was no psychiatric-related diagnosis in Resident #1's face sheet. Record review of Resident #1's initial care plan, dated [DATE], revealed the following: Cognition . Intervention: Social Services to provide psychosocial support as needed. Record review of Resident #1's entry MDS assessment, dated [DATE], revealed no documentation of depression or other psychiatric illnesses. Record review of Resident #1's admission MDS assessment, dated [DATE], revealed Resident #1 had a BIMS score of 15, signifying no cognitive impairment. This admission MDS did not contain any documentation of depression or other psychiatric illnesses. Record review of Resident #1's PHQ-9 assessment [an assessment for screening, diagnosing, monitoring, and measuring the severity of depression], dated [DATE] and written by MDS Coordinator D, revealed Resident #1 had a severity score of 8, signifying mild depression. Further record review of this document revealed Resident #1 denied suicidal ideation, but Resident #1 was noted with: - Little interest or pleasure in doing things, with a symptom frequency of 7-11 days. - Trouble falling asleep or staying asleep, or sleeping too much, with a symptom frequency of 12-14 days. - Feeling tired or having little energy, with a symptom frequency of 12-14 days. Further record review of this document revealed a score of 15-19 was Moderately Severe Depression. Record review of Resident #1's Social Services assessment, dated [DATE] and written by Community Liaison Staff C, revealed Resident #1 did not have any psychosocial needs. Record review of Resident #1's inventory sheet, dated [DATE], revealed no firearms in Resident #1's inventory. Record review of Resident #1's nursing progress notes, dated from [DATE] to [DATE], revealed no progress note regarding any notification or coordination of psychiatric services. Record review of Resident #1's Physician Progress Note, dated [DATE] at 9:41 a.m. and written by NP H, revealed no documentation of any depression or referral to psychiatric services. There was no documentation of any physician or nurse practitioner notification for psychiatric-related reason prior to Resident #1's suicide on [DATE]. Record review of Resident #1's PHQ-9 assessment, dated [DATE] at 12:36 p.m. and written by Community Liaison Staff C, revealed Resident #1 did not have a PHQ-9 score. Resident #1 denied suicidal ideation but Resident #1 was noted with: - Feeling down, depressed, or hopeless, with a symptom frequency of 12-14 days (nearly every day [over the last 2 weeks].) This was a new finding that was not noted on Resident #1's previous PHQ-9 assessment on [DATE]. - Trouble falling asleep or staying asleep, with a symptom frequency of 7-11 days (half or more of the days [over the last 2 weeks].) - Feeling tired or having little energy, with a symptom frequency of 12-14 days (nearly every day [over the last 2 weeks]). - Poor appetite or overeating, with symptom frequency of 12-14 days (nearly every day [over the last 2 weeks].) This was a new finding that was not noted on Resident #1's previous PHQ-9 assessment on [DATE]. - Feeling bad about yourself, with a symptom frequency of 7-11 days (half or more of the days [over the last 2 weeks]). This was a new finding that was not noted on Resident #1's previous PHQ-9 assessment on [DATE]. - Trouble concentrating on things, with a symptom frequency of 12-14 days (nearly every day [over the last 2 weeks].) This was a new finding that was not noted on Resident #1's previous PHQ-9 assessment on [DATE]. - Moving or speaking so slowly, with a symptom frequency of 7-11 days (half or more of the days) [over the last 2 weeks]. This was a new finding that was not noted on Resident #1's previous PHQ-9 assessment on [DATE]. Record review of Resident #1's physician orders, obtained on [DATE], revealed no orders for psychiatric services or medications for psychiatric illnesses. Record review of Resident #1's care plan, obtained [DATE], revealed no care plan specifically for psychiatric illnesses such as depression. Record review of an email from this surveyor to the Administrator, dated [DATE], revealed this surveyor requested for the following: Anything and everything related to your [self-reported incident] (even if it's in progress. In-services, photographs, video footage.) During the entrance conference and joint interview on [DATE] at 12:47 p.m., the Administrator stated the facility began their in-services last night, [DATE], and in-serviced staff members on the evening shift (2:00 p.m. - 10:00 p.m.) working on [DATE] and the overnight shift (10:00 p.m. - 6:00 a.m.) working from the evening of [DATE] into the morning of [DATE]. The Administrator stated there was a team of social workers currently in the facility conducting 1:1 interviews with residents. The Director of Nursing stated the facility should be 90% finished with their educational in-services. During this entrance conference, this surveyor requested for everything related to Resident #1's suicide, including educational in-services. During an interview on [DATE] at 2:29 p.m., the DON provided three educational in-services: one educational in-service on social media and resident rights, a second educational in-service on Active Shooter Procedure, and a third educational in-service on Abuse and Neglect. There were no other educational in-services provided to this surveyor prior to the identification of the Immediate Jeopardy on [DATE]. During an interview on [DATE] at 2:35 p.m., LVN B stated he worked with Resident #1 on the evening of [DATE]. LVN B stated Resident #1 went to chemotherapy every day and Resident #1 went to chemotherapy earlier in the morning shift of [DATE] and returned on his shift, which was the afternoon shift. LVN B denied Resident #1 verbalized suicidal ideation. LVN B stated Resident #1 seemed happy that day. LVN B stated, from what I understand, I think [Resident #1] was going into hospice on Wednesday [[DATE]]. I think that was the story but as far as that, I had no knowledge of him being depressed or any of those ideation. LVN B stated, I was doing my last rounds. I was in the room diagonal of the hall. I was flushing the tube-feeding pump [in the other room] and around 8:30 [p.m.] I heard a pop . I walked outside [the room], I looked at [the residents in room [ROOM NUMBER]], I looked if everyone was ok. They were all asleep. I went to [room] 115, which was across [Resident #1's] room, and everyone was asleep. And as soon as I got to [Resident #1's door] I smelled the gunpowder . So I opened up the door and I noticed he had-the gun [a handgun] was in his right hand and it was pointed at him with his thumb on the trigger and a bullet wound in his forehead . And so I stepped out of the room. And I said [to his co-workers] ' you guys aren't allowed to go into that room . I called 911. I got EMS on the scene, 911 on the scene. And I was on the phone with them and I got to explain what happened . I had to stay out there at the front door . They got there within a couple minutes. I want to say 5 to 6 cop cars got there . They had me sit back in the cop car because they said, 'you can't be around your co-workers. You need to be isolated from there.' They had a CSI guy and I did my statement with them. I explained what happened . [Resident #1] had a visitor who I had never seen before. I've never seen anyone enter that room besides us giving him treatment, changing him, things like that. LVN B stated he never saw the gun Resident #1 used before. During an interview on [DATE] at 8:52 a.m., Representative F (social worker from a local hospital) stated Resident #1 did not have any psychiatric diagnoses or psychiatric services during his hospital stay from [DATE] to [DATE] prior to his admission to the facility on [DATE]. During an interview and record review on [DATE] at 10:15 a.m., video footage of Resident #1's hallway was reviewed with the Administrator. The camera angle was from the very end of the hallway and pointed towards the nurses' station at the center of the building, which was near the facility's main entrance. The entire hallway was in view, but the inside of the residents' room were not in view except for the resident's doors. The video did not include sound. The Administrator stated the video footage's clock was ahead by one hour, therefore the timestamps are one hour ahead of the actual time of events. Record review of video footage of Resident #1's hallway revealed at the video timestamp [DATE] at 15:03 [2:03 p.m.] a visitor visited Resident #1 in his room. At the video timestamp [DATE] at 16:47 [3:47 p.m.], Resident #1's visitor pushed Resident #1 out of Resident #1's room on Resident #1's wheelchair. Resident #1 wore a bulky, dark-colored jacket. Resident #1 and his visitor moved towards the nurses' station at the center of the building and then moved off-camera. At the video timestamp [DATE] at 19:44 [6:44 p.m.], Resident #1 and his visitor returned to Resident #1's room. Resident #1 and his visitor did not have any visible packages or bags with them upon their return. Resident #1 did not reappear on the video footage after this. At the video timestamp [DATE] at 20:34 [7:34 p.m.], Resident #1's visitor left Resident #1's room, moved towards the nurses' station at the center of the building, and then moved off-camera. Resident #1's visitor did not reappear on the video footage after this. At the video timestamp [DATE] at 21:24 [8:24 p.m.], LVN B entered another resident's room across the hall from Resident #1's room. At the video timestamp [DATE] at 21:26 [8:26 p.m.], LVN B exited the other resident's room and looked around the hallway and checked the rooms of other residents. The Administrator stated LVN B must have heard the gunshot at this point. At the video timestamp [DATE] at 21:27 [8:27 p.m.], LVN B entered Resident #1's room. At the video timestamp [DATE] at 21:28 [8:28 p.m.], LVN B exited Resident #1's room with his personal phone in one hand and his other palm on his forehead. LVN B paced in front of Resident #1's room and eventually moved towards the nurses' station, speaking to his co-workers as he walked. At the video timestamp [DATE] at 21:33 [8:33 p.m.], LVN B walked to his nurse cart parked in the middle of the hallway. LVN B's phone was in his hand and he was speaking into his phone. Then LVN B left his nurses cart, moved towards the nurses' station at the center of the facility, and then moved off-camera. LVN B did not reappear on the camera footage after this. At the video timestamp [DATE] at 21:40 [8:40 p.m.], local police officers and EMTs arrive at Resident #1's room. At the video timestamp [DATE] at 21:44 [8:44 p.m.], the EMTs leave. Resident #1's remains were not removed by the EMTs. During an interview on [DATE] at 11:33 a.m., Representative G (psychologist from a local hospital) stated Resident #1 did not have a history of suicidal ideation or mental health history. Representative G stated Resident #1 had never been treated for any sort of mental health condition and never called the suicide crisis hotline. During an interview and record review on [DATE] at 11:47 a.m., MDS Coordinator D stated upon admission she typically performed a PHQ-9 assessment on the resident. MDS Coordinator D stated, PHQ-9 entails depression. I want to say anything over 10 is major depression, 9 and under is moderate, mild. After that's done and if it's major [depression] we get psych consult involved. I can't remember what [Resident #1's PHQ-9 score] was off-hand. We do that [assessment] and if [the resident] was still