**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) of four residents reviewed for abuse. The facility failed to protect Resident #1 from physical and emotional abuse when CNA A forcefully dragged her to the shower room and sprayed her while still wearing her clothes while she was screaming and crying in June of 2024. The DON was notified and failed to take any action to protect Resident #1 from further abuse as CNA A continued to work at the facility and with Resident #1 and continued to emotionally abuse her. CNAs B and C did not intervene during the incident. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/24 at 3:01 PM. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, and unspecified psychosis . Review of Resident #1's quarterly MDS assessment, dated 06/05/24, reflected a BIMS score of 14, indicating she was cognitively intact. Section GG (Functional Abilities and Goals) reflected she needed setup or clean-up assistance with Showering and did not require a wheelchair or walker for ambulating. Review of Resident #1's quarterly care plan, dated 06/07/24, reflected she required assistance with ADLs with an intervention of assisting with ADLs as needed. Review of a witness statement, dated 07/30/24 and documented by CNA C, reflected the following: Around July or June (2024) me and my coworkers were working on 500 hall. Me and 2 other coworkers and it was [Resident #1]'s shower day. I had asked her if she wanted to shower and she said no so I left it at that. My other coworker (CNA A ) comes in and says that the DON said to do whatever it takes to get her in the shower cause [sic] she hadn't had one in months. She then grabbed [Resident #1] by the arm and forced her to shower meanwhile [Resident #1] was screaming and telling her that she didn't want to shower. I left then went into the shower room to get gloves and saw [CNA A] wet her clothes to get her to sit down. A couple minutes later [Resident #1] storms out of the shower room mad then goes to her room. Me and [CNA B] were passing snacks and [Resident #1] then comes to us and throws us chunks of her hair . [Resident #1] did let therapy know and she described who it was. Review of the text message received by the OT, dated 07/02/24, reflected the following: . [CNA B] pulled me aside to tell me that [CNA A] showered [Resident #1] a couple weeks ago against her will because the DON told them to make it happen. So [CNA B] said that [CNA A] pulled [Resident #1] down the hall with her trying to fight her. Evidently [Resident #1] was put in the shower with her clothes on bc [sic] she refused to take them off and [CNA A] sprayed [Resident #1] down with the shower spray anyway. [CNA A] then took the clothes off [Resident #1] bc [sic] they were wet and changed her into dry clothes. [CNA B] stated that [CNA A] combed her hair so aggressively that it pulled a lot of her hair out. [Resident #1] has been worried about her hair falling out every time I have showered her . Review of Staffing Sheets, from 06/01/24 - 07/30/24, reflected CNA A worked the following days: 06/05/24 - Resident #1's hall 06/06/24 - Resident #1's hall 06/08/24 06/09/24 - Resident #1's hall 06/10/24 06/11/24 - Resident #1's hall 06/12/24 06/13/24 06/17/24 06/18/24 - Resident #1's hall 06/19/24 - Resident #1's hall 06/20/24 06/22/24 - Resident #1's hall 06/23/24 06/26/24 06/28/24 06/29/24 06/30/24 - Resident #1's hall 07/01/24 - Resident #1's hall 07/08/24 07/11/24 - Resident #1's hall 07/14/24 07/17/24 - Resident #1's hall 07/18/24 07/19/24 - Resident #1's hall During an interview on 07/30/24 at 10:21 AM, Resident #1 stated a few weeks ago CNA A dragged her to the shower room even though she was screaming and crying and did not want to shower. She stated once they got into the shower room, she sprayed her down with water until her clothes were soaked. She stated CNA A took a picture of her and was laughing and making fun of her. She stated she felt humiliated and had feared her ever since. She stated she felt so helpless as she could not fight back. She stated CNA A brushed her hair so rough she had chunks coming off her head. She stated she continued to mess with her even after that day and she had been miserable. She stated she was not sure if she worked there anymore because she had not seen her in at least a week and never wanted to see her again. During an interview on 07/30/24 at 10:38 AM, CNA B stated sometime back in June (2024) she walked into the shower room and saw CNA A spraying Resident #1 with the shower head. She stated she was so appalled she had to walk out. She stated she and CNA C had initially walked in because they heard Resident #1 screaming and crying. She stated CNA A was laughing the whole time. She stated she notified the DON and everyone knew about it. She stated the DON told everyone CNA A had been fired but she did not get fired until the week prior for something unrelated to the incident. She stated after the incident, CNA A continued to work on the same hall and would often go into Resident #1's room and taunt her. She stated she would laugh and ask her, Do you want a shower today? She stated Resident #1 had been a mess and very distraught. During an interview on 07/30/24 at 10:52 AM, CNA C stated it had been at least over a month since the incident with Resident #1 and CNA A. She stated Resident #1 refused showers a lot and CNA A told her the DON told her to do whatever it took to give her a shower. She stated she witnessed CNA A drag Resident #1 to the shower room while she was resisting and screaming. She stated she went into the shower room and saw CNA A spraying her with the shower head to get her to sit down on the shower chair while she continued to scream and cry. She stated CNA A was laughing and saying things like, You stinky! You stink! She stated eventually Resident #1 stormed out of the shower room and then threw chunks of her hair on the ground. She stated she and CNA B had spoken to the DON about it and were even interviewed separately. She stated CNA A continued to work on the same hall and taunt Resident #1 she had been irritated and scared . She stated Resident #1 had been affected by the whole thing and she believed it had been abusive. During a telephone interview on 07/30/24 at 12:25 PM, the ADM stated he was not notified by the DON of the incident involving Resident #1 and CNA A until that day (07/30/24). He stated the DON told him she had not been made aware of the incident until 07/19/24. He stated he was informed Resident #1 was refusing a shower and CNA A sprayed her with water. He stated CNA A was now suspended, he would be submitting a self-report to HHSC, and conducting a thorough investigation. During an interview on 07/30/24 at 12:32 PM, the DON stated she could not remember the date of when she was notified of the incident between Resident #1 and CNA A. She stated she believed it was in the middle of July (2024). She stated she interviewed CNAs B and C but did not have any documentation except for the witness statement she obtained that day from CNA A. She stated she was told that CNA A wet the bottom of Resident #1's pajamas in the shower room. She stated when she told CNA A to do whatever it took to give Resident #1 a shower, she stated she meant to encourage her. She stated spraying her with water would be mean. She stated she did take CNA A off the schedule and sent her home. She stated she did not tell the ADM sooner because she was still in the investigation stage. She stated the OT also notified her of the incident and he may remember the date more clearly. During an interview on 07/30/24 at 12:48 PM, the OT stated he received a text message from another therapist he worked with on 07/02/24 detailing the abusive incident between Resident #1 and CNA A. He stated because he received it in the evening, he notified the DON the next day first thing . He stated he read the text message to her and she did not seem that concerned. He stated about 2-3 days later he saw CNA A working on Resident #1's hall and noticed Resident #1 was visibly upset. He stated he went to the DON and asked her why she would have working on Resident #1's hallway as she was traumatized by the incident that had happened. He stated the DON appeared unaffected and stated, Oh, I did not know she was working on the same hall. He stated CNA A should not have bee been able to work at all at this time because all residents were being put at risk of further abuse. Review of the facility's undated Abuse Prevention and Investigation Policy reflected the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse . 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish, which can include staff to resident abuse . 'Willful' means the individual must have acted deliberately, not the individual must have intended to inflict injury or harm. 'Physical Abuse' includes, but is not limited to, hitting, slapping, punching, biting, and kicking. 'Mental Abuse' includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. The DON and RADM were notified on 07/30/24 at 3:01 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 08/01/24 at 4:53 PM: F600 - Plan Of Removal On 7/30/2024 the surveyor provided an Immediate Jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the resident health and safety. The notification of Immediate Jeopardy states as follows: F600 ' The facility failed to keep the residents free from abuse. The facility failed to ensure the safety of Resident #1 during and after she was physically dragged into the shower room by CNA A, sprayed with the shower head in her full clothes to get her to sit down, all the while screaming and crying. The facility failed to ensure CNA A was suspended/terminated or removed from working with Resident #1 after the incident, causing more emotional distress. Action: *Administrator self-reported the incident on 7/30/2024 to HHSC via online portal through TULIP (reporting system), report # 521272. *Medical Director was informed of the IJ on 7/30/2024 at approx. 4:00pm and an adhoc QAPI meeting was held. In attendance were the MD, Administrator, Regional Administrator, and Regional Nurse. Discussion included what transpired leading up to the IJ, the content of the allegations and the alleged incident, personnel involved, what possibly lead to the events that caused the IJ, retraining topics, and resident care plan. *The Regional Administrator or Administrator began re-in-servicing all staff on Abuse/Neglect/Exploitation policy and procedures, specifically who to notify (Abuse Coordinator, Administrator) or in their absence (Regional leadership, Corporate Compliance), and to take immediate action to ensure residents are not abused by staff, and actions are followed per policy and procedure once leadership is made aware for the protection of all residents in the facility. If abuse/neglect/exploitation is suspected, it is the witnesses responsibility to report directly to the Abuse Coordinator, or Corporate Compliance should there be a concern. Resident safety is paramount, and it is expected that all residents are treated with dignity and respect at all times. Should an unsatisfactory response or action be given by any person regardless of position, it is the reporters responsibility to ensure actions are taken to safeguard the resident. Additionally, education is provided by Regional Administrator or Administrator for understanding of residents rights, and their right to refuse care. Should the person receiving report provide an unsatisfactory response, this individual will receive disciplinary action. *Post test will be provided to staff covering training of ANE/Resident Rights, and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. *Alleged Perpetrator was terminated out of the system effective 7/30/2024, and call was made by Regional Administrator to employee to inform the status change. *1:1 education was completed on 7/30/2024 by Regional Administrator and Administrator with DON regarding investigating, reporting, and addressing all allegations of ANE, including disciplinary action. While the DON has formal oversight of the nursing personnel to include agency/PRN /new staff, the Administrator will ensure education is provided to all staff regarding ANE/Resident Rights prior to their next shift. *1:1 education was completed on 7/31/2024 at 10:15am by Administrator with witness CNA#1, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Providing emotional support and counseling to the resident during and after the investigation, as needed; E. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *1:1 education was completed on 7/31/2024 at 11:30am by Administrator with witness CNA#2, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Providing emotional support and counseling to the resident during and after the investigation, as needed; E. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *Resident #1 was informed by the Administrator that the alleged perpetrator was terminated, and that the Administrator was going to ensure staff are educated on ANE/Resident Rights and held accountable by the Administrator to safeguard the residents. Resident # 1 remains on Psych Services. *All new hires will meet with Administrator before working a shift 1:1 to ensure understanding of ANE Policy and Procedures and will sign an acknowledgement attesting to the training *PRN/Agency staff will be educated on ANE/Resident Rights upon arrival by Administrator or designee, and resource binder left at the nurses station to reference for quick access for Policy and Procedures related to ANE/Resident Rights. Start Date: 07/30/2024 4:00pm Completion Date: Prior to any staff coming on shift, education will be provided and post test given and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. Target Audience: All staff Responsible person: Regional Administrator or Administrator How do you evaluate effectiveness: Administrator will begin completing interviews beginning 8/5/2024 of at least 3 random staff, and 3 random alert and oriented residents a week regarding ANE expectations, who to report to, when, how, and expectations of safe guarding residents who are suspected to be victim of ANE. This will be tracked via spreadsheet and will remain in effect for at least 3 months, or until substantial compliance is achieved. Information will be reviewed during QAPI and findings adjusted as necessary. The Surveyor monitored the POR on 08/02/24 as followed: During an interview on 08/02/24 at 11:18 AM, the ADM stated staff were being in-serviced before working the floor. He stated after further investigation, the DON was let go from the facility. During interviews on 08/02/24 from 11:29 AM - 2:38 PM, one RN, two LVNs, three CNAs, a HSK, and the TS (from different shifts) all stated they were in-serviced and took a post-test before working their shifts. All were able to state that their ADM was the Abuse and Neglect Coordinator and give examples of different types of abuse such as physical, verbal, emotional, and psychosocial. All stated if they saw a resident being abused by a staff member, another resident, or a family member they would intervene to ensure the resident was in a safe space and would notify the ADM immediately. They all stated if the ADM or DON was not immediately available, they would call the corporate hotline that was in the breakroom to notify the RADM. They all stated it was important to notify the ADM because he needed to conduct a thorough investigation, ensure residents safety, and report to the appropriate agencies. Each staff member stated residents had the right to refuse care, such as showers, and should never be forced to do something they did not want to do. During an interview on 08/023/24 at 2:46 PM, Resident #1 stated the ADM had spoken to her about the actions taken and she was just glad the CNA (CNA A) was no longer working at the facility. She stated she felt safe and had no further concerns. Review of Safe Surveys, dated 07/30/24, reflected all residents were interviewed regarding their safety with no concerns. Review of the facility's Ad Hoc QAPI Meeting Minutes, dated 07/30/24, reflected the ADM, RADM, RegN, and MD were in attendance. Review of a Disciplinary Notice , dated 07/30/24, reflected the DON received a final warning due to the following: [The DON] failed to investigate and report an allegation of abuse and neglect. This failure resulted in 4 IJ's being declared on 07/30/24. [The DON] failed to follow the abuse and neglect policy, also did not file a self-report with HHS as required. Further investigation is on-going. Additional disciplinary actions will be determined upon completion of internal investigation. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the ADM had a 1:1 training to review abuse, neglect and exploitation, investigation steps, and the reporting policy. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the SW had a 1:1 training to review abuse, neglect and exploitation, the reporting policy, and SW action steps. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA B had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA C had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of in-services, dated 07/30/24 - 08/01/24 and conducted by the ADM, reflected staff from all shifts were in-serviced on ANE policy and procedures, the Abuse and Neglect Coordinator, reporting, resident rights (right to refuse care), and corporate compliance. Review of Abuse Post-Tests, dated 07/30/24 - 08/01/24, reflected all staff completed the test with passing scores. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for one (Resident #1) of four residents reviewed for developing and implementing abuse and neglect policies. The facility failed to implement the facility abuse policy when they failed to protect Resident #1 from physical and emotional abuse when CNA A forcefully dragged her to the shower room and sprayed her while still wearing her clothes while she was screaming and crying in June of 2024. The DON was notified and failed to take any action to protect Resident #1 from further abuse as CNA A continued to work at the facility and with Resident #1 and continued to emotionally abuse her. CNAs B and C did not intervene during the incident. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/24 at 3:01 PM. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, and unspecified psychosis. Review of Resident #1's quarterly MDS assessment, dated 06/05/24, reflected a BIMS of 14, indicating she was cognitively intact. Section GG (Functional Abilities and Goals) reflected she needed setup or clean-up assistance with Showering and did not require a wheelchair or walker for ambulating. Review of Resident #1's quarterly care plan, dated 06/07/24, reflected she required assistance with ADLs with an intervention of assisting with ADLs as needed. Review of a witness statement, dated 07/30/24 and documented by CNA C, reflected the following: Around July or June (2024) me and my coworkers were working on 500 hall. Me and 2 other coworkers and it was [Resident #1]'s shower day. I had asked her if she wanted to shower and she said no so I left it at that. My other coworker (CNA A) comes in and says that the DON said to do whatever it takes to get her in the shower cause [sic] she hadn't had one in months. She then grabbed [Resident #1] by the arm and forced her to shower meanwhile [Resident #1] was screaming and telling her that she didn't want to shower. I left then went into the shower room to get gloves and saw [CNA A] wet her clothes to get her to sit down. A couple minutes later [Resident #1] storms out of the shower room mad then goes to her room. Me and [CNA B] were passing snacks and [Resident #1] ten comes to us and throws us chunks of her hair . [Resident #1] did let therapy know and she described who it was. Review of the text message received by the OT, dated 07/02/24, reflected the following: . [CNA B] pulled me aside to tell me that [CNA A] showered [Resident #1] a couple weeks ago against her will because the DON told them to make it happen. So [CNA B] said that [CNA A] pulled [Resident #1] down the hall with her trying to fight her. Evidently [Resident #1] was put in the shower with her clothes on bc [sic] she refused to take them off and [CNA A] sprayed [Resident #1] down with the shower spray anyway. [CNA A] then took the clothes off [Resident #1] bc [sic] they were wet and changed her into dry clothes. [CNA B] stated that [CNA A] combed her hair so aggressively that it pulled a lot of her hair out. [Resident #1] has been worried about her hair falling out every time I have showered her . Review of Staffing Sheets, from 06/01/24 - 07/30/24, reflected CNA A worked the following days: 06/05/24 - Resident #1's hall 06/06/24 - Resident #1's hall 06/08/24 06/09/24 - Resident #1's hall 06/10/24 06/11/24 - Resident #1's hall 06/12/24 06/13/24 06/17/24 06/18/24 - Resident #1's hall 06/19/24 - Resident #1's hall 06/20/24 06/22/24 - Resident #1's hall 06/23/24 06/26/24 06/28/24 06/29/24 06/30/24 - Resident #1's hall 07/01/24 - Resident #1's hall 07/08/24 07/11/24 - Resident #1's hall 07/14/24 07/17/24 - Resident #1's hall 07/18/24 07/19/24 - Resident #1's hall During an interview on 07/30/24 at 10:21 AM, Resident #1 stated a few weeks ago CNA A dragged her to the shower room even though she was screaming and crying and did not want to shower. She stated once they got into the shower room, she sprayed her down with water until her clothes were soaked. She stated CNA A took a picture of her and was laughing and making fun of her. She stated she felt humiliated and had feared her ever since. She stated she felt so helpless as she could not fight back. She stated CNA A brushed her hair so rough she had chunks coming off her head. She stated she continued to mess with her even after that day and she had been miserable. She stated she was not sure if she worked there anymore because she had not seen her in at least a week and never wanted to see her again. During an interview on 07/30/24 at 10:38 AM, CNA B stated sometime back in June (2024) she walked into the shower room and saw CNA A spraying Resident #1 with the shower head. She stated she was so appalled she had to walk out. She stated she and CNA C had initially walked in because they heard Resident #1 screaming and crying. She stated CNA A was laughing the whole time. She stated she notified the DON and everyone knew about it. She stated the DON told everyone CNA A had been fired but she did not get fired until the week prior for something unrelated to the incident. She stated after the incident, CNA A continued to work on the same hall and would often go into Resident #1's room and taunt her. She stated she would laugh and ask her, Do you want a shower today? She stated Resident #1 had been a mess and very distraught. During an interview on 07/30/24 at 10:52 AM, CNA C stated it had been at least over a month since the incident with Resident #1 and CNA A. She stated Resident #1 refused showers a lot and CNA A told her the DON told her to do whatever it took to give her a shower. She stated she witnessed CNA A drag Resident #1 to the shower room while she was resisting and screaming. She stated she went into the shower room and saw CNA A spraying her with the shower head to get her to sit down on the shower chair while she continued to scream and cry. She stated CNA A was laughing and saying things like, You stinky! You stink! She stated eventually Resident #1 stormed out of the shower room and then threw chunks of her hair on the ground. She stated she and CNA B had spoken to the DON about it and were even interviewed separately. She stated CNA A continued to work on the same hall and taunt Resident #1 she had been irritated and scared. She stated Resident #1 had been affected by the whole thing and she believed it had been abusive. During a telephone interview on 07/30/24 at 12:25 PM, the ADM stated he was not notified by the DON of the incident involving Resident #1 and CNA A until that day (07/30/24). He stated the DON told him she had not been made aware of the incident until 07/19/24. He stated he was informed Resident #1 was refusing a shower and CNA A sprayed her with water. He stated CNA A was now suspended, he would be submitting a self-report to HHSC, and conducting a thorough investigation. During an interview on 07/30/24 at 12:32 PM, the DON stated she could not remember the date of when she was notified of the incident between Resident #1 and CNA A. She stated she believed it was in the middle of July (2024). She stated she interviewed CNAs B and C but did not have any documentation except for the witness statement she obtained that day from CNA A. She stated she was told that CNA A wet the bottom of Resident #1's pajamas in the shower room. She stated when she told CNA A to do whatever it took to give Resident #1 a shower, she stated she meant to encourage her. She stated spraying her with water would be mean. She stated she did take CNA A off the schedule and sent her home. She stated she did not tell the ADM sooner because she was still in the investigation stage. She stated the OT also notified her of the incident and he may remember the date more clearly. During an interview on 07/30/24 at 12:48 PM, the OT stated he received a text message from another therapist he worked with on 07/02/24 detailing the abusive incident between Resident #1 and CNA A. He stated because he received it in the evening, he notified the DON the next day first thing. He stated he read the text message to her and she did not seem that concerned. He stated about 2-3 days later he saw CNA A working on Resident #1's hall and noticed Resident #1 was visibly upset. He stated he went to the DON and asked her why she would have working on Resident #1's hallway as she was traumatized by the incident that had happened. He stated the DON appeared unaffected and stated, Oh, I did not know she was working on the same hall. He stated CNA A should not have bee able to work at all at this time because all residents were being put at risk of further abuse. Review of the facility's undated Abuse Prevention and Investigation Policy reflected the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse . .V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation. . 3. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; . 