here for more than 20 or 30 days, we do another one. MDS Coordinator D stated Resident #1 never verbalized suicidal ideation. MDS Coordinator D stated she did Resident #1's PHQ-9 assessment on [DATE] and she did not remember what Resident #1's PHQ-9 score was (which was an 8), but stated Resident #1 was not somber or sad. MDS Coordinator D stated if the PHQ-9 score was an 8, she did not notify the physician but she would notify the nurse. MDS Coordinator D stated they discussed the PHQ-9 score in the morning meeting. Resident #1's PHQ-9 score, dated [DATE], was reviewed with MDS Coordinator D. MDS Coordinator D stated Resident #1's score on the PHQ-9, dated [DATE], would have been 16. MDS Coordinator D stated Community Liaison Staff C (who performed the PHQ-9 assessment on [DATE]) would have reported her findings to the SW. The MDS Coordinator stated if the resident had major depression, psychiatric services would have been notified. The MDS Coordinator stated she was not aware if there were any referral to psychiatric services due to Resident #1's latest PHQ-9 score on [DATE]. During an interview on [DATE] at 12:09 p.m., Community Liaison Staff C stated she completed Resident #1's PHQ-9 assessment on [DATE]. Community Liaison Staff C stated she conducted the PHQ-9 assessment on Resident #1 because Resident #1 was going to be discharged . Community Liaison Staff C stated, I asked if he lost motivation with activities, [was he] feeling tired, low energy, [was he] sleeping at night, [was he] feeling depression, and his situation. He did answer yes to a lot of those questions, which signified he was depressed. But he did answer no to self-harm . I asked [Resident #1] if he wanted to talk to somebody and he said maybe. Community Liaison Staff C denied Resident #1 verbalized suicidal ideation. Community Liaison Staff C stated she reported Resident #1's assessment findings to the SW after lunch on [DATE]. Community Liaison Staff C could not recall the specific time. Community Liaison Staff C stated the SW stated a referral for psychiatric services would be sent. Community Liaison Staff C stated she was unsure if the SW sent a referral to psychiatric services for Resident #1. During an interview on [DATE] at 12:30 p.m., the SW stated Community Liaison Staff C helped her conduct the PHQ-9 scale and she oversaw Community Liaison Staff C's work. The SW stated Community Liaison Staff C usually spoke to her [the SW] about any findings on the PHQ-9. The SW stated, [the PHQ-9] is basically assessing for depression. If there's symptoms in mood, behavior, any behavioral changes, if they're [the resident is] having little interest in eating or overeating, sleep hygiene, if they don't have focus or memory, if they're having problems concentrating. It has questions about if they feel bad about themselves or if they want to hurt themselves, if they feel better off dead . It ranges between 1-9 is low. Anything over 9 is a higher number. The SW stated if the resident's PHQ-9 score was over 9, she would refer the resident to the facility's psychiatric service. The psychiatric service would then come and evaluate the patient and see if the resident required counseling or medication. The SW stated she visited Resident #1 frequently and denied Resident #1 verbalized any feelings of depression or suicidal ideation. The SW stated Community Liaison Staff C reported Resident #1's PHQ-9 score, dated [DATE], to her on the afternoon of [DATE]. The SW stated, Community Liaison Staff C] stated it was high and I said I was going to call [Resident #1's] case manager (from a local agency) the next morning. When asked if she notified anyone about Resident #1's PHQ-9 score, the SW stated, No. I'm not sure if I attempted to call [Resident #1's case manager] . I just hadn't gotten to it that day. I usually talk to [Resident #1's case manager] in the morning and we were going to discuss his discharge in the morning. In a follow-up interview on [DATE] at 1:25 p.m., when asked how soon she would notify psychiatric services if a resident required psychiatric evaluation the SW stated she did not know and referred this surveyor to the DON. During an interview on [DATE] at 1:26 p.m., when asked how soon the facility would notify psychiatric services if a resident required psychiatric evaluation, the DON stated the facility would notify psychiatric services immediately if it was an emergent issue such as self harm. The DON stated during the week the facility could contact the on-call psychiatric services within twenty-four hours. The DON stated if the psychiatric services could not see the resident within the same day, the facility would put the resident on a 1:1 observation. During an interview on [DATE] at 1:28 p.m., Resident #1's visitor stated at around 11:00 a.m. on [DATE] Resident #1 texted him [the visitor] that he wanted a tool from his truck. Resident #1's visitor stated, I had an idea . he was probably talking about a gun. He's a gun guy . I got up there right away [at around 3:00 p.m.] and [Resident #1] said he wanted to kill himself. [Resident #1] said, 'I'm done fighting.' [Resident #1] said he could smell his braining burning and he went on to tell me all these things that brought him to his low . So we decided he was going to move to my house on Wednesday [[DATE]] and go to the hospice and not to treatment and just die. Me and him, we talked about the suicide part. I said, 'what are you going to do? Blow your brains out in the [facility]?' We talked about it. We talked about the trauma he's causing innocent people. I said, 'you need to get out of this place. We need fresh air.' And so we left, we signed out. We loaded him in [Resident #1's] truck and the first place we went to was [the visitor's relative's] house . And then we went out to the lake and we sat there and talked about various things . We brought him back to the nursing home and got him in bed . I want to say I left at around 7:49 p.m. Resident #1's visitor stated after Resident #1 was discharged from the hospital to the facility, he drove Resident #1's truck from the hospital and left it at the facility. Resident #1's visitor stated he did not know if Resident #1 had a firearm in his truck and did not check if Resident #1 had a firearm in his vehicle. Resident #1's visitor stated he did not know how Resident #1 obtained the firearm. Resident #1's visitor stated he did not notify the facility or Resident #1's case manager about Resident #1's suicidal ideation. Resident #1's visitor stated, He didn't indicate that he was going to do anything specific to himself. I never heard anything out of his mouth to indicate that he had any depression or mental health issues. And that was the first time I ever heard him talk about wanting to die . If I had any indication he was going to harm himself, I wouldn't tell anybody, but I wouldn't leave him alone. I would have stayed with him. During an interview on [DATE] at 2:42 p.m., NP H stated Resident #1 was admitted to the facility with cancer and was getting outpatient radiation. NP H stated she denied Resident #1 verbalized depression and suicidal ideation to her. NP H stated the PHQ-9 was an assessment for depression. When asked what would be a significant finding on the PHQ-9, NP H stated, I would have to look up the scale and go off what it is. I know it breaks it down for you. NP H stated she did not recall Resident #1's PHQ-9 score. When asked if she would be concerned if Resident #1's PHQ-9 score was an 8, NP H stated, I'd have to pull up the score. NP H stated she did not know Resident #1 had a PHQ-9 score the day he passed away and she would have liked to have been notified of an increase in his PHQ-9 score. NP H stated, normally when something is critical they notify us right away. It would have been within thirty minutes to one hour . I would have asked [Resident #1] more intense questions and then depending on what he would have reported I would have gotten him the needed orders or assistance at that time. During an interview on [DATE] at 4:04 p.m., the DON stated the PHQ-9 assessment was usually completed by the SW, the MDS Coordinators and Community Liaison Staff C. The DON stated the PHQ-9 was an assessment to check a resident's mindset and mental well-being. When asked what would be a significant finding on the PHQ-9, the DON stated, depending on question and how [the resident] answered the question. There's a question on there that says if you're having any suicidal thoughts or if you're trying to kill yourself. If you say yes in any form or fashion it would raise a red flag. When asked what was her expectation if a resident had a high PHQ-9 score, the DON stated, I would like to be made aware. I would like to see if they notified psych services, or if they notified the nurse. Or if they did do any interventions . As soon as you identify it, you would call [psychiatric services.] If you go straight to the doctor, the doctor would ask or the NP would ask if it's immediate harm. Or maybe if it's not immediate, they'll say go ahead and refer to psychiatric services. The DON stated she could not recall if Resident #1 had significant findings on his PHQ-9 scores, but she stated she knew Resident #1 did not verbalize suicidal ideation. The DON stated she was not aware of any interventions put in place following Resident #1's first PHQ-9 score on [DATE] or his second PHQ-9 score on [DATE]. The DON stated she did not know if Resident #1's physician was notified of Resident #1's increased PHQ-9 score on [DATE]. When asked what she would have done if she had known Resident #1's PHQ-9 had increased during his PHQ-9 assessment on [DATE], the DON stated, Based on the questions, I would have asked [the SW] to go and talk to him and see his thoughts . and maybe follow-up from there and see what the outcome was. We would have definitely followed up with the intervention that was needed. When asked if the facility had a quality assurance process to ensure physicians were notified if a resident had an increased or significant PHQ-9 score, the DON stated, I would say reviewing the education with the administrative team. The DON stated the facility would also review changes in the clinical morning meeting. When asked what sort of negative effects could occur to the residents if physicians were not notified of an increase in their PHQ-9 score, the DON stated, increased behaviors. Maybe aggressive behaviors as far as lashing at the staff or verbally aggressive to the staff or verbally aggressive to the residents. Something in the nature of a decline. During an interview on [DATE] at 4:33 p.m., the Administrator stated Resident #1's PHQ-9 score doubled and stated the facility's policy stated psychiatric services will be contacted on elevated PHQ-9 scores within 24 hours. The Administrator stated, the plan with [Resident #1] was to get services for him as quickly as possible or get someone down here and we didn't have any time. [Resident #1] went out at 4:00 [p.m.] When would we have someone come in? Now if we knew he was in danger and he said, 'I'm going to kill myself,' then yes. We would get a 1:1, keep him in his room, get rid of sharp objects. We had nothing to say that this [Resident #1's suicide] was going to happen . The Administrator stated the policy stated psychiatric services will see the resident within 24 to 72 hours. During an interview on [DATE] at 6:53 p.m., Physician E stated she was the Medical Director of the facility. Physician E stated usually the social worker will conduct the PHQ-9 assessment upon admission and frequently. We do have psych services if they [the resident] triggered for BIMS or something. They can refer to behavioral health services. When asked what interventions would she expect if a resident had mild depression, Physician E stated, I would try to engage if there's an immediate risk. I feel if there's an issue that needs no immediate intervention I would prescribe a mild anti-depressant and call psychiatric services. Physician E stated she would expect some interventions if the resident had a PHQ-9 score indicating mild depression and stated the interventions would depend on the situation because sometimes the resident would refuse treatments. Physician E stated on [DATE] at around 9:30 p.m. or 10:00 p.m. (after Resident #1's suicide) she was notified by the Administrator that Resident #1 had moderate depression but denied self-harm. Physician E stated the Administrator also informed her of Resident #1's increased PHQ-9 score. Physician E stated she did not know if Resident #1 had any interventions for his depression. During an interview on [DATE] at 9:23 a.m., the Administrator stated the facility educated their staff members on the PHQ-9 and interventions of the PHQ-9 on [DATE]. The Administrator stated this education was done because of Resident #1's high PHQ-9 score dated on [DATE]. The Administrator stated he didn't know this surveyor was asking for any education on the PHQ-9 and he thought when the surveyor asked for all educational in-services that this surveyor was asking for large educational in-service. In a follow-up interview on [DATE] at 1:07 p.m., LVN B stated he did not know what a PHQ-9 assessment was and he was not made aware Resident #1's PHQ-9 score was high the day he committed suicide. In a follow-up interview on [DATE] at 11:21 a.m., when asked what should have been done when Resident #1 had a PHQ-9 score of 8 on [DATE], considering his new cancer diagnosis and his lack of mental illness history, the SW stated, I could have asked him if he wanted me to refer him to counseling services. I could have coordinated with [the local hospital] if he wanted. I would have just let him know what his score was and ask him if he needed any services or needed to talk to anybody. Record review of the facility's staff roster revealed the facility had 141 staff members. Record review of the facility's educational in-services titled, Social Media - Resident Rights, do not give out information, re-direct to ED/DON, dated [DATE] and provided to this surveyor on [DATE], revealed a total of 131 staff signatures or documentation of verbal education on the educational in-service. However, upon further inspection there were 5 staff members who were noted twice. This brought the actual total number to 126 of 141 (89%) staff members who were educated on how to handle social media and resident rights. Record review of the facility's educational in-service titled, Active Shooter Procedure, dated [DATE] and provided to this surveyor on [DATE], revealed a total of 143 staff signatures or documentation of verbal education on the educational in-service. However, upon further inspection there were 8 staff members who were noted at least twice. This brought the actual total number to 134 of 141 (95%) staff members who were educated on the facility's Active Shooter Procedure. Record review of the facility's educational in-service titled, Abuse & Neglect, dated [DATE] and provided to this surveyor on [DATE], revealed a total of 140 staff signatures or documentation of verbal education on the educational in-service. However, upon further inspection there were 6 staff members who were noted at least twice. This brought the actual total number to 133 of 141 (94%) staff members who were educated on the facility's abuse and neglect policy. Record review of the facility's electronic health record revealed 48 residents did not have a PHQ-9 assessment completed as part of this facility's action plan following Resident #1's suicide until after this surveyor entered the facility on [DATE] at 12:47 p.m. Two of these residents did not have their PHQ-9 assessments completed until after surveyor intervention on [DATE] at 10:57 a.m. Record review of a facility policy titled, Behavior Management, dated 7/2007, revealed, The physician and psychiatric services will be contacted if a resident presents with an elevated PHQ-9 score and or signs and symptoms of behavioral changes. Psychiatric services will perform an assessment within 24-72 hours of notification. There was no verbiage regarding how quickly the facility should contact psychiatric services. Record review of a facility policy titled, Behavior Management and the use of medications, dated 7/2007, revealed: Social Services will make the appropriate referral if needed following agreement from the resident and/or responsible party. There was no verbiage regarding how quickly the facility should contact psychiatric services. Record review of a facility policy titled, Change of Condition Reporting, dated 5/2007, revealed the following: Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The Administrator was notified of an IJ on [DATE] at 5:31 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal accepted on [DATE] and included the following: Immediate Action - Medical Director notified of Immediate Jeopardy on [DATE]. - Resident RP . was notified of incident on [DATE]. - Resident #1 expired. - PHQ9 will be completed on all residents to identify residents with potential depression scores that may require psychosocial treatment to be completed on [DATE]. - Psych services on site on [DATE] and [DATE] to assist with identified issues from PHQ9 assessment. - Inservice on PHQ9 completion and comparing score from current to prior to identify any potential needed intervention, notification to MD and Policy on PHQ9 started on [DATE] and completed on [DATE]. Inservice given by MDS resource. - The following in-services were conducted Abuse and neglect, Resident Rights, Active shooter and Behaviors Management. Started on [DATE] and completed on [DATE]. Any employee not receiving inservices will not be allowed to work their shift until inservices have been received. Inservices will be in person or via phone. - Residents safe surveys were completed on [DATE]. - Staff interviews conducted on [DATE] thru [DATE]. - Off Cycle QAPI completed on [DATE]. Identification of Others Affected All residents have the potential to be affected by this alleged deficient practice. &q[TRUNCATED]

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 3 of 16 residents (Resident # 1, #2, and #3) reviewed for significant medication errors, in that; The facility failed to ensure Resident #1 insulin glargine (a long-acting insulin used to treat high blood sugar from diabetes) was held and not administered for a blood sugar level less than 100 per physician orders which resulted in the resident becoming unresponsive and requiring hospitalization in the ICU. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 1/12/2024 at 3:49 p.m. The IJ template was provided to the facility on 1/12/24 at 3:59 p.m. While the IJ was removed on 1/13/24 the facility remained out of compliance at a level of actual harm with a scope identified as isolated until interventions were put in place to ensure staff members were in compliance with following physician orders for insulin administration. The facility failed to ensure Resident #2's medication; insulin glargine was held for a blood sugar level less than 100 per physician order. The facility failed to ensure Resident #3's medication; insulin glargine was held for a blood sugar level less than 100 per physician order. This failure could place residents at risk for a drop in blood sugar levels, a decline in health, unresponsiveness, hospitalization and/or death. The findings included: Record review of Form 3613-a Provider Investigative Report dated 1/06/2024 revealed the DON self-reported an allegation of neglect when Resident #1's family member alleged negligence after Resident #1 was administered insulin glargine 20u (when her) blood sugar was 77. The report indicated insulin glargine 20 u was administered when Resident #1's blood sugar was 77 with orders that stated not to administer if less than 100. The resident was nonresponsive to verbal stimuli/sternal rub, but vital signs were present. The resident was transferred to a local ER. The investigative findings were confirmed and the document was signed by the DON on 1/12/2024. Record review of Resident #1's face sheet dated 1/11/2024 revealed an admission date of 12/27/2023 with diagnoses which included: type 2 diabetes mellitus with hyperglycemia (blood sugar levels that are elevated and above normal), acute kidney failure and hypertension (high blood pressure). The face sheet indicated Resident #1 was discharged on 1/06/2024 to a local hospital. Record review of Resident #1's baseline care plan dated 1/02/2024 revealed the resident had diabetes mellitus with goals to be free from signs and symptoms of hypoglycemia (blood sugar levels that are below normal) and would not have a re-hospitalization within 30 days with no medication or insulin interventions. Record review of Resident #1's medical record for a comprehensive MDS assessment revealed it had not been completed due to new admission status. Record review of Resident #1's insulin glargine orders dated 12/28/2023 revealed an order for insulin glargine subcutaneous (injection under the skin) solution 100 u/ml, inject 25 units subcutaneously two times a day related to type 2 diabetes mellitus with hyperglycemia, hold if blood sugar less than 100. Record review of Resident #1's January 2024 MAR revealed orders for insulin glargine 100 u/ml, inject 20 units subcutaneously two times a day related to diabetes mellitus, hold if blood sugar less than 100. On -1/06/2024, Resident #1 had a documented BS of 77, insulin was documented as given (instead of held) by RN A. Record review of Resident #1's SBAR documentation dated 1/06/2024 at 10:00 a.m. by the RN Weekend Supervisor revealed Resident #1, who was full code status, had a change of condition of decrease in level of consciousness and was unresponsive. Record review of Resident #1's progress notes dated 1/06/2024 at 12:45 p.m., as documented by RN A revealed: .0700 (7:00 a.m.) I started my morning accuchecks (blood glucose monitoring). Resident (#1) was awake, alert. I asked resident how she was and she stated she was doing fine. I checked her blood sugar, and it was 77. At that time, I administered 20 units of Lantus (insulin glargine) as per MD orders. I mistakenly saw parameters to hold insulin if BS < 70 when the actual order said to hold if BS was < 100 .At 0900 (9:00 a.m. I went to resident's room to check her incision sight (sic) .at this time I noted resident (Resident #1) was nonresponsive to verbal (communication/stimulation) or sternal rub. I immediately checked her vitals .blood sugar machine read lo (sic). At 0910 (9:10 am), I gave resident (Resident #1) glucose oral gel as per MD orders. I stayed with resident and had another nurse call 911. EMS called at 0920 (9:20 a.m.). EMS arrived at 0925 (9:25 a.m.) and transported (Resident #1) to (local hospital) at 0930 (9:30 a.m.). At 0945 (9:45 a.m.), I called the hospital and gave report (to a hospital staff member) and informed her at that time that I had mistakenly given her 20 units of Lantus (insulin glargine). At 1130 (11:30 a.m.), I called to check on Resident #1 and was told she was intubated (required a tube in