6. Providing complete and thorough documentation of the investigation. VI. Protection of the Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. The DON and RADM were notified on 07/30/24 at 3:01 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 08/01/24 at 4:53 PM: F607 - Plan Of Removal On 7/30/2024 the surveyor provided an Immediate Jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the resident health and safety. The notification of Immediate Jeopardy states as follows: F607 - The facility must develop and implement written policies and procedures that prohibit and prevent abuse. The facility failed to follow their policies and procedures related to abuse. The facility failed to ensure CNA A was suspended/terminated or removed from working with Resident #1 after the incident, causing more emotional distress. Action: *Administrator self-reported the incident on 7/30/2024 to HHSC via online portal through (reporting system), report # 521272. *Medical Director was informed of the IJ on 7/30/2024 at approx. 4:00pm and an adhoc QAPI meeting was held. In attendance were the MD, Administrator, Regional Administrator, and Regional Nurse. Discussion included what transpired leading up to the IJ, the content of the allegations and the alleged incident, personnel involved, what possibly lead to the events that caused the IJ, retraining topics, and resident care plan. *The Regional Administrator or Administrator began re-in-servicing all staff on Abuse/Neglect/Exploitation policy and procedures, specifically who to notify (Abuse Coordinator, Administrator) or in their absence (Regional leadership, Corporate Compliance), and to take immediate action to ensure residents are not abused by staff, and actions are followed per policy and procedure once leadership is made aware for the protection of all residents in the facility. If abuse/neglect/exploitation is suspected, it is the witnesses responsibility to report directly to the Abuse Coordinator, or Corporate Compliance should there be a concern. Resident safety is paramount, and it is expected that all residents are treated with dignity and respect at all times. Should an unsatisfactory response or action be given by any person regardless of position, it is the reporters responsibility to ensure actions are taken to safeguard the resident. Additionally, education is provided by Regional Administrator or Administrator for understanding of residents rights, and their right to refuse care. Should the person receiving report provide an unsatisfactory response, this individual will receive disciplinary action. *Post test will be provided to staff covering training of ANE/Resident Rights, and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. *Alleged Perpetrator was terminated out of the system effective 7/30/2024, and call was made by Regional Administrator to employee to inform the status change. *1:1 education was completed on 7/30/2024 by Regional Administrator and Administrator with DON regarding investigating, reporting, and addressing all allegations of ANE, including disciplinary action. While the DON has formal oversight of the nursing personnel to include agency/PRN/new staff, the Administrator will ensure education is provided to all staff regarding ANE/Resident Rights prior to their next shift. *1:1 education was completed on 7/31/2024 at 10:15am by Administrator with witness CNA#1, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: F. Responding immediately to protect the alleged victim and integrity of the investigation; G. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; H. Increased supervision of the alleged victim and residents; I. Providing emotional support and counseling to the resident during and after the investigation, as needed; J. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *1:1 education was completed on 7/31/2024 at 11:30am by Administrator with witness CNA#2, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: F. Responding immediately to protect the alleged victim and integrity of the investigation; G. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; H. Increased supervision of the alleged victim and residents; I. Providing emotional support and counseling to the resident during and after the investigation, as needed; J. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *Resident #1 was informed by the Administrator that the alleged perpetrator was terminated, and that the Administrator was going to ensure staff are educated on ANE/Resident Rights and held accountable by the Administrator to safeguard the residents. Resident # 1 remains on Psych Services. *All new hires will meet with Administrator before working a shift 1:1 to ensure understanding of ANE Policy and Procedures and will sign an acknowledgement attesting to the training *PRN/Agency staff will be educated on ANE/Resident Rights upon arrival by Administrator or designee, and resource binder left at the nurses station to reference for quick access for Policy and Procedures related to ANE/Resident Rights. Start Date: 07/30/2024 4:00pm Completion Date: Prior to any staff coming on shift, education will be provided and post test given and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. Target Audience: All staff Responsible person: Regional Administrator or Administrator How do you evaluate effectiveness: Administrator will begin completing interviews beginning 8/5/2024 of at least 3 random staff, and 3 random alert and oriented residents a week regarding ANE expectations, who to report to, when, how, and expectations of safe guarding residents who are suspected to be victim of ANE. This will be tracked via spreadsheet and will remain in effect for at least 3 months, or until substantial compliance is achieved. Information will be reviewed during QAPI and findings adjusted as necessary. The Surveyor monitored the POR on 08/02/24 as followed: During an interview on 08/02/24 at 11:18 AM, the ADM stated staff were being in-serviced before working the floor. He stated after further investigation, the DON was let go from the facility. During interviews on 08/02/24 from 11:29 AM - 2:38 PM, one RN, two LVNs, three CNAs, a HSK, and the TS (from different shifts) all stated they were in-serviced and took a post-test before working their shifts. All were able to state that their ADM was the Abuse and Neglect Coordinator and give examples of different types of abuse such as physical, verbal, emotional, and psychosocial. All stated if they saw a resident being abused by a staff member, another resident, or a family member they would intervene to ensure the resident was in a safe space and would notify the ADM immediately. They all stated if the ADM or DON was not immediately available, they would call the corporate hotline that was in the breakroom to notify the RADM. They all stated it was important to notify the ADM because he needed to conduct a thorough investigation, ensure residents safety, and report to the appropriate agencies. Each staff member stated residents had the right to refuse care, such as showers, and should never be forced to do something they did not want to do. During an interview on 08/02/24 at 2:46 PM, Resident #1 stated the ADM had spoken to her about the actions taken and she was just glad the CNA (CNA A) was no longer working at the facility. She stated she felt safe and had no further concerns. Review of Safe Surveys, dated 07/30/24, reflected all residents were interviewed regarding their safety with no concerns. Review of the facility's Ad Hoc QAPI Meeting Minutes, dated 07/30/24, reflected the ADM, RADM, RegN, and MD were in attendance. Review of a Disciplinary Notice, dated 07/30/24, reflected the DON received a final warning due to the following: [The DON] failed to investigate and report an allegation of abuse and neglect. This failure resulted in 4 IJ's being declared on 07/30/24. [The DON] failed to follow the abuse and neglect policy, also did not file a self-report with HHSC as required. Further investigation is on-going. Additional disciplinary actions will be determined upon completion of internal investigation. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the ADM had a 1:1 training to review abuse, neglect and exploitation, investigation steps, and the reporting policy. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the SW a 1:1 training to review abuse, neglect and exploitation, the reporting policy, and SW action steps. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA B had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA C had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of in-services, dated 07/30/24 - 08/01/24 and conducted by the ADM, reflected staff from all shifts were in-serviced on ANE policy and procedures, the Abuse and Neglect Coordinator, reporting, resident rights (right to refuse care), and corporate compliance. Review of Abuse Post-Tests, dated 07/30/24 - 08/01/24, reflected all staff completed the test with passing scores. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported to the facility Administrator immediately but no later than 2 hours for one (Resident #1) of four residents reviewed for abuse and neglect. The facility failed to notify their Abuse and Neglect Coordinator (The ADM) within 2 hours when CNA A forcefully dragged Resident #1 to the shower room and sprayed her while still wearing her clothes while she was screaming and crying in June of 2024. The DON was notified and failed to take any action to protect Resident #1 from further abuse as CNA A continued to work at the facility and with Resident #1 and continued to emotionally abuse her. CNAs B and C did not intervene during the incident. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/24 at 3:01 PM. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, and unspecified psychosis . Review of Resident #1's quarterly MDS assessment, dated 06/05/24, reflected a BIMS score of 14, indicating she was cognitively intact. Section GG (Functional Abilities and Goals) reflected she needed setup or clean-up assistance with Showering and did not require a wheelchair or walker for ambulating. Review of Resident #1's quarterly care plan, dated 06/07/24, reflected she required assistance with ADLs with an intervention of assisting with ADLs as needed. Review of a witness statement, dated 07/30/24 and documented by CNA C, reflected the following: Around July or June (2024) me and my coworkers were working on 500 hall. Me and 2 other coworkers and it was [Resident #1]'s shower day. I had asked her if she wanted to shower and she said no so I left it at that. My other coworker (CNA A) comes in and says that the DON said to do whatever it takes to get her in the shower cause [sic] she hadn't had one in months. She then grabbed [Resident #1] by the arm and forced her to shower meanwhile [Resident #1] was screaming and telling her that she didn't want to shower. I left then went into the shower room to get gloves and saw [CNA A] wet her clothes to get her to sit down. A couple minutes later [Resident #1] storms out of the shower room mad then goes to her room. Me and [CNA B] were passing snacks and [Resident #1] ten comes to us and throws us chunks of her hair . [Resident #1] did let therapy know and she described who it was. Review of the text message received by the OT, dated 07/02/24, reflected the following: . [CNA B] pulled me aside to tell me that [CNA A] showered [Resident #1] a couple weeks ago against her will because the DON told them to make it happen. So [CNA B] said that [CNA A] pulled [Resident #1] down the hall with her trying to fight her. Evidently [Resident #1] was put in the shower with her clothes on bc [sic] she refused to take them off and [CNA A] sprayed [Resident #1] down with the shower spray anyway. [CNA A] then took the clothes off [Resident #1] bc [sic] they were wet and changed her into dry clothes. [CNA B] stated that [CNA A] combed her hair so aggressively that it pulled a lot of her hair out. [Resident #1] has been worried about her hair falling out every time I have showered her . Review of Staffing Sheets, from 06/01/24 - 07/30/24, reflected CNA A worked the following days: 06/05/24 - Resident #1's hall 06/06/24 - Resident #1's hall 06/08/24 06/09/24 - Resident #1's hall 06/10/24 06/11/24 - Resident #1's hall 06/12/24 06/13/24 06/17/24 06/18/24 - Resident #1's hall 06/19/24 - Resident #1's hall 06/20/24 06/22/24 - Resident #1's hall 06/23/24 06/26/24 06/28/24 06/29/24 06/30/24 - Resident #1's hall 07/01/24 - Resident #1's hall 07/08/24 07/11/24 - Resident #1's hall 07/14/24 07/17/24 - Resident #1's hall 07/18/24 07/19/24 - Resident #1's hall During an interview on 07/30/24 at 10:21 AM, Resident #1 stated a few weeks ago CNA A dragged her to the shower room even though she was screaming and crying and did not want to shower. She stated once they got into the shower room, she sprayed her down with water until her clothes were soaked. She stated CNA A took a picture of her and was laughing and making fun of her. She stated she felt humiliated and had feared her ever since. She stated she felt so helpless as she could not fight back. She stated CNA A brushed her hair so