her airway and mechanical ventilation) but stable and her sugars were up and down .I notified NP C of transfer and medication error, DON and family member . Record review of Resident #1's hospital records dated 1/06/2024 revealed Resident #1 was brought to the emergency department with altered mental status by EMS, after she found unresponsive at the nursing home facility and was given glycogen (medication used to raise blood sugar levels) (at the nursing home). The resident was hypotensive 80/45 (low blood pressure) and hypoglycemic (low blood glucose). EMS checked her blood glucose, and it was also low. She was given D10 (water with 10% sugar via IV) by the paramedic staff and in route her blood sugar improved to 300, however the patient's mental status did not improve. Medical Decision Making: This patient arrived completely unresponsive. Even correcting her glucose with D50 (50% glucose solution via IV), she remained unresponsive. We made the pretty rapid decision to intubate her in order to protect her airway. Normal CT findings (of her brain). Her blood sugar continued to drop despite 2 A (2 doses) of D 50. I think her mental status is due to the hypoglycemia. At this point we will need to admit her to the ICU for further ventilator management. She does not appear to have acute sepsis and her white blood cell count is normal. I am not going to start her on any antibiotics at this point .Her procalcitonin was within normal limits (high levels of procalcitonin indicate sepsis or bacterial infection). Impression/Plan: 1. Altered mental status 2. Acute respiratory failure 3. Acute metabolic encephalopathy due to hypoglycemia (alteration in level of consciousness and global brain function as a result of acute metabolic functions) 4. Acute hypokalemia (low potassium levels) (a documented side effect of insulin administration in medical literature). Record review Resident #1's medication administration time audit for 1/06/2024 revealed insulin glargine 100 u/ml was documented as given on 1/06/2024 at 7:02 a.m. by RN A, which was slightly more than 2 hours before Resident #1 was found unresponsive. During an interview on 1/12/2024 at 8:30 a.m., Resident #1's family member stated Resident #1 was in a local hospital ICU. She stated Resident #1 was found unresponsive and the nursing facility told her they found Resident #1 with a blood sugar of 75. The family member stated 75 was low for Resident #1. The family member stated the nurses should have treated Resident #1 with a sugar pill and they should have made sure she ate and retook her blood sugar level to ensure it improved. She stated she did not understand what happened and had questions that were unanswered. The family member stated Resident #1 was treated at the hospital for low blood sugar, e-coli infection, and flu. During an observation/interview on 1/12/2024 at 8:55 a.m., Resident #1 was observed seated in a chair beside a hospital bed in the ICU. She was alert, oriented x 4 (cognitively intact) and talkative. Resident #1 stated she had a history of low blood sugar levels that had previously led to hospitalization. She stated she could feel when her blood sugar was low and would take a glucose tablet. Resident #1 stated she had not been feeling ill prior to this current hospitalization. She stated she had a runny nose a few days before but was already recovering and had never felt bad. Resident #1 stated on 1/06/2024 she does not remember the day at all. She stated she had no memory of the evening before either. She stated she woke up in the hospital with a sore throat and was told by the hospital she was found unresponsive with a low blood sugar and had to have a tube in her throat. Resident #1 stated the nursing home told her family member they made a medication error, but she had not spoken to anyone from the nursing home facility. Resident #1 stated she was hopeful to be discharged from the hospital soon but did not want to return to the nursing home. During an interview on 1/12/2024 at 9:17 a.m., an RN from the local hospital ICU stated Resident #1's diagnosis was hypoglycemia (low blood glucose). She stated Resident #1 had been intubated and, in the ICU, but was now downgraded, was no longer ICU status and was waiting transfer to a regular hospital room. The RN stated Resident #1 came to the hospital with extremely low blood sugar and altered mental status that required intubation. The RN stated during the course of her hospital stay she was also diagnosed with a UTI and the flu. During an interview on 1/12/2024 at 10:08 a.m., RN A stated she was not familiar with Resident #1 because she only worked on the weekends. She stated she had a routine that she completed when she worked. She stated at 6:15 a.m. she checked on Resident #1 at the start of her shift and noted the resident opened her eyes. RN A stated Resident #1 was her first accucheck (blood glucose monitoring) of the day. RN A stated on the MAR she saw a blood glucose monitor order and a Lantus (insulin glargine) order. She stated she thought the blood glucose monitoring order which had a hold if less than 70 order in it meant to hold Lantus (insulin glargine) if less than 70. RN A stated Resident #1's BS was 77 so she gave the insulin and did not hold the medication. RN A stated she confused the two orders. She stated Resident #1 was a little bit awake at 7:00 a.m. when she administered insulin glargine. RN A stated she knew Resident #1 was a little bit awake because she held her finger out and showed her (RN A) what site she wanted her to use before falling back to sleep. RN A stated she went back into the room at 8:30 a.m. and Resident #1 was asleep but woke up. RN A stated a little after 9:00 a.m. she went into Resident #1's room to check on her surgical incision and found the resident unresponsive. RN A stated she took Resident #1's vitals, which were normal and took a BS reading. RN A stated the BS reading said low. She stated low meant the machine could not register a number and the number was lower than the machine was able to read. RN A stated she gave Resident #1 glucagon gel in her mouth, but because she was unresponsive, she was unable to keep the gel in her mouth. RN A stated she knew she needed to get Resident #1 some sugar, so she gave the resident a glucagon injection in her left arm. RN A stated she asked LVN K to call 911. RN A stated EMS arrived shortly after, and they also checked Resident #1's blood sugar and also got a low reading. She stated EMS took Resident #1 from the facility immediately. RN A stated she determined unresponsiveness because Resident #1 had a different look, she did not open her eyes, did not respond to her name or to touch and when she did a sternal rub there was no response. RN A stated Resident #1's breathing was fine, in fact Resident #1 was snoring a little but otherwise had normal respiration and she had no change in her temperature or other vitals. RN A stated Resident #1 had not complained of feeling ill and other staff had told her it was normal for Resident #1 to sleep in a little. RN A stated at 7:30 a.m. she had put Resident #1's breakfast tray in the room but never checked to see if the resident had eaten. RN A stated she assumed she had eaten. RN A stated she realized she made a medication error when Resident #1's BS read low. RN A stated she went and looked at her actual chart, re-read the order and saw her mistake. RN A stated she then notified the DON and told her she read the order wrong. RN A stated the DON then told her she needed to document what happened in Resident #1's medical record, call the hospital, and tell them what she did. RN A stated she did call the hospital and then Resident #1's NP C. RN A stated NP C stated okay 77 is low, but it is long-acting, not sure why it would drop the sugar so fast: RN A stated she then notified Resident #1's family member. She stated she told the family member she found the resident unresponsive and sent her out (to the hospital). RN A stated the family member came to the facility upset and said she (RN A) was neglectful. RN A stated the Weekend Supervisor had her read the policy on insulin education and read parameters and they had her sign the document. RN A stated she had not yet been called in for her 1:1 education although she had been told it would be done. RN A stated she had training on the 5 Rights of Medication Administration which included the right dose, right patient, right timing and she could not remember the last right. She stated she was trained to read all information on the MAR. She stated the MAR for Resident #1 had more information, but she did not click on it. She stated she should have clicked on it and she should have read the parameters. RN A stated she had never seen parameters in Lantus (insulin glargine) before. She stated since Lantus was a long-acting medicine it was give it and done (meaning she gave the medication without the need for further action). She stated with a short acting insulin she had to make sure the resident ate. RN A stated every facility has their own parameters for low sugar levels. She stated typically normal was 70-110. She stated 70 or lower would be considered critical low. RN A stated she was not concerned about a BS of 77 because she knew Resident #1 was going to eat. RN A stated her mistake was not reading the whole order and confusing two orders. During an observation/interview on 1/12/2024 at 11:50 a.m., LVN N demonstrated on the nurses computerized medical record and medication administration records on the computer how an order for insulin glargine appeared. LVN N clicked on a resident name for medication administration which pulled up the medication insulin glargine. LVN N hovered her curser over the medication name and a short but incomplete order was visible (snip-it of information). Once she clicked on the medication insulin glargine a new screen popped up with the home page which indicated the entire physician order including parameters for holding the medication for blood sugar less than 100. LVN N was then able to navigate from the physician order page to additional tabs that allowed her to document administration. LVN N stated there were several screens to choose from when administering insulin glargine after clicking on the medication name. She stated the first screen that auto populated was the physician order screen with dosage instructions and parameters. She stated she could then click on an additional screen to document actual administration. She stated the snip-it of information might not be complete but once the button was actually pushed the entire order with parameters was visible. LVN N stated she had taken care of Resident #1 in the past (date unknown) and had held insulin glargine for a blood sugar less than 100. LVN N stated to her the order was not confusing. During an interview on 1/12/2024 at 12:15 p.m., the DON stated RN A had a medication error with Resident #1's insulin. The DON stated as a result of the medication error involving Resident #1, the facility had completed an incident report, conducted an audit on insulin to ensure each resident had the right orders and parameters, completed a 1:1 training over the phone with RN A and initiated competencies reviews for licensed staff. The DON stated an in-service training for licensed staff and medication aides had been started on 1/06/2024. The DON said 11 of 42 staff had not completed the in-service training and only 14 of 32 licensed staff had completed skills competencies check offs. During an interview on 1/12/2024 