rough she had chunks coming off her head. She stated she continued to mess with her even after that day and she had been miserable. She stated she was not sure if she worked there anymore because she had not seen her in at least a week and never wanted to see her again. During an interview on 07/30/24 at 10:38 AM, CNA B stated sometime back in June (2024) she walked into the shower room and saw CNA A spraying Resident #1 with the shower head. She stated she was so appalled she had to walk out. She stated she and CNA C had initially walked in because they heard Resident #1 screaming and crying. She stated CNA A was laughing the whole time. She stated she notified the DON and everyone knew about it. She stated the DON told everyone CNA A had been fired but she did not get fired until the week prior for something unrelated to the incident. She stated after the incident, CNA A continued to work on the same hall and would often go into Resident #1's room and taunt her. She stated she would laugh and ask her, Do you want a shower today? She stated Resident #1 had been a mess and very distraught. During an interview on 07/30/24 at 10:52 AM, CNA C stated it had been at least over a month since the incident with Resident #1 and CNA A. She stated Resident #1 refused showers a lot and CNA A told her the DON told her to do whatever it took to give her a shower. She stated she witnessed CNA A drag Resident #1 to the shower room while she was resisting and screaming. She stated she went into the shower room and saw CNA A spraying her with the shower head to get her to sit down on the shower chair while she continued to scream and cry. She stated CNA A was laughing and saying things like, You stinky! You stink! She stated eventually Resident #1 stormed out of the shower room and then threw chunks of her hair on the ground. She stated she and CNA B had spoken to the DON about it and were even interviewed separately. She stated CNA A continued to work on the same hall and taunt Resident #1 she had been irritated and scared . She stated Resident #1 had been affected by the whole thing and she believed it had been abusive. During a telephone interview on 07/30/24 at 12:25 PM, the ADM stated he was not notified by the DON of the incident involving Resident #1 and CNA A until that day (07/30/24). He stated the DON told him she had not been made aware of the incident until 07/19/24. He stated he was informed Resident #1 was refusing a shower and CNA A sprayed her with water. He stated CNA A was now suspended, he would be submitting a self-report to HHSC, and conducting a thorough investigation. During an interview on 07/30/24 at 12:32 PM, the DON stated she could not remember the date of when she was notified of the incident between Resident #1 and CNA A. She stated she believed it was in the middle of July (2024). She stated she interviewed CNAs B and C but did not have any documentation except for the witness statement she obtained that day from CNA A. She stated she was told that CNA A wet the bottom of Resident #1's pajamas in the shower room. She stated when she told CNA A to do whatever it took to give Resident #1 a shower, she stated she meant to encourage her. She stated spraying her with water would be mean. She stated she did take CNA A off the schedule and sent her home. She stated she did not tell the ADM sooner because she was still in the investigation stage. She stated the OT also notified her of the incident and he may remember the date more clearly. During an interview on 07/30/24 at 12:48 PM, the OT stated he received a text message from another therapist he worked with on 07/02/24 detailing the abusive incident between Resident #1 and CNA A. He stated because he received it in the evening, he notified the DON the next day first thing . He stated he read the text message to her and she did not seem that concerned. He stated about 2-3 days later he saw CNA A working on Resident #1's hall and noticed Resident #1 was visibly upset. He stated he went to the DON and asked her why she would have working on Resident #1's hallway as she was traumatized by the incident that had happened. He stated the DON appeared unaffected and stated, Oh, I did not know she was working on the same hall. He stated CNA A should not have bee able to work at all at this time because all residents were being put at risk of further abuse. Review of the facility's undated Abuse Prevention and Investigation Policy reflected the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse . . 2. The facility has designated the Administrator as the Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law . The DON and RADM were notified on 07/30/24 at 3:01 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 08/01/24 at 4:53 PM: F609 - Plan Of Removal On 7/30/2024 the surveyor provided an Immediate Jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the resident health and safety. The notification of Immediate Jeopardy states as follows: F609 ' The facility must ensure all allegations of abuse are reported immediately but no more than two hours after the allegation is made. The facility failed to ensure the safety of Resident #1 during and after she was physically dragged into the shower room by CNA A, sprayed with the shower head in her full clothes to get her to sit down, all the while screaming and crying. The facility did not self-report this allegation the Administrator. Action: *Administrator self-reported the incident on 7/30/2024 to HHSC via online portal through TULIP , report # 521272. *Medical Director was informed of the IJ on 7/30/2024 at approx. 4:00pm and an adhoc QAPI meeting was held. In attendance were the MD, Administrator, Regional Administrator, and Regional Nurse. Discussion included what transpired leading up to the IJ, the content of the allegations and the alleged incident, personnel involved, what possibly lead to the events that caused the IJ, retraining topics, and resident care plan. *The Regional Administrator or Administrator began re-in-servicing all staff on Abuse/Neglect/Exploitation policy and procedures, specifically who to notify (Abuse Coordinator, Administrator) or in their absence (Regional leadership, Corporate Compliance), and to take immediate action to ensure residents are not abused by staff, and actions are followed per policy and procedure once leadership is made aware for the protection of all residents in the facility. If abuse/neglect/exploitation is suspected, it is the witnesses responsibility to report directly to the Abuse Coordinator, or Corporate Compliance should there be a concern. Resident safety is paramount, and it is expected that all residents are treated with dignity and respect at all times. Should an unsatisfactory response or action be given by any person regardless of position, it is the reporters responsibility to ensure actions are taken to safeguard the resident. Additionally, education is provided by Regional Administrator or Administrator for understanding of residents rights, and their right to refuse care. Should the person receiving report provide an unsatisfactory response, this individual will receive disciplinary action. *Post test will be provided to staff covering training of ANE/Resident Rights, and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. *Alleged Perpetrator was terminated out of the system effective 7/30/2024, and call was made by Regional Administrator to employee to inform the status change. *1:1 education was completed on 7/30/2024 by Regional Administrator and Administrator with DON regarding investigating, reporting, and addressing all allegations of ANE, including disciplinary action. While the DON has formal oversight of the nursing personnel to include agency/PRN /new staff, the Administrator will ensure education is provided to all staff regarding ANE/Resident Rights prior to their next shift. *1:1 education was completed on 7/31/2024 at 10:15am by Administrator with witness CNA#1, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: K. Responding immediately to protect the alleged victim and integrity of the investigation; L. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; M. Increased supervision of the alleged victim and residents; N. Providing emotional support and counseling to the resident during and after the investigation, as needed; O. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *1:1 education was completed on 7/31/2024 at 11:30am by Administrator with witness CNA#2, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: K. Responding immediately to protect the alleged victim and integrity of the investigation; L. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; M. Increased supervision of the alleged victim and residents; N. Providing emotional support and counseling to the resident during and after the investigation, as needed; O. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *Resident #1 was informed by the Administrator that the alleged perpetrator was terminated, and that the Administrator was going to ensure staff are educated on ANE/Resident Rights and held accountable by the Administrator to safeguard the residents. Resident # 1 remains on Psych Services. *All new hires will meet with Administrator before working a shift 1:1 to ensure understanding of ANE Policy and Procedures and will sign an acknowledgement attesting to the training *PRN/Agency staff will be educated on ANE/Resident Rights upon arrival by Administrator or designee, and resource binder left at the nurses station to reference for quick access for Policy and Procedures related to ANE/Resident Rights. Start Date: 07/30/2024 4:00pm Completion Date: Prior to any staff coming on shift, education will be provided and post test given and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. Target Audience: All staff Responsible person: Regional Administrator or Administrator How do you evaluate effectiveness: Administrator will begin completing interviews beginning 8/5/2024 of at least 3 random staff, and 3 random alert and oriented residents a week regarding ANE expectations, who to report to, when, how, and expectations of safe guarding residents who are suspected to be victim of ANE. This will be tracked via spreadsheet and will remain in effect for at least 3 months, or until substantial compliance is achieved. Information will be reviewed during QAPI and findings adjusted as necessary. The Surveyor monitored the POR on 08/02/24 as followed: During an interview on 08/02/24 at 11:18 AM, the ADM stated staff were being in-serviced before working the floor. He stated after further investigation, the DON was let go from the facility. During interviews on 08/02/24 from 11:29 AM - 2:38 PM, one RN, two LVNs, three CNAs, a HSK, and the TS (from different shifts) all stated they were in-serviced and took a post-test before working their shifts. All were able to state that their ADM was the Abuse and Neglect Coordinator and give examples of different types of abuse such as physical, verbal, emotional, and psychosocial. All stated if they saw a resident being abused by a staff member, another resident, or a family member they would intervene to ensure the resident was in a safe space and would notify the ADM immediately. They all stated if the ADM or DON was not immediately available, they would call the corporate hotline that was in the breakroom to notify the RADM. They all stated it was important to notify the ADM because he needed to conduct a thorough investigation, ensure residents safety, and report to the appropriate agencies. Each staff member stated residents had the right to refuse care, such as showers, and should never be forced to do something they did not want to do. During an interview on 08/02/24 at 2:46 PM, Resident #1 stated the ADM had spoken to her about the actions taken and she was just glad the CNA (CNA A) was no longer working at the facility. She stated she felt safe and had no further concerns. Review of Safe Surveys, dated 07/30/24, reflected all residents were interviewed regarding their safety with no concerns. Review of the facility's Ad Hoc QAPI Meeting Minutes, dated 07/30/24, reflected the ADM, RADM, RegN, and MD were in attendance. Review of a Disciplinary Notice, dated 07/30/24, reflected the DON received a final warning due to the following: [The DON] failed to investigate and report an allegation of abuse and neglect. This failure resulted in 4 IJ's being declared on 07/30/24. [The DON] failed to follow the abuse and neglect policy, also did not file a self-report with HHS as required. Further investigation is on-going. Additional disciplinary actions will be determined upon completion of internal investigation. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the ADM had a 1:1 training to review abuse, neglect and exploitation, investigation steps, and the reporting policy. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the SW had a 1:1 training to review abuse, neglect and exploitation, the reporting policy, and SW action steps. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA B had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA C had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of in-services, dated 07/30/24 - 08/01/24 and conducted by the ADM, reflected staff from all shifts were in-serviced on ANE policy and procedures, the Abuse and Neglect Coordinator, reporting, resident rights (right to refuse care), and corporate compliance. Review of Abuse Post-Tests, dated 07/30/24 - 08/01/24, reflected all staff completed the test with passing scores. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to, in response to allegations of abuse, neglect or mistreatment, have evidence that all alleged violations were thoroughly investigated for one (Resident #1) of four residents reviewed for abuse and neglect. The facility failed to investigate an allegation of abuse when CNA A forcefully dragged Resident #1 to the shower room and sprayed her while still wearing her clothes while she was screaming and crying in June of 2024. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 07/30/24 at 3:01 PM. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, and unspecified psychosis . Review of Resident #1's quarterly MDS assessment, dated 06/05/24, reflected a BIMS score of 14, indicating she was cognitively intact. Section GG (Functional Abilities and Goals) reflected she needed setup or clean-up assistance with Showering and did not require a wheelchair or walker for ambulating. Review of Resident #1's quarterly care plan, dated 06/07/24, reflected she required assistance with ADLs with an intervention of assisting with ADLs as needed. Review of a witness statement, dated 07/30/24 and documented by CNA C, reflected the following: Around July or June (2024) me and my coworkers were working on 500 hall. Me and 2 other coworkers and it was [Resident #1]'s shower day. I had asked her if she wanted to shower and she said no so I left it at that. My other coworker (CNA A) comes in and says that the DON said to do whatever it takes to get her in the shower cause [sic] she hadn't had one in months. She then grabbed [Resident #1] by the arm and forced her to shower meanwhile [Resident #1] was screaming and telling her that she didn't want to shower. I left then went into the shower room to get gloves and saw [CNA A] wet her clothes to get her to sit down. A couple minutes later [Resident #1] storms out of the shower room mad then goes to her room. Me and [CNA B] were passing snacks and [Resident #1] ten comes to us and throws us chunks of her hair . [Resident #1] did let therapy know and she described who it was. Review of the text message received by the OT, dated 07/02/24, reflected the following: . [CNA B] pulled me aside to tell me that [CNA A] showered [Resident #1] a couple weeks ago against her will because the DON told them to make it happen. So [CNA B] said that [CNA A] pulled [Resident #1] down the hall with her trying to fight her. Evidently [Resident #1] was put in the shower with her clothes on bc [sic] she refused to take them off and [CNA A] sprayed [Resident #1] down with the shower spray anyway. [CNA A] then took the clothes off [Resident #1] bc [sic] they were wet and changed her into dry clothes. [CNA B] stated that [CNA A] combed her hair so aggressively that it pulled a lot of her hair out. [Resident #1] has been worried about her hair falling out every time I have showered her . Review of Staffing Sheets, from 06/01/24 - 07/30/24, reflected CNA A worked the following days: 06/05/24 - Resident #1's hall 06/06/24 - Resident #1's hall 06/08/24 06/09/24 - Resident #1's hall 06/10/24 06/11/24 - Resident #1's hall 06/12/24 06/13/24 06/17/24 06/18/24 - Resident #1's hall 06/19/24 - Resident #1's hall 06/20/24 06/22/24 - Resident #1's hall 06/23/24 06/26/24 06/28/24 06/29/24 06/30/24 - Resident #1's hall 07/01/24 - Resident #1's hall 07/08/24 07/11/24 - Resident #1's hall 07/14/24 07/17/24 - Resident #1's hall 07/18/24 07/19/24 - Resident #1's hall During an interview on 07/30/24 at 10:21 AM, Resident #1 stated a few weeks ago CNA A dragged her to the shower room even though she was screaming and crying and did not want to shower. She stated once they got into the shower room, she sprayed her down with water until her clothes were soaked. She stated CNA A took a picture of her and was laughing and making fun of her. She stated she felt humiliated and had feared her ever since. She stated she felt so helpless as she could not fight back. She stated CNA A brushed her hair so rough she had chunks coming off her head. She stated she continued to mess with her even after that day and she had been miserable. She stated she was not sure if she worked there anymore because she had not seen her in at least a week and never wanted to see her again. During an interview on 07/30/24 at 10:38 AM, CNA B stated sometime back in June (2024) she walked into the shower room and saw CNA A spraying Resident #1 with the shower head. She stated she was so appalled she had to walk out. She stated she and CNA C had initially walked in because they heard Resident #1 screaming and crying. She stated CNA A was laughing the whole time. She stated she notified the DON and everyone knew about it. She stated the DON told everyone CNA A had been fired but she did not get fired until the week prior for something unrelated to the incident. She stated after the incident, CNA A continued to work on the same hall and would often go into Resident #1's room and taunt her. She stated she would laugh and ask her, Do you want a shower today? She stated Resident #1 had been a mess and very distraught. During an interview on 07/30/24 at 10:52 AM, CNA C stated it had been at least over a month since the incident with Resident #1 and CNA A. She stated Resident #1 refused showers a lot and CNA A told her the DON told her to do whatever it took to give her a shower. She stated she witnessed CNA A drag Resident #1 to the shower room while she was resisting and screaming. She stated she went into the shower room and saw CNA A spraying her with the shower head to get her to sit down on the shower chair while she continued to scream and cry. She stated CNA A was laughing and saying things like, You stinky! You stink! She stated eventually Resident #1 stormed out of the shower room and then threw chunks of her hair on the ground. She stated she and CNA B had spoken to the DON about it and were even interviewed separately. She stated CNA A continued to work on the same hall and taunt Resident #1 she had been irritated and scared . She stated Resident #1 had been affected by the whole thing and she believed it had been abusive. During a telephone interview on 07/30/24 at 12:25 PM, the ADM stated he was not notified by the DON of the incident involving Resident #1 and CNA A until that day (07/30/24). He stated the DON told him she had not been made aware of the incident until 07/19/24. He stated he was informed Resident #1 was refusing a shower and CNA A sprayed her with water. He stated CNA A was now suspended, he would be submitting a self-report to HHSC, and conducting a thorough investigation. During an interview on 07/30/24 at 12:32 PM, the DON stated she could not remember the date of when she was notified of the incident between Resident #1 and CNA A. She stated she believed it was in the middle of July (2024). She stated she interviewed CNAs B and C but did not have any documentation except for the witness statement she obtained that day from CNA A. She stated she was told that CNA A wet the bottom of Resident #1's pajamas in the shower room. She stated when she told CNA A to do whatever it took to give Resident #1 a shower, she stated she meant to encourage her. She stated spraying her with water would be mean. She stated she did take CNA A off the schedule and sent her home. She stated she did not tell the ADM sooner because she was still in the investigation stage . She stated the OT also notified her of the incident and he may remember the date more clearly. During an interview on 07/30/24 at 12:48 PM, the OT stated he received a text message from another therapist he worked with on 07/02/24 detailing the abusive incident between Resident #1 and CNA A. He stated because he received it in the evening, he notified the DON the next day first thing. He stated he read the text message to her and she did not seem that concerned. He stated about 2-3 days later he saw CNA A working on Resident #1's hall and noticed Resident #1 was visibly upset. He stated he went to the DON and asked her why she would have working on Resident #1's hallway as she was traumatized by the incident that had happened . He stated the DON appeared unaffected and stated, Oh, I did not know she was working on the same hall. He stated CNA A should not have been able to work at all at this time because all residents were being put at risk of further abuse. Review of the facility's undated Abuse Prevention and Investigation Policy reflected the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse . .V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation. . 3. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; . 6. Providing complete and thorough documentation of the investigation. VI. Protection of the Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. The DON and RADM were notified on 07/30/24 at 3:01 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 08/01/24 at 4:53 PM: F610 - Plan Of Removal On 7/30/2024 the surveyor provided an Immediate Jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the resident health and safety. The notification of Immediate Jeopardy states as follows: F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must have evidence that all alleged violations are thoroughly investigated. The facility failed to thoroughly investigate an allegation of abuse after the DON was notified of an incident with CNA A and Resident #1 when she was physically dragged into the shower room by CNA A, sprayed with the shower head in her full clothes to get her to sit down, all the while screaming and crying. Action: *Administrator self-reported the incident on 7/30/2024 to HHSC via online portal through TULIP , report # 521272. *Medical Director was informed of the IJ on 7/30/2024 at approx. 4:00pm and an adhoc QAPI meeting was held. In attendance were the MD, Administrator, Regional Administrator, and Regional Nurse. Discussion included what transpired leading up to the IJ, the content of the allegations and the alleged incident, personnel involved, what possibly lead to the events that caused the IJ, retraining topics, and resident care plan. *The Regional Administrator or Administrator began re-in-servicing all staff on Abuse/Neglect/Exploitation policy and procedures, specifically who to notify (Abuse Coordinator, Administrator) or in their absence (Regional leadership, Corporate Compliance), and to take immediate action to ensure residents are not abused by staff, and actions are followed per policy and procedure once leadership is made aware for the protection of all residents in the facility. If abuse/neglect/exploitation is suspected, it is the witnesses responsibility to report directly to the Abuse Coordinator, or Corporate Compliance should there be a concern. Resident safety is paramount, and it is expected that all residents are treated with dignity and respect at all times. Should an unsatisfactory response or action be given by any person regardless of position, it is the reporters responsibility to ensure actions are taken to safeguard the resident. Additionally, education is provided by Regional Administrator or Administrator for understanding of residents rights, and their right to refuse care. Should the person receiving report provide an unsatisfactory response, this individual will receive disciplinary action. *Post test will be provided to staff covering training of ANE/Resident Rights, and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. *Alleged Perpetrator was terminated out of the system effective 7/30/2024, and call was made by Regional Administrator to employee to inform the status change. *1:1 education was completed on 7/30/2024 by Regional Administrator and Administrator with DON regarding investigating, reporting, and addressing all allegations of ANE, including disciplinary action. While the DON has formal oversight of the nursing personnel to include agency/PRN/new staff, the Administrator will ensure education is provided to all staff regarding ANE/Resident Rights prior to their next shift. *1:1 education was completed on 7/31/2024 at 10:15am by Administrator with witness CNA#1, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: P. Responding immediately to protect the alleged victim and integrity of the investigation; Q. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; R. Increased supervision of the alleged victim and residents; S. Providing emotional support and counseling to the resident during and after the investigation, as needed; T. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *1:1 education was completed on 7/31/2024 at 11:30am by Administrator with witness CNA#2, regarding immediate safeguarding of the residents, including but not limited to removing the resident themselves from the situation, ensuring resident safety by removing the threat, and using best judgement to ensure the resident is in a safe location before reporting to the Abuse Coordinator/Corporate Compliance. Per policy: P. Responding immediately to protect the alleged victim and integrity of the investigation; Q. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; R. Increased supervision of the alleged victim and residents; S. Providing emotional support and counseling to the resident during and after the investigation, as needed; T. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. *Resident #1 was informed by the Administrator that the alleged perpetrator was terminated, and that the Administrator was going to ensure staff are educated on ANE/Resident Rights and held accountable by the Administrator to safeguard the residents. Resident # 1 remains on Psych Services. *All new hires will meet with Administrator before working a shift 1:1 to ensure understanding of ANE Policy and Procedures and will sign an acknowledgement attesting to the training *PRN/Agency staff will be educated on ANE/Resident Rights upon arrival by Administrator or designee, and resource binder left at the nurses station to reference for quick access for Policy and Procedures related to ANE/Resident Rights. Start Date: 07/30/2024 4:00pm Completion Date: Prior to any staff coming on shift, education will be provided and post test given and employee understanding will be measured by being required to successfully answer all post test questions. Additionally, the administrator will interview 3 random staff and 3 random alert and oriented residents to ensure understanding. Target Audience: All staff Responsible person: Regional Administrator or Administrator How do you evaluate effectiveness: Administrator will begin completing interviews beginning 8/5/2024 of at least 3 random staff, and 3 random alert and oriented residents a week regarding ANE expectations, who to report to, when, how, and expectations of safe guarding residents who are suspected to be victim of ANE. This will be tracked via spreadsheet and will remain in effect for at least 3 months, or until substantial compliance is achieved. Information will be reviewed during QAPI and findings adjusted as necessary. The Surveyor monitored the POR on 08/02/24 as followed: During an interview on 08/02/24 at 11:18 AM, the ADM stated staff were being in-serviced before working the floor. He stated after further investigation, the DON was let go from the facility. During interviews on 08/02/24 from 11:29 AM - 2:38 PM, one RN, two LVNs, three CNAs, a HSK, and the TS (from different shifts) all stated they were in-serviced and took a post-test before working their shifts. All were able to state that their ADM was the Abuse and Neglect Coordinator and give examples of different types of abuse such as physical, verbal, emotional, and psychosocial. All stated if they saw a resident being abused by a staff member, another resident, or a family member they would intervene to ensure the resident was in a safe space and would notify the ADM immediately. They all stated if the ADM or DON was not immediately available, they would call the corporate hotline that was in the breakroom to notify the RADM. They all stated it was important to notify the ADM because he needed to conduct a thorough investigation, ensure residents safety, and report to the appropriate agencies. Each staff member stated residents had the right to refuse care, such as showers, and should never be forced to do something they did not want to do. During an interview on 08/03/24 at 2:46 PM, Resident #1 stated the ADM had spoken to her about the actions taken and she was just glad the CNA (CNA A) was no longer working at the facility. She stated she felt safe and had no further concerns. Review of Safe Surveys, dated 07/30/24, reflected all residents were interviewed regarding their safety with no concerns. Review of the facility's Ad Hoc QAPI Meeting Minutes, dated 07/30/24, reflected the ADM, RADM, RegN, and MD were in attendance. Review of a Disciplinary Notice , dated 07/30/24, reflected the DON received a final warning due to the following: [The DON] failed to investigate and report an allegation of abuse and neglect. This failure resulted in 4 IJ's being declared on 07/30/24. [The DON] failed to follow the abuse and neglect policy, also did not file a self-report with HHS as required. Further investigation is on-going. Additional disciplinary actions will be determined upon completion of internal investigation. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the ADM had a 1:1 training to review abuse, neglect and exploitation, investigation steps, and the reporting policy. Review of an in-service, dated 07/31/24 and conducted by the RADM, reflected the SW a 1:1 training to review abuse, neglect and exploitation, the reporting policy, and SW action steps. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA B had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of an in-service, dated 07/31/24 and conducted by the ADM, reflected CNA C had a 1:1 training to review and discuss ANE/Reporting Policy and Procedures. Review of in-services, dated 07/30/24 - 08/01/24 and conducted by the ADM, reflected staff from all shifts were in-serviced on ANE policy and procedures, the Abuse and Neglect Coordinator, reporting, resident rights (right to refuse care), and corporate compliance. Review of Abuse Post-Tests, dated 07/30/24 - 08/01/24, reflected all staff completed the test with passing scores. While the IJ was removed on 08/02/24 at 3:00 PM, the facility remained at a level of actual no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) and a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one of ten residents (Resident #1) reviewed for notification of change. The facility failed to ensure Resident #1's physician was consulted when she slept for 25 hours after an unwitnessed fall resulting in required intubation (a medical procedure that involves passing a tube into a person ' s airway to help with airway management and breathing) and two craniotomies (a brain surgery that involves cutting a piece of the skull to reach the brain and then putting it back) because of injuries sustained. This failure resulted in the identification of an IJ on 09/06/23 at 05:20 PM. IJ template was provided to the facility on [DATE] at 05:26 PM. While the immediacy was removed on 09/09/23 at 09:45 AM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate due to the facility's need to continue training and monitoring of change in condition assessments and notification to the physician. This failure resulted in two craniotomies for Resident #1 and placed residents at risk of brain injury after falls . Findings included: Review of the face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of depression, iron deficiency anemia, anxiety disorder, dementia, hypothyroidism , gastroesophageal reflux disease, mild protein-calorie malnutrition, Alzheimer's disease, abnormalities of gait and mobility, history of falling, muscle weakness, repeated falls, and cognitive communication deficit. Review of the quarterly MDS assessment for Resident #1 dated 07/12/23 reflected a BIMS score of 3, indicating a severe cognitive impairment. The section of the MDS for function status reflected Resident #1 required the limited assistance of one person for bed mobility and transfers. The section that assessed health conditions reflected she had sustained two or more falls since admission and that one fall had resulted in a minor injury. Review of a care plan item for Resident #1 dated 07/05/23 reflected the following: Care Plan Description- Falls: History of Falling Care Plan Goal- Injury from falls will not occur Care Plan Interventions- Refer to physical therapy for evaluation. Remind to ask staff for assistance with ambulation. Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician. Keep walker within reach at all times. Assist with one staff member for all ambulation. Review of a care plan item for Resident #1 dated 07/05/22 reflected the following: Care Plan Description- Code status: Full Code Care Plan Goal- Resident's advance directive will be followed as specified Directive: full code Care Plan Interventions- Allow family to expressed feelings and concerns regarding their family member. Give emotional support. Allow family to discuss concerns and allow them privacy when visiting. Notify MD/RP of changes in resident's condition. Respect and give support for resident and family regarding code status. Review of a nurse practitioner exam note dated 08/15/23 reflected the following : Neurologic physical exam: cranial nerves: grossly intact. Sensation: grossly intact. Assessment and Plan: 2. Domiciliary services - patient will get assistance with ADLs, supervision when walking, assistance with meals, and medication is managed. Review of an incident report for Resident #1 dated 09/02/23 reflected the following: CNA heard resident calling out for help at (09:30 PM) Found resident beside her bed, sitting. Resident stated she rolled out of bed. Educated resident on the importance of calling for help. Provided call light. Head to toe assessment complete- no injuries. Informed MD and family. Neuros have initiated. Review of an incident report for Resident #1 dated 09/03/23 reflected the following: Patient calling out and was observed laying on the floor on her back in doorway of her room with head towards hallway and walker tipped over on the ground next to her. Skin tear to right elbow. Neuros within normal limits. Assisted to wheelchair. Review of nursing progress notes for Resident #1 reflected the following: 09/02/23 10:08 PM by LVN F At approximately (09:15 PM) patient was observed sitting on the floor on bottom next to bed and in center of room between beds. CNA reported a few minute (sic) before PT was observed, leaning over in her bed and fidgeting with her belongings in her drawer. CNA reports patient informed her that she rolled out of bed. Patient was in bare feet. No injuries noted. Neuros within normal limits. Assisted back to bed. Vitals WNL. Grip socks applied and patient bed moved closer to bedside drawer to be able to reach easier from bed and prevent fall. Door ajar and call light in reach. DON notified, on-call admin aware as well. Notified (FM). On-call admin apprised on-call for (PCP). 09/03/23 05:16 AM by LVN E Resident up and down during night not sleeping well and very anxious. Resident repeatedly putting shoes on and, then, removing shoes, laying down, then getting shoes again. Resident worried about being alone in room. Resident stated that she previously fell and is now scared to be alone. Reassured resident that staff is always present if she needs anything and encouraged use of call light for assistance. Resident asking about her (FM) and when is (FM) coming. Resident Informed (FM) would be in later today. Offered resident a snack and distraction. Resident ate half chocolate muffin and drink sips of water before laying back down. Resident wanted to call (FM), we called (FM) on the phone and talked with her. 09/03/23 05:29 AM by LVN E Resident continues on F/U fall monitoring with neuro assessments WNL. No C/O pain during night shift. 09/03/23 09:55 AM by LVN F New fall this a.m. Patient was already on follow up fall precautions from fall last night. This a.m. patient was calling out and was observed laying on her back in her doorway with head towards the doorway and walker tipped over next to her. Notice skin tear to right elbow that was crescent in shape. Neuros WNL. No other injuries noted. ROM at baseline. Assisted up to wheelchair from floor. Skin tear cleansed with W/C and put skin back together and laid flat with Steri-Strips. Patient was last seen by this nurse at approximately three minutes before coming out of her bathroom with walker. No S/S of distress or anxiety at the time of fall. This nurse understood part of what patient was explaining to her in Spanish that she tripped on the carpet. Called and notified patient (FM) a fall. (FM) requested that psych meds to be looked into changing. (FM) informed that (Resident #1) will often get better when her meds are adjusted and then her body gets used to them and the meds stop working. On-call admin and DON at facility and aware. On-call admin notified (NP B) for PCP. NP to look into psych med changes. Patient also has order for UA to be collected. No frequent abnormal frequent urination noted by this nurse. Patient does have habit of taking self to the bathroom frequently at times when awake R/T forgetting that she just went to the bathroom. Fluids in reach and encouraged. No C/O pain. Patient at this time in W/C and is kept with staff or in staff line of sight for safety. 