at 2:33 p.m., the DON stated her expectations for medication administration were for staff to follow physician orders, to hold the medication if it was below physician prescribed parameters and to notify the physician of a change of condition. During an interview on 1/12/2024 at 3:49 p.m., the Administrator stated the facility had documentation that the medication error made by RN A was not the facility's fault from the NP (unknown name). The Administrator stated he was unable to locate the document and asked the DON to give the surveyor the document. The DON responded by saying there was no document, only a text conversation between herself and the NP (unknown name). A copy of the text communication was requested but was not received prior to exit. During an interview on 1/12/2024 at 4:10 p.m., the Medical Director stated she was not Resident #1's physician. She stated she had not reviewed Resident #1's medical record and did not have full access to the records. She stated she was told Resident #1's diagnosis at the hospital was metabolic encephalopathy without hypoglycemia by staff (unknown names). The Medical Director stated she thought the findings would be that Resident #1 was septic and her blood sugar was fluctuating from sepsis. The Medical Director, when replying to a question about what staff should do in response to resident illness and fluctuating blood sugars stated staff should call (the physician) to clarify an order if it was below parameters. The Medical Director stated, obviously there was a medication error but the nurse went to monitor the resident as she should have and sent the resident out (to the hospital) as she should have. The Medical Director stated the insulin was long acting and should not have bottomed her (Resident #1) out (caused a rapid decrease in blood sugar) like a short acting . The Medical Director stated she was told there was only a 1-hour window from the time the insulin was administered and her hypoglycemic event. The Medical Director stated she felt like the nurse did what she was supposed to do by getting the resident to the hospital. During an interview on 1/13/2024 at 3:10 p.m., the Weekend Supervisor stated on 1/06/2024, LVN L came and got her for an emergency and stated RN A needed her. The Weekend Supervisor stated she went to Resident #1's room and found the resident unresponsive. She stated they had already tried a sternal rub to wake her up and had tried to raise her blood sugar. The Weekend Supervisor stated they retook Resident #1's BS and it read low, so they called 911. The Weekend Supervisor stated EMS arrived and also took a BS reading but she was not able to see what it read. She stated low meant the blood sugar was too low for the machine to pick up a number. The Weekend Supervisor stated right after Resident #1 left for the hospital, RN A came up to her and said she thought she made a mistake by giving insulin when she was not supposed to. The Weekend Supervisor stated RN A stated she read the order wrong. The Weekend Supervisor stated they completed a risk management/medication error/incident report and RN A called the hospital and informed them she gave the insulin. The Weekend Supervisor stated RN A also notified the RP for Resident #1 and was given a 1:1 in-service by the DON. The Weekend Supervisor stated the DON told her she was to complete blood sugars and insulin for RN A for the rest of the weekend and was told RN A could not give any insulins. The Weekend Supervisor stated RN A was compliant and she (the Weekend Supervisor) completed insulin administration on RN A's residents over the weekend. She stated she did review Resident #1's medical record after the incident and agreed there was a medication error. The Weekend Supervisor stated her job duties did not included auditing or monitoring medical records for accuracy of medication administration. She stated she did not follow up on medication orders because it was not part of her job duties. During an interview on 1/13/2024 at 5:12 p.m., the ADON stated his job duties included medication and medical record audits. He stated he reviews new admissions and ensures medication parameters are in place. He stated he was supposed to review insulin administration by auditing records daily by order listing and review medications. He stated he looked to ensure all residents got all medications. He stated he had not noticed any medication errors prior to the incident with Resident #1 on 1/06/2024. He stated he was not in the facility on that day and had no knowledge of the event. He stated education including medication rights and the right to refuse medications was important to prevent medication errors. He stated he also gave in-service training to staff as part of his job duties but had not given any in-services on medication until 1/06/2024. He stated he reports his finding daily to the DON. During an interview on 1/13/2024 at 6:07 p.m., the DON stated during morning meetings she and the ADON were responsible for running e-mar (electronic medication administration record) reports and reviewing for medication accuracy. The DON stated the ADON should have been reviewing that insulin parameters were followed. The DON stated RN A should have followed Resident #1's physician orders for insulin parameters. The DON stated if the medication was not held when the BS was less than parameters, the RN should notify the physician and the documentation should have clear indicators on why the medication was not held based on the physician order. The DON stated the nurse who administered the medication was responsible for the accuracy of medication administration. The DON stated the ADON and DON were responsible for supervising the nurses. The DON stated when she reviewed reports for medication administration, she was checking for daily medication administration and ensuring new orders were inputted correctly into the computer. The DON stated she thought the medication error occurred because of education. She stated RN A was and old school nurse who was taught that insulin was not held unless blood sugar was less than 70. The DON stated she did not believe RN A intentionally gave the medication (incorrectly). The DON stated she thinks RN A became comfortable and the facility needs to make sure they (nurses) review orders for changes. The DON stated accurate insulin administration was important because the resident could have changes in blood glucose or have an underlying diagnosis which could affect how the body handles insulin. She stated they could result in either hypoglycemia (low blood glucose) or hyperglycemia (high blood glucose) and could lead to unresponsiveness, becoming comatose, and result in a change of condition and/or hospitalization. During an interview on 1/13/2024 at 6:43 p.m., the Administrator stated the DON was responsible for ensuring accuracy of medication administration and reports to him. He stated if the DON found a deficiency, she should report to him so they could collaborate on the best course of action. The Administrator stated he was notified of the medication error late in the morning (1/06/2024) by the DON. He stated he collaborated with the Corporate RN to get a second opinion to ensure they followed guidelines for reporting because Resident #1 went to the hospital. The Administrator stated he ensured in-service training was started. He stated he monitored staff by holding daily meetings with managers, reviewing 24-hour reports, making room rounds and also attending in-depth clinical meetings. He stated they then take action if needed. He stated they address each hallway as reported by the Charge Nurses and PCC documentation, The Administrator stated he thought the medication error occurred because RN A was rushed. He stated he had not solidified a root cause analysis of the event. He stated he thought she was probably rushing and did not take her time. The Administrator stated there were two orders, both with holds for Resident #1 and he thought RN A looked at one order and not the other. The Administrator stated he did not have a policy on management of diabetes. He stated the facility followed physician orders. Attempted interview on 1/12/2024 at 2:15 p.m. with NP C. Left a message with live physician answering service requesting a call back from NP C and the on-call NP, NP J. On 1/12/2024 at 3:49 p.m., the Administrator was informed of surveyor attempt to reach NP C and NP J. The Administrator stated he would have the NP call this surveyor. No call backs were received. Record review of a Counseling/Disciplinary Notice for RN A dated 1/06/2024 revealed RN A was given counseling. Staff member (RN A) failed to correctly read and administer the insulin dosage according to the physician order which resulted in change of condition. The facility corrective action was listed as, Failure to follow the policies and procedures could result in further disciplinary action. The document was signed by the DON on 1/06/2024. RN A wrote I take full responsibility for my mistake and have learned a very valuable lesson for my mistake. RN A also signed the document on 1/06/2024. Record review of RN A Nursing Competency Skills Checklist dated 2/11/2023 and signed off by the DON revealed RN A was marked as competent to perform testing blood glucose, patient assessment, administering subcutaneous injections. Medication administration was not part of the competencies assessed. Record review of a job description for Registered Nurse signed by RN A on 11/18/2022 listed her Essential Job Functions/Drug Administration Functions as prepare and administer medications as ordered by the physician. Record review of a website describing diabetes and the effects of long-acting insulin (such as insulin glargine) as it appeared on 1/19/2024 https://www.healthline.com/health/type-2diabetes/basal-insulin/how-long-for-insulin-to-work#insulin-types revealed: Because every person is different, the way your body responds to insulin may not be the same as someone else's. The type of insulin you take, and many factors can influence how rapidly insulin works in your body and how long it stays. In general, long-acting insulin (insulin glargine) take effect within 2 hours, has no peak level and lasts up to 24 hours. One possible side effect of long-acting insulin (insulin glargine) is low blood sugar (hypoglycemia). Researchers have pointed out that the behavior of insulin after administration may vary. Several factors can influence the absorption of insulin including site of administration, concentration of insulin, frequency of injection site use, and physical factors such as exercise .massaging the injection site .heat exposure. Record review of a drug reference website as it appeared on 1/19/2024 https://www.drugs.com/sfx/insulin-glargine-side-effects.html revealed under the section titled For Healthcare Professionals: Serious Side Effects: metabolic: very common (affecting 10% or more) hypoglycemia. Insulin glargine should not be used if you are having an episode of hypoglycemia or low blood sugar. Record review of insulin glargine side effects as it appeared on 1/19/2024 https://www.lantus.com/how-to-use/insulin-glargine-u100/?utm_source=bing&utm_medium=cpc&utm_campaign=Lantus+-+DTC_MSFT_BRND_General_AWA_SEA_ALLM_US_EN+KW+-+EN+BR_ALL&utm_term=insulin+glargine&gclid=51cebe7a3f971538dfa5dbd0ee11cd89&gclsrc=3p.ds& revealed: The most common side effecting of insulin, including Lantus (brand name for insulin glargine) is low blood sugar (hypoglycemia), which may be serious and life threatening. Other side effects may include .low potassium levels (hypokalemia). Contraindications: Lantus (insulin glargine) is contraindicated during episodes of hypoglycemia .Monitor blood glucose in all patients treated with insulin. Modify insulin regimen only under medical supervision. As with all insulins, Lantus (insulin glargine) use can lead to life-threatening hypokalemia. Record review of a facility policy titled Care and Treatment-Insulin Administration undated revealed: Procedures: 5. Verify medication/dose to order in computer. Record review of a facility policy titled Medication Administration (undated) revealed: It is the policy of this facility that medications shall be administered as prescribed by the attending physician. Procedures: 2. Medications must be administered in accordance with the written orders of the attending physician. The Administrator was notified of an IJ on 1/12/2024 at 3:49 p.m. and was given a copy of the IJ Template and a Plan of Removal (POR) was requested. The Plan of Removal was accepted on 1/12/2024 at 8:02 p.m. and included the following: Immediate Action 1. Medical Director notified of Immediate Jeopardy on 1/12/2024 at 4:33 p.m. 2. Resident #1 no longer in the facility. Resident #1 was discharged to the hospital on 1/06/2024 at 9:30 p.m. 3. Pharmacist was notified on 1/12/2024 at 5:35 p.m. of medication error and facility receiving an IJ for pharmaceutical services. 4. 100% Audit was completed on 1/06/2024 by DON for all residents who require insulin administration and have parameters to ensure all parameters are being followed. 5. In-service began on 1/06/2024 for licensed nurses and CMA's. The importance of reporting medication errors, possible adverse effects to medication errors, review of medication rights and overview of insulin different types and outcomes by 1/12/2024. Abuse and Neglect in-service was started on 1/12/2024 and will be completed by 8:00 am on 1/13/2024. Any employee not in facility will receive in-service via phone, any employee who had not received in-service will not be allowed to work until in-service had been received. 6. A 1:1 in-service was conducted with nurse who administered insulin on 1/06/2024. 7. Insulin administration skill check off for all nurses was started on 1/07/2024 and will be completed at 100% by 8:00 a.m. on 1/13/2024. Any employee who had not been checked off will not be allowed to work. A log will be created for employees who have not received competencies or in-service and will be highlighted. Once received a copy of this log will also be given to the staffing coordinator to ensure no one is placed on schedule prior to training starting 1/12/2024. 8. An off cycle QAPI (meeting) was conducted on 1/12/2024 with the Medical Director, IDT team, clinical resource to review the IJ POR. Identification of others: All residents who have insulin orders with parameters have the potential to be affected by this alleged deficient practice. Systemic Change to prevent re-occurrence: 1. The clinical resource or DON/ADON will verify blood glucose level documentation daily to include the weekend via remote for weekend monitoring to ensure glucose parameters are being followed. This will start on 1/12/2024 at 8:00 pm. Daily review of all insulin parameters will be reviewed in the clinical meeting by the DON/ADON/Administrator. 2. New Admissions with insulin orders with parameters will be reviewed by nurse managers to ensure orders are being followed 1/12/2024. Monitoring to ensure ongoing compliance: 1. DON will share summary of Plan of Removal activity with managers an[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for adequate supervision. Resident #1 was found unresponsive in his room. Facility staff performed CPR and discovered a non identifiable white substance in Resident #1's throat. Resident #1 was pronounced deceased by EMS. Facility did not investigate the choking accident or put in place adequate supervision for other residents with dysphasia. These failures resulted in an Immediate Jeopardy (IJ) on 05/31/23 at 5:45 PM. While the IJ was removed on 06/02/23 at 11:40 AM., the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope of isolated due to facility's need to evaluate the effectiveness of their plan of removal. These failures could result in residents with diagnosis of dysphasia having a diminished quality of life, medical complications, and/or death. The findings included: Record review of Resident #1's face sheet, dated 05/8/23 revealed, resident was admitted on [DATE] diagnoses that included dysphagia oropharyngeal phase (A small pouch that forms and collects food particles in your throat, often just above your esophagus, leads to difficulty swallowing), and cognitive communication deficit (impairment in an individual's mental processes). Record review of Resident #1's admission MDS dated [DATE] revealed: initial (baseline) BIMS of 14 (cognitively intact). The ADLs for eating was independent. Record review of Resident #1's Physician Order Summary dated 01/06/23 read, .Regular diet Regular texture, THIN LIQUIDS .ST to eval and tx (treatment) as indicated . Record review of Resident #1's comprehensive person-centered care plan, revision dated 01/08/23, revealed the resident had a performance deficit for ADLs; and the care plan had missing information such as related diagnosis. The interventions for eating were blank and not completed. Further review revealed the care plan did not capture the SP recommendations made on 01/10/23. Record review of EMT report dated 01/14/23 read: [EMT] dispatched for cardiac arrest. [EMT] arrived on scene to facility to be directed to room [ROOM NUMBER]. Staff performing compressions only cpr on a 42 yom (year old male) who presents [apneic], pulseless, and pale.prior to arrival of fire/ems they [staff] pulled out a large white piece object found in pts (patient's) airway. Staff unsure what white object was that was impeding pts airway . Record review of police report dated 01/14/23 revealed local police officer was dispatched to the listed location for a report. While at the location local police officer met with EMT ; . who informed him (local police) on Resident #1's time of death of 4:20 AM . The EMT also advised the local police officer that Resident #1 had something extracted from his airway while CPR was being performed by LVN A, CNA B, and an unidentified staff member. Upon the local police officer's arrival LVN A was on the phone with the DON and notified her of Resident #1's death. LVN A was told by CNA B, Resident #1 was dying around 4:00 AM. LVN A check if Resident #1 was full code and ran over with CNA B and another unidentified staff member and began CPR. Upon performing breaths with a mask LVN A noticed Resident #1's chest was not rising and falling. LVN A inspected the resident's airway and noticed a gray matter napkins or putty. LVN A told the local police officer she was the one who extracted the object from the resident's airway. The local police officer spoke with CNA B who stated she last saw Resident #1 living around 1:30 AM. during her rounds. CNA B stated she was going to make another round and checked on Resident #1. CNA B entered the room and observed Resident #1 pale and unresponsive. CNA B did not take any lifesaving action until after she notified LVN A and another unidentified staff member. CNA B assisted LVN A and another unidentified staff member and performed CPR. LVN A stated she was sitting at the front office when CNA B ran in and stated she thought Resident #1 had passed. CNA B and LVN A checked Resident #1's chart to verify if he was full code. LVN A then grabbed the crash cart and AED and proceeded to the room. CNA B applied the shock pads for the AED on Resident #1's torso LVN A stated the AED analyzed but did not perform a shock.[Status of AED was not checked by surveyor] The local police officer observed Resident #1 lying on his back with his head turned towards the door. The gray item logged in his throat was adjacent to him. The scene was secured by another local police officer while he conducted a preliminary investigation. Resident #2 was made to exit the crime scene and stay in the immediate area; he was uncooperative at the time. A detective was notified and arrived at the location due to the unusual circumstances of Resident #1's death. A Medical Examiner was notified and made [ documented] location where the body was released with an assigned case number. Crime Scene Investigator made location to process the scene and collect evidence. Resident #1's Representative was notified by LVN A and local police officer. Record review of Resident #1's Autopsy report dated 01/15/23 at 8:00 AM authored by the Deputy Medical Examiner read; It is my opinion that [Resident #1], a [AGE] year old male , died as a result of apparent choking. The decedent was discovered unresponsive with a large portion of chewing gum within his mouth/back of the throat likely occluded his airway. Record review of Resident #1's SP assessment dated [DATE] revealed: mild dysphagia due to lingual (tongue) and poor PO (food by mouth). Recommendations included: monitor severe malnutrition .to regain heath, develop and instruct patient in compensatory strategies (feeding) .and referral to dietician . Record review of facility's Diagnosis Report dated 05/31/2023 revealed 52 residents with a diagnosis of dysphagia (difficulty swallowing foods or liquids). Record review of facility's incident report from January 2023 to May 2023 revealed: no documented incidents of residents choking. During an interview on 05/10/23 at 12:07 PM, LVN A stated CNA B told her she thought Resident #1 was dead. LVN A stated they performed CPR on the resident. LVN A stated she was using the ambu bag (manual resuscitator) LVN A then looked in Resident #1's mouth and observed something white [CPR continued until EMT arrived]. LVN A stated after the incident they recalled a meeting where they told the CNAs and Nurses to do more rounds and check Residents more often. During an interview on 05/10/23 at 11:48 AM, CNA B stated around 4 AM, she looked at Resident #1 and he did not appear to be alive anymore but was still warm to touch. CNA B stated she called the charge nurse over and they began CPR until EMS arrived. CNA B stated when Resident #1 was on the floor he had something in his mouth, and it appeared to be a big wad of gum. CNA B stated it was huge and whatever he had it looked like he was trying to eat a bunch of it together. During an interview on 05/10/23 at 8:27 AM, the DON stated CNA B did her rounds every 2 3 hours, found Resident #1 unresponsive, ran to get the nurse, and started CPR. The DON stated in the process of doing CPR they found something lodged in his throat. The DON stated she was not at the facility when the incident occurred. The DON stated the Resident was not known to have any swallowing issues and he got the gum on his own. The DON stated she did not know if it was gum, and it was white. The DON stated the Resident was on a regular diet. The DON stated they would normally do a risk management if someone choked but because he died, they did not need to do one. The DON stated she did not think the incident needed to be reported to the State Survey Agency because it was an accident. The DON stated they did not do any investigation or additional training because the incident was a choking accident. The DON stated they do risk management if someone chokes. The DON stated they did not do a risk assessment for this resident because he died so there