09/03/23 03:40 PM by LVN F Patient up in wheelchair in hallway and visiting with fellow patients and upon group disbursing. Patient begin to call out in Spanish that she did not want to be alone. Patient brought to the nurses station to help keep her calm and patient repeatedly asked in Spanish what she needed to do. Staff continues to reassure. PRN APAP given this afternoon for C/O pain to right hip. Apprised (NP B) of C/O pain post fall and gave orders to x-ray. Spoke with x-ray tech and scheduled x-ray stat. 09/03/23 05:23 PM by RN H Patient yelling out loud, attempting to get up from her chair, attempted to redirect patient with poor results. Patient continues to yell out loud, called (NP B), new order for Ativan 0.5 mg PO daily PRN X 14 days. Called pharmacy. Initial dose given at this time. One on one with patient at this time. Will continue to monitor. Awaiting for x-rays to be done. 09/03/23 06:08 PM by RN H Mobile x-ray here, to view x-ray done at this time. Assisted patient back up in a wheelchair until patient calms down. 09/03/23 09:30 PM by LVN F Right hip x-ray negative for fracture. 09/04/23 03:05 AM by LVN E Resident continues on F/U fall monitoring. Resident resting in bed asleep with no S/S pain or distress. Call light in reach. 09/04/23 01:53 PM by LVN D Patient remains on F/U falls and neuros R/T to patient fall on the third. Neuros within normal limits. Patient slept throughout this shift and refused meds. No C/O of pain or distress noted on the shift. 09/04/23 02:45 PM by RN C Resident asleep in bed. Bed in lowest position. Call light within reach. 09/04/23 04:00 PM by RN C Resident continues to sleep. Opens eyes to calling name. 09/04/23 06:31 PM by RN C Awakened to administer medication, and then fell back to sleep. Gave (FM) update on the phone. 09/04/23 07:30 PM by RN C (FM) at bedside. Patient opened eyes but did not respond as usual to her (FM). Notified (NP B) that resident has been sleeping since last night. 09/04/23 09:30 PM by RN C No change in condition. Pulse 90 BP 156/78, respirations 16. Notified (alternate on call NP service) for PCP (NP A) responded and after updating her on condition decided to send her to ER. Called transport. Transported to local hospital at 10:20 PM. (FM) notified. DON notified through phone message. Review of neurological check documentation for Resident #1 reflected the following: 09/02/23 09:15 PM within normal limits 09:30 PM within normal limits 09:45 PM within normal limits 10:00 PM within normal limits 10:30 PM Asleep 11:00 PM Asleep 12:00 AM Asleep 09/03/23 01:00 AM Asleep 02:00 AM restless/agitated 03:00 AM resting in bed 07:00 AM within normal limits 10:30 AM NEW FALL unable to obtain due to tending to skin 10:45 AM within normal limits 11:00 AM within normal limits 11:15 AM within normal limits 11:45 AM within normal limits 12:15 AM within normal limits 01:15 PM within normal limits 02:15 PM within normal limits 03:15 PM within normal limits 04:15 PM within normal limits 08:15 PM Asleep 09/04/23 12:15 AM Asleep 04:15 AM Asleep 08:15 AM Asleep 12:15 PM Asleep 08:15 PM Asleep 09/05/23 12:15 AM Hospital Review of Emergency Documentation for Resident #1 dated 09/05/23 at 03:54 AM reflected the following: Chief complaint - category 1 trauma multiple falls two days ago intubated. History of present illness- [AGE] year-old female presents for evaluation after multiple falls today. Reportedly had AMS and was intubated. CT showed bilateral SDH. Pt was transferred here for trauma admission. CT head without contrast - impression 1. large bilateral subdural hematomas (brain bleeds on both sides). Review of hospital History and Physical dated 09/05/23 at 04:39 AM reflected the following: History of Present Illness The patient is an [AGE] year-old female who has a trauma stat transferred from (other hospital) for large bilateral subdural hematomas. Patient reportedly sustained multiple ground level falls 2 to 3 days ago at her nursing home, was evaluated at (other hospital) where she had chest x-ray and pelvic x-rays. Yesterday she was noted to have slurred speech and altered mental status today for which she was taken back to (other hospital) where a CT head and C-spine was obtained showing large bilateral subdural hematomas. Patient was intubated and transferred to this hospital for higher level of care and neurosurgical evaluation. -Glasgow coma scale (a clinical scale used to reliably measure a person's level of consciousness after a brain injury.): 3T (Patients with scores of 3 to 8 are considered to be in a coma. Patients with a T next to the score are intubated.) Assessment/plan -Acute respiratory failure Intubated and sedated -Large bilateral SDH CT showed slight right to left midline shift Neurosurgery consult emergently Going to the OR emergently for craniotomy History and physical addendum 09/05/23 (10:45 PM) Neuro: not alert or oriented, does not awaken with noxious stimuli, does not follow commands. Observation on 08/06/23 at 08:37 AM in a local hospital ICU revealed Resident #1 laying in a hospital bed, ventilated and receiving IV fluids. Her head had been shaved, and there was a bandage wrapped around a portion of it. During an interview on 08/06/23 at 08:45 AM, the hospital RN for Resident #1 stated Resident #1 had two brain bleeds and had to have two [NAME] holes dripped into her skull to relieve pressure. She stated Resident #1 had been unresponsive to most stimuli prior to that morning, but she had been waking up for a few moments that morning. During an interview on 08/06/23 at 02:00 PM, LVN D stated he had worked at the facility for five months and had worked the 06:00 AM to 02:00 PM shift on 09/04/23, the day after Resident #1's falls. He stated protocol after a resident fall was to initiate neurological checks if there was head involvement or if the fall was unwitnessed. LVN D stated he did not know the circumstances of Resident #1's falls on 09/02/23 and 09/03/23, but he could surmise that she was anxious and trying to get out of her room and slipped. LVN D stated the facility had initiated neurological checks after the first fall on 09/02/23. LVN D stated when he came onto shift at 06:00 AM on 09/04/23, the neurological checks at that point were at a frequency of each four hours. He stated Resident #1 slept through the first neurological check and during his second neurological check, Resident #1 woke up with stimuli only to refuse her medications. He stated she had already been sleeping since bedtime the night before at that point, and he was concerned that she did not wake up. When asked if she would normally sleep that long at once, he stated it depended on her sleep pattern how long she slept. LVN D stated she often slept during the day if she was up all night. When asked at what point or at how many hours of sleep during neurological checks would he see a problem, he stated again he had gotten concerned when she refused her noon medications. He stated she still woke up at that time but was lethargic which was weird, and at that point she had already been asleep fourteen hours. When asked if he spoke to anyone about his concern, he stated he recommended to RN C, who came in to relieve him, that they increase the neurological checks to more often than every four hours. LVN D stated he would have called nurse management and the nurse practitioner by the third round of neurological check in which she was still asleep. LVN D stated he would have called at 16 or 20 hours of sleep since he knew she had been awake for 24 hours before that. During an interview on 09/04/23 at 02:18 PM, RN C stated she worked the 02:00 PM to 10:00 PM shift at the facility and was the charge nurse for Resident #1 on 09/04/23, the day after her falls. RN C stated when she started her shift, Resident #1 was sound asleep. RN C stated the nurses did hourly check on all residents to prevent falls as part of their routine supervision, and on the second check of her shift, she took Resident #1's vitals, which were all normal. RN C stated Resident #1 had a history of talking and moving around constantly and then sleeping for a long time. RN C stated it was not unusual for Resident #1 to sleep a long time, and she had gotten report that Resident #1 had woken up to get her medication, but that Resident #1 had refused the meds and gone back to sleep. RN C stated during her shift, she went in and checked on Resident #1 to make sure she was breathing and not in distress, her call light was accessible, and her bed was in low position. When asked when she became concerned enough to engage the nurse practitioner, RN C stated it was when Resident #1's FM arrived at the facility, and Resident #1 did not respond much to the FM. RN C stated Resident #1 was not talking and could not follow directions enough for RN C to conduct a neurological check on her. RN C stated she became worried at that point and left a voicemail for NP B who did not call back. RN C stated when she did not hear back, she called an alternate number for an on-call nurse practitioner service and spoke with NP A who did order that Resident #1 be sent out to the hospital. RN C stated Resident #1 was not completely asleep the entire time, and she had a history of staying up for several hours and sleeping for several hours. RN C stated she had not seen Resident #1 sleep all day before, but the resident was not completely asleep the whole time. RN C stated Resident #1 had not slept during her entire shift before, and it was potentially a sign of a head injury. RN C stated if she had hindsight, she would have called the nurse practitioner earlier. An attempt was made by telephone on 09/09/23 at 02:32 PM to interview NP A and voicemail left but no return contact was received. An attempt was made by telephone on 09/09/23 at 02:34 PM to interview the PCP for Resident #1 and voicemail left but no return contact was received. During an interview on 09/06/23 at 02:50 PM, the MD stated sending a resident to ER should have been the knee jerk reaction to any change in mentation, nausea, vomiting, or change in pupils. When asked if sleeping for excessively long stretches constituted a change in mentation, he stated he would want the resident to be sent out. When the circumstances of Resident #1's hospitalization were explained to him, he stated Resident #1 should have been sent out to the hospital at 12 hours of sleeping at the latest, and he should have been updated about the incident as the medical director for the facility. The MD stated he did not really have a role at the facility in training staff to make clinical decisions. He stated he spoke about any concerns he had, to the ADON and DON, but unfortunately the staff is very heterogenous and there could be little uniformity in the various staff member's assessments. An attempt was made by telephone on 09/09/23 at 03:12 PM to interview LVN E but no return contact was received. An attempt was made by telephone on 09/09/23 at 02:13 PM to interview LVN F and voicemail left but no return contact was received. During an interview on 09/06/23 at 03:20 PM, the ADON stated she did not know much about what had happened with Resident #1, because she had been off on the weekend. She stated none of her staff reached out to her on Monday while they were conducting neurological checks on Resident #1 and voiced any concerns. She stated her understanding was that Resident #1 was sent to the ER because of falls. The ADON stated she also had gotten report that Resident #1 was up for 48 hours prior to that. The ADON stated Resident #1 had a lot of anxiety on 09/03/23 after her falls, which was normal for her. The ADON stated she would have hoped the charge nurses would have reached out to the nurse manager or nurse practitioner after 12 hours of sleeping during the process of monitoring for head injury. The ADON stated Resident #1 stayed up and then slept for a long time regularly, but the longest she had heard of Resident #1 sleeping was the day shift after she had been up the night before. The ADON stated Resident #1 was prescribed antianxiety medications to help her rest, and they did not always work, but then all of a sudden, they would catch up with her and she would sleep deeply for hours. The ADON stated it was part of her role to train the staff to assess properly during the process of charting neurological evaluations. She stated she hoped they would have contacted the physician by 12 hours of sleeping. The ADON stated that was outside of Resident #1's baseline. When it was pointed out that Resident #1 had not been awake for 48 hours prior to falling asleep for 25 hours, she stated she would have seen the excessive sleeping as a problem if that was the case. During an interview on 09/06/23 at 3:32 PM, the DON stated she had worked the floor on 09/03/23, and she had a gut feeling that something was going to happen with Resident #1, so when she stepped away from the hall for a few minutes to the medication cart, and Resident #1 immediately fell, she was upset. The DON stated that all unwitnessed falls resulted in the neurological checks protocol. The DON stated she stayed with Resident #1 most of that day, and the resident was agitated and having some pain, so the DON assessed her hips. The DON stated there was no obvious deformity, but they ordered a STAT x-ray, which was negative for any fracture. The DON stated Resident #1 was still agitated and anxious, so they called for PRN order for Ativan and administered the medication. She stated soon after that, Resident #1 was ready to lay down. The DON stated she was off the following day on 09/04/23 and received a call at around 10:30 PM that they were