is nothing to prevent for him. The DON stated they did not do anything concerning his death and later stated they did call 911 and did perform CPR. During an interview on 05/10/23 at 9:13 AM, the Administrator stated he was not working for the facility at the time of the incident on 01/15/23 but in hindsight he would have reported the incident to the State Survey Agency. During an interview on 05/30/23 at 12:15 PM, Detective I (Homicide Unit) stated: he participated in the police investigation and a criminal act was not suspected. Based on police interviews of staff the resident likely died from choking on gum. The Homicide Unit (Detective J) would likely close the case given that no foul play was suspected. Detective I added, it was a choking accident that caused the resident's death. During a joint interview on 05/30/23 at 1:20 PM, the DON stated no training was conducted, and no internal investigation was conducted because: the resident died from an accident. The DON stated the resident was alert and oriented, there were no swallowing issues and the resident had a regular diet. The DON stated the resident was assessed by the SP therapist on 06/10/23; and the diet was not changed. The Administrator stated he did not investigate because the resident died from an accident and staff appropriately responded when the resident was found unresponsive. During an interview on 05/31/23 at 8:40 AM, MD H stated: his medical staff only saw the resident twice during the short time Resident #1 was in the facility (01/06/23 to 01/14/23). MD H stated he did not know the cause of death other than Resident #1 died due to choking on a foreign substance. Resident # 1 was alert and oriented and was referred to a speech therapist because the resident was not eating and drinking well. MD H's expectation was that Resident #1 like any other residents with a swallowing issue be closely monitored. After the death of Resident #1, MD H's expectation was close visual monitoring of patients with swallowing issues. MD H added that staff needed to be trained on accidents and hazards involving residents with swallowing issues. MD H stated the facility needed to identify residents that were at risk for choking. During an observation and interview on 05/31/23 at 9:35 AM, Resident #2 (Roommate to Resident #1) was in his room sitting on a wheelchair, alert and oriented. No signs of wounds, skin tears or bruises. The resident was cleaned and groomed. The resident did not reveal signs of anxiety, fear or sadness. The resident stated, I was here when the resident (Resident #1 ) was coughing at night around 4 o'clock in the morning .somehow the nurses arrived .I do not know what he swallowed or drank in the early morning .I saw him around 11:30 PM and he was alive .I woke up and he was choking .I saw him stop breathing .I thought he was just coughing and went back to bed .I do not know what he swallowed .I do not want to talk about it anymore . it is depressing [resident ended the interview]. During a telephone interview on 05/31/23 at 10:00 AM, Detective J stated: Resident #1 died from choking on gum. Detective J stated that the Medical Examiner described the substance that choked the resident as gum. The criminal case would be closed because there was no foul play and the resident died from a choking accident. During an interview on 05/31/23 at 10:21 AM, Speech Therapist stated: a referral was sent to the Rehab Department on 01/10/23 for SP evaluation by the physician. The SP evaluation was completed on 01/10/23 and it revealed: mild dysphagia due to lingual (tongue) and poor PO (food by mouth). The Speech Therapist stated the recommendations for Resident #1 included: [direct quote]monitor severe malnutrition .to regain heath, develop and instruct patient in compensatory strategies (feeding) .and referral to dietician .with focus on dysphasia and eating. The SP Therapist stated her observations revealed the resident was not eating unless he was cued. She was not aware of any in services given on accidents and hazards or choking since the incident on 01/14/23. The SP Therapist stated, based on their assessment Resident #1 was okay to be on a regular diet'. During an interview on 05/31/23 at 10:55 AM, Staff K stated: when a case was closed the ADLs defaulted to being blank. Staff K stated after the SP assessment the CP should have been updated and the family invited to the CP meeting. Per policy a CP needed to be updated if an interdisciplinary team assessment revealed new recommendations for Resident #1. Staff K stated she did not receive an in service on dysphasia or accidents and hazards after the incident on 01/15/25 involving Resident #1. Resident #1 did not receive a 14 day CP because he died on the 9th day of residency. Regarding the Baseline CP dated 01/06/23 the family did not participate. The family was notified of the pending comprehensive CP meeting on 01/11/23 to occur within 14 days of admissions. Family member was notified by telephone by the social worker. Record review of Resident #1's Social Work note dated 01/11/23 revealed: a call was placed to family to discuss discharged plan. The family member [RP]stated that she worked 8 hours per day and would not be home most of the time'. During an interview on 05/31/23 at 11:24 AM, SW stated a call was placed to family on 01/011/23 to discuss the discharged plan. The family member (RP) stated she worked 8 hours per day and would not be home most of the time'. She stated a Discharge Plan was for resident to return home with family after rehab. The SW was not aware of a CP meeting after the SP assessment on 01/10/23. She had not received an in service on accidents and accidents since the death of Resident #1 to the present [05/31/23]. During joint interview on 05/31/23 at 11:45 AM, the Administrator and DON were not aware of family members bringing food or drinks from the outside to the resident (Resident #1). During an interview on 05/31/23 at 1:11 PM, the SP Therapist stated cuing was defined as sending a message to a resident to initiate a response or action to do a targeted task; such as eating. As for Resident #1, the SP Therapist stated, [direct quote]although Resident (#1) was independent in eating and was on a regular diet .he needed messages to initiate the task of eating. The resident had diagnoses of severe protein malnutrition (not enough protein) and dysphagia oropharyngeal phase The SP Therapist stated Resident #1 based on the SP assessment was okay to a on a regular diet'. During an interview on 05/31/23 at 1:25 PM, the DON stated: the residents with dysphasia at the time of the incident on 01/14/23 had care plans in place. Therefore at the time of the incident on 01/14/23 no intervention were required or indicated. The DON stated that at the morning meeting on 01/15/23 the nursing staff discussed whether any other residents were displaying any issues with meals, coughing, and swallowing food or liquids. No resident surfaced on 01/15/23 requiring any further interventions. The morning meeting on 01/15/23 might have been documented on the 24 Communication sheet .but the sheet needs to be found. Record review of 01/15/23 Nurse Morning Report (24 report) revealed the death of Resident #1 was not discussed and no evidence of CP reviews or audits done or discussion of residents with the diagnosis of dysphasia. During an interview on 05/31/23 at 1:36 PM, the Administrator stated he was not present at time of incident but verbally the DON and MDS team stated they audited the CPs residents with dysphasia in April 2023. Record review of the facility's policy tilted Abuse: Prevention of and Prohibition Against, dated 01/2021, stated 5. At the conclusion of the investigation, the facility will take action as necessary in light of the information gathered, which may include but is not limited to: if the allegation is substantiated, analyzing current to determine why abuse, neglect, or misappropriation of resident property, or exploitation occurred, and determine what changes are needed to prevent further occurrences define how care provisions will be changed and or improved to protect residents receiving services, if appropriate, training staff on changes made and demonstration of staff competency after training is implemented, identify staff responsible for the implementation of corrective action, the expected date for implementation, and identify staff responsible for monitoring the implementation of the plan. Record review of facility's Diet Order policy, undated, read: It is the policy of this facility that all changes in dietary orders will be communicated accurately and timely from nursing to dietary .Examples of 'special needs' may include .dysphasia, wight loss . Record review of facility's policy on dysphasia requested by surveyor on 05/30/23 from the DON revealed, at the time of exit on 06/02/23, the said requested policy was not provided to the surveyor. Record review of facility's Incident Reporting policy, undated, read, .It is the policy of this facility to ensure all incidents/accidents occurring on our premises are investigated and reported to the administrator and/or DON. Record review of facility's Comprehensive Plan if Care policy, dated revised 05/2007, read: .The plan of care facilitates continuity of care over time as the Resident moves to various care setting, and is revised as necessary . The Executive Director was given the IJ template and was notified of the Immediate Jeopardy {IJ} on 05/31/23 at 5:45 PM; and a plan of removal (POR) was requested. On 06/01/23 at 9:00 AM the POR was accepted on 06/01/23 at 10:44 AM. It was documented as follows: [Faciliy] Plan of Removal 5/31/23 Immediate Action o Medical Director notified of Immediate Jeopardy. o Resident #1 expired o A complete audit will be completed to identify residents with the diagnosis of dysphagia on 5/31/23. o Care plans for residents identified with the diagnosis of dysphagia will have care plans reviewed for appropriate Intervention and will be completed on 6/1/23. o Residents with a diagnosis of dysphagia who received a swallow study or evaluation will have results reviewed to ensure all recommendations are being followed to be completed on 6/1/23. o Residents with diagnosis of Dysphagia families were called to Inform of the process of bringing food into the facility and will be asked to speak with a charge nurse or designee before taking any food to room and will be educated on the possible outcomes such as choking, aspiration pneumonia and other issues with choking. We will contact all families and completed on 6/1/23 and this will be documented in PCC in a progress note. o An audit was completed on all incident reports for the past 6 months to identify any residents with choking episodes this was completed on 6/1/23. oClinical Resource will in service the ED/DON/ADONS on completing investigations after incidents, to include root cause analysis, interviews and training on prevention of further issues and needed assessments. This will be completed on 6/1/23. o The following in services will be conducted Abuse and neglect, how to care for a resident with dysphagia, choking review of common causes and signs and symptoms and completing a risk management report on residents with a choking episode the in services listed will be completed by 6/1/23. o All Staff including administrative staff will be trained on any changes made to plan of care for residents with dysphagia training will be completed on 6/1/23. o All Staff including administrative staff will be trained on Supervision measures for residents with dysphagia who require special measures and will be completed on 6/1/23. Identification of Others Affected All residents have the potential to be affected by this alleged deficient practice Currently there are 52 residents with a diagnosis of dysphagia. Systemic Change to Prevent Re occurrence 1.DON / ADON started in service on 5/31/23 with all staff on staff on Choking review of common causes and signs and symptoms, and abuse and neglect and will be completed on 6/1/23. 2. Don/ADON started an Inservice on 5/31/23 with all license nurses and CNAS on How to care for a resident with dysphagia, choking review of common causes and signs and symptoms and on completing a risk management report for residents with a choking episode will be completed on 6/1/23. 3. All residents receiving a swallow study or evaluation will be reviewed by the IDT team for proper interventions for recommendations and will be communicated to all staff through a communication binder which will identify interventions for the recommendations. All staff will be in serviced on the binder and this will be completed on 6/1/23. 4.Daily monitoring will occur by DON /DESIGNEE on all new admissions for diagnosis of dysphagia for proper intervention, for orders for swallow studies and proper intervention of any interventions which will then be added to communication binder this will be initiated with all new admissions effective 6/1/23 and will continue to be part of the admission process as of 6/1/23. Monitoring 1.Audit completed for dysphagia and interventions will be presented to QAPI. 2.Daily monitoring will occur by DON /DESIGNEE on all new admissions for diagnosis of dysphagia for proper intervention and risk management reports will be reviewed daily for episodes of choking this will begin on 6/1/23. Daily monitoring will be done for 90 days and will continue with all new admissions. 4. Staff will not be allowed to take a shift until all in services have been received. [5.] Summary of IJ and corrective action to be reviewed by QAPI monthly until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance Respectfully Submitted, Administrator Verification of the Plan of Removal: POR Item: Immediate Action Record review of Resident #1's Nurse Progress Note dated 06/01/23 at 8:55 AM authored by the DON, Medical Director was notified of the Immediate Jeopardy. During telephone interview at 06/01/23 at 12:43 PM, Medical Director confirmed she was notified of the IJ in the facility today (01/06/23). POR Item: Identification of Others Affected Record review of facility's Diagnosis Report dated 05/31/2023 [requested by surveyor on 05/31/23] revealed 52 residents with a diagnosis of dysphagia (difficulty swallowing foods or liquids). Record review of 52 residents diagnosed with dysphasia revealed: Care Plans were reviewed by RN K and Director of Rehab . Record review of 52 CPs of residents with a diagnosis of dysphasia revealed: 12 CPs were updated with new interventions involving nursing care and not needing a medical order. The new nursing intervention for the 12 Residents (Resident # 4 through Resident #14) was monitor meals for any changes in swallowing. During an interview on 06/01/23 at 1:09 PM, RN K stated: she completed CP audits for 52 residents and only 12 CPs needed an update for a nursing care intervention involving more monitoring before, during and after meals. Record review of 52 SLP (speech language pathologist) assessments revealed the assessments were reviewed and completed and no resident required any new SLP interventions. During an interview on 06/01/23 at 12:57 PM, the Rehab Director stated, a complete audit was done on 05/31/23 by her and no resident with a diagnosis of dysphagia required any new interventions, or new MD orders, or no need to contact families. Record review of facility binder for contact with families of residents with dysphasia revealed: 22 families had been contacted. The message sent to family basically entailed informing families to get approval from nursing station before bringing gum, snacks, foods or liquids from the outside to give to resident or residents. During an interview on 06/01/23 at 1:24 PM, the SW stated: she was contacting families and informing them of the need to check in with the charge before bringing gum, snacks, foods or liquids from the outside to give to resident or residents.[SW did not address the issue of Resident Rights if a family still wanted to bring a resident food from the outside.] During an interview on 06/01/23 at 1:30 PM, RN F (6A 2P) stated: the process had always been to monitor families/visitors on bringing snacks, food and drinks from the outside. If something is inappropriate the item is rejected, and the family/visitor is educated. During an interview on 6/01/23 at 1:35 PM, LVN L (10P 6A) stated: the procedure is to check that gum, snacks, foods or liquids from the outside need to be approved by the nursing staff based upon the MD and diet order. During an interview on 06/01/23 at 1:40 PM, LVN M stated (2P 10P) stated: the process is to check and verify what the family/visitor is bringing is compatible with diet and MD orders. Record review of facility's incident report from January 2023 to May 2023 revealed: no documented incidents of residents choking. During an interview on 06/01/23 at 1:47 PM, the DON stated except for Resident #1 there have been no choking incidents in the past 6 months. POR Item: Training: During an interview on 06/01/23 at 1:49 PM, DON stated she received training from the Clinical Resource POC, and the highlight was to investigate anything that looks suspicious and do a root cause analysis. During a joint interview on 06/01/23 at 1:58 PM, the LVN M and LVN N and the ED stated: the training from the Clinical Resource POC involved to investigate any suspicious incidents to include deaths and to do root a cause analysis. ED added, to develop any appropriate interventions. Record review of sign in sheet dated 06/01/23 revealed: DON, 2 ADONs (LVN M and LVN N), and ED received the training on investigation and root cause analysis. Record review of in service training sheets on the topic of dysphagia revealed: that 72 nursing staff had attended the training (N=72 nursing staff (100%). Record review of in service training sheets revealed 126 signatures (100%) for abuse/neglect. Observation on 06/02/23 at 8:00 AM revealed a dysphagia binder located at the Nurse Station and the same binder located at the outside door of the kitchen. The binder contained the list of dysphasia residents and their special diets. Record review of the facility's staff list revealed a total staff of 126; to include 72 nursing staff . Record review of facility's in service sign in sheets revealed: 72 nursing staff received the training on dysphasia; 100%. Record review of facility's in service sign in sheets revealed: 126 staff received the training on abuse/neglect; 100% . 1. During an interview on 6/01/23 at 1:35 PM, LVN L (10P 6A (all halls) stated: the highlight of the dysphasia training was to control substances that could lead to swallowing accidents. The highlight of the training on abuse and neglect to report immediately. 2. During an interview on 06/01/23 at 1:40 PM, LVN M stated (2P 10P (all halls) stated: the high light was to know the signs and symptoms of dysphasia. The highlight of the training was to know the signs and symptoms of abuse and neglect and report any incidents to the Administrator. 3. During an interview on 06/01/23 at 1:30 PM, RN F (6A 2P (all halls) stated:. the highlight of the training on dysphasia was to understand the sighs and symptom and to monitor; and to report swallowing issues. The highlight of the neglect training to report neglect immediately. 4. During an interview on 06/01/23 at 8:18 PM, LVN O (PRN), (2P 10P (all halls) stated the highlight of the dysphasia training was to be checking the resident when feeding, know the right, and inform families/visitors about food restrictions. She was informed of the update of 12 CPs of dysphagia basically to monitor more often. The highlight for the abuse/neglect training was to report any suspicious abuse/neglect to the Administrator immediately. 5. During an interview on 06/01/23 at 8:23 PM, LVN C , (2P 10P (hall 400) stated the highlight of the dysphasia training was to make sure resident was on the correct diet and monitor for signs and symptoms of choking. She was informed of the update of 12 CPs of dysphagia; basically to monitor more often. Also there is a dysphasia book at the nurse station listing residents with dysphasia and their diet. The highlight for the abuse/neglect training was to contact Administration or the DON for suspicion of abuse or neglect. 6. During an interview on 06/01/23 at 8:25 PM, Medication Aide P, 2P 10P (halls 200 and 300) stated the highlight of the dysphasia training was to check coughing call the nurse immediately; and make sure residents got the correct diet. The highlight for the abuse/neglect training was to contact the Administrator or the DON when there is an incident of abuse or neglect. 7. During an interview on 06/01/23 at 8:30 PM, CNA Q , (2P 10P (hall 400) stated the highlight of the dysphasia training was to check for choking, check for diet, and monitor when the resident is eating. Also the DON covered: How to care for a resident with dysphagia, choking review of common causes and signs and symptoms and on completing a risk management report for residents with a choking episode. The highlight for the abuse/neglect training was to report any suspicion of abuse or neglect. 8. During an interview on 06/01/23 at 8:32 PM, LVN R , 2P 10P (hall 100) stated the highlight of the dysphasia training was to make sure the residents that are on dysphagia, monitor when they are eating, and check the correct diet. She was informed of the update of 12 CPs of dysphagia residents; basically to monitor more often. There is a special book in the nurse in the nurse that states the list the dysphasia residents; and diet. The highlight for the abuse/neglect training was to report immediately to the ED. [staff made the latter comment throughout the interviews. 9. During an interview on 06/01/23 at 8:36 PM, LVN S 2P 10P (hall 300) stated the highlight of the dysphasia training was to check the signs and symptoms of dysphagia, choking and the resident was eating the correct diet; and to control families/visitors from bringing outside foods , snacks, or liquids and provide education. She was informed of the update of 12 CPs of dysphagia; basically to monitor more often. Also there is a dysphasia book at the nurse station listing residents with dysphasia and their diet. The highlight for the abuse/neglect training was to report immediately to the ED. 10. During an interview on 06/01/23 at 8:39 PM, CNA T 2P 10P (all halls) stated the highlight of the dysphasia training was to monitor eating and look for signs of choking. The DON trained on how to care for a resident with dysphagia, choking review of common causes and signs and symptoms and on completing a risk management report for residents with a choking episode. A resident could choke on anything he had trouble swallowing. The highlight for the abuse/neglect training was to report immediately to the DON or ED. 11. During an interview on 06/01/23 at 10:05 PM, CNA U (in Spanish), 10P 6A (100 hall) stated the highlight of the dysphasia training was to inform nurses if resident was choking, check how they eat. The highlight for the abuse/neglect training[TRUNCATED]