sending Resident #1 out to the hospital. The DON stated she got an update from the family that Resident #1 had two brain bleeds. The DON stated RN C had told her Resident #1 slept all night Sunday and all day and evening Monday. The DON stated after coming back to the facility, she looked into the incident reports and neurological check sheets and realized the resident's lethargy and extended sleep should have been addressed earlier than it was. When asked at what point she would have expected the nurses call nurse management or the nurse practitioner, the DON stated it depended on the resident. The DON then said, though that if they were checking every one to two hours for signs of head injury, they were checking for a reason and needed to act when the resident was out of baseline. The DON stated the first time they could not wake up the resident or keep her awake, they should have called. The DON stated when LVN D was concerned at noon, he should not have passed that off to the next shift. The DON stated she had only been at the facility a short time and was still identifying what systems needed improvement. She stated they were still doing a lot of training and in-servicing. During an interview on 09/06/23 at 3:47 PM, the ADM stated his understanding was Resident #1 had two falls over the weekend, and he was notified yesterday morning that Resident #1 had gone to the hospital and was in surgery. The ADM stated he started asking questions when he learned that, to figure out what had occurred and gather information to do the self-report. He stated when he started asking questions, he found out she fell twice, the DON was in the building most of the day 09/03/23, and the DON was side by side with Resident #1 all day. The ADM stated Resident #1 had been acting normally and they initiated the neurological checks . The ADM stated he had not reviewed the entire neurological check log yet, but he knew something happened 09/04/23 where a decline was noticed. The ADM stated Resident #1 was sent to the hospital at that point and was currently in the ICU and not expected to live. The ADM stated he had been at the facility for five weeks and did not know the entire protocol for falls and change of condition, but his thought was if there was a possibility of head injury, they should have just sent her out right away. Review of undated facility policy titled Acute Condition Changes- Clinical Protocol reflected the following: Assessment and recognition 1. During the initial assessment, the nurse shall assess and document/report the following baseline information: vital signs; a. Neurological status; b. Current level of pain; c. Level of consciousness d. Cognitive and emotional status e. Residence, age and sex; f. History of psychiatric disturbances, mental illness, depression, etc. g. All active diagnoses; and h. All current medications. 4. Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician; a. Phone calls to attending or on-call physician should be made by an adequately prepared nurse, who has collected and organized, pertinent information, including the residents current symptoms, and status. 5. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately 1/2 hour or less). 6. The Attending Physician, or a practitioner, providing back up coverage, will respond in a timely manner to notification of problems or changes in condition and status. a. The staff will notify the medical Director for additional guidance and consultation if they do not receive a timely or appropriate response. 7. The Nurse and Physician will discuss and evaluate the situation. a. The physician should ask questions to clarify the situation; for example, vital signs, physical findings, and a description of symptoms. Treatment/Management 1. The physician will help identify and authorize appropriate treatments. 2. If it is decided, after sufficient review, the care or observation cannot reasonably prove be provided in the facility, the attending physician will authorize transfer to an acute hospital, emergency room, or another appropriate setting. On 09/09/23 at 05:26 PM, the ADM was notified of an IJ due to above listed failures and an IJ Template was provided and POR requested. The facility's POR was accepted on 09/08/23 at 05:08 PM and included: 580 Plan of Removal Introduction: On September 6, 2023, an immediate Jeopardy was identified because of resident falls. Resident 1 sustained two falls within 13 hours, was hospitalized after sleeping for a period of 25 hours. Resident was diagnosed with two brain bleeds, underwent surgery for repair. Resident 1 remains on a ventilator and may not recover. All current residents at (facility) center are at risk of falling and have the potential to be impacted by this deficient practice. 1. As a result of the IJ, the facility has implemented the following. Administrator, DON, were in serviced by chief nursing officer, as well as regional nurse: healthcare, regarding resident changes in condition, follow up, incident and accident, monitoring staff, staff, reporting of incidents and changes in condition/neurochecks. Admin and DON in serviced on the need for increased staff education and monitoring new hires and agency staff. Both verbalized understanding. 2. ADON was in serviced by corporate/regional nurse: regarding Resident changes in condition, follow up, incidents and accidents, monitoring staff, staff reporting of incidents and changes in condition/neurochecks. Admin and DON in-serviced on the need for increased staff education and monitoring, including new hires and agency staff. Both verbalized understanding. 3.As a result of the two falls Resident 1 sustained the facility, DON & ADON on 9/6/23 at 6 PM implemented the following: a. all on duty nursing staff were in serviced on the following by DON and a DOM. i. MD notification of change in condition, including change in mental status/alertness ii. Notification of DON/administrator of any change in condition iii. Resident and Falls, and follow up monitoring iv. Completion of neurological checks, including waking resident to complete assessment and signs/symptoms of subdural hematoma v. Monitoring residents for change in condition, including sleeping for abnormal periods of time. b. Signs/symptoms of resident change of condition to include, but not limited to: i. Mental status ii. Unarousable while sleeping iii. Changes to pupils iv. Changes to normal behavior patterns v. Inability to/or refusing to eat, drink, or take medications c. These in-services were completed on 9/7/23 4. All other nurses will be in service prior to starting their next scheduled shift. The DON, or designee will train the nurses. 5. All nurses will be tested for understanding in these areas and re-educated if they do not score 100% on the test. 6. The facility will add additional falls and neurological check training for the nurses. DON, ADON, will provide training and in-service training to nurses upon higher, and then semiannually and staff in-services. 7. Additionally, DON/ADON have in-serviced nurses by phone prior to the start of their next shift. 8. A reference binder has been set up for nursing staff to quickly access policy on incidents and accidents and neurological checks. New hires, agency, staff, and existing stuff will be oriented to the location of the information. And will complete the in-service and related test 9. Completion date, 9/7/2023 at 7 AM 10. The facility completed an internal review and audit of falls for the past 90 days. The review was completed by administrator, corporate/regional nurse, and DON/ADON. All resident falls were reviewed for the potential of head injury. Files that were identified a sustaining a head injury were audited for compliance with the fall policy. a. The facility identified 101 total incidents in the review. Period 86 of which were false. b. Facility reviewed all 86 falls and identified 15 initially identified as head injuries or potential head injuries. A review of the other 71 Falls was conducted. The review found 63 where neurological checks were performed. Instances of incomplete documentation were noted. No adverse were identified during the review. c. Additional in servicing was initiated, to reinforce earlier and service on documentation, and the requirement on documentation completion and follow up. d. This review was completed on 9/7/23. The review identified additional in-services completed regarding incident reporting a neurological checks. 11. The facility completed an ad hoc QAPI, regarding the incident resulting in the IJ. QAPI committee will add Resident Falls with, and without head injuries to the agenda, and will review data for eight weeks. Additionally falls will be reviewed in the morning QA, a specific file review has been added to the daily QA meeting. The POR was monitored in the following ways: Observation on 09/09/23 at 08:30 AM revealed the DON in-servicing two agency medication aides. The DON went over the detailed information in the in-service including protocol for MD notification of change in condition, including change in mental status/alertness, notification of DON/administrator of any change in condition, resident falls, and follow up monitoring, completion of neurological checks, including waking resident to complete assessment and signs/symptoms of subdural hematoma, and monitoring residents for change in condition, including sleeping for abnormal periods of time. She checked for understanding from both medication aides and observed as they signed the in-service. During interviews on 09/07/23 between 04:30 PM and 05:15 PM, one RN, three LVNs, a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one of fourteen residents (Resident #1) reviewed for falls and supervision. The facility failed to prevent Resident #1 from falling again on [DATE] after an initial fall on [DATE]. She sustained two subdural hematomas, required intubation (mechanical breathing), and underwent two craniotomies (surgical operation on skull) and died on [DATE]. This failure resulted in the identification of an IJ on [DATE] at 02:05 PM. IJ template was provided to the facility on [DATE] at 02:07 PM. While the immediacy was removed on [DATE] at 04:50 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate due to the facility's need to continue training and monitoring of change in condition assessments and notification to the physician . This failure resulted in two craniotomies for Resident #1 and placed residents at risk of brain injury after falls. Findings included: Review of the face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of depression, iron deficiency anemia, anxiety disorder, dementia, hypothyroidism, gastroesophageal reflux disease, mild protein-calorie malnutrition, Alzheimer's disease, abnormalities of gait and mobility, history of falling, muscle weakness, repeated falls, and cognitive communication deficit. Review of the quarterly MDS assessment for Resident #1 dated [DATE] reflected a BIMS score of 3, indicating a severe cognitive impairment. The section of the MDS for function status reflected Resident #1 required the limited assistance of one person for bed mobility and transfers as well as toileting and other ADLs. The section that assessed health conditions reflected she had sustained two or more falls since admission and that one fall had resulted in a minor injury. Review of a care plan item for Resident #1 dated [DATE] reflected the following: Care Plan Description- Falls: History of Falling Care Plan Goal- Injury from falls will not occur Care Plan Interventions- Refer to physical therapy for evaluation. Remind to ask staff for assistance with ambulation. Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician. Keep walker within reach at all times. Assist with one staff member for all ambulation . Review of a nurse practitioner exam note dated [DATE] reflected the following : Neurologic physical exam: cranial nerves: grossly intact. Sensation: grossly intact. Assessment and Plan: 2. Domiciliary services - patient will get assistance with ADLs, supervision when walking, assistance with meals, and medication is managed. Review of an incident report for Resident #1 dated [DATE] reflected the following: CNA heard resident calling out for help at (09:30 PM) Found resident beside her bed, sitting. Resident stated she rolled out of bed. Educated resident on the importance of calling for help. Provided call light. Head to toe assessment complete- no injuries. Informed MD and family. Neuros have initiated. Review of an incident report for Resident #1 dated [DATE] reflected the following: Patient calling out and was observed laying on the floor on her back in doorway of her room with head towards hallway and walker tipped over on the ground next to her. Skin tear to right elbow. Neuros within normal limits. Assisted to wheelchair. Review of nursing progress notes for Resident #1 reflected the following: [DATE] 10:08 PM by LVN F At approximately (09:15 PM) patient was observed sitting on the floor on bottom next to bed and in center of room between beds. CNA reported a few minute (sic) before PT was observed, leaning over in her bed and fidgeting with her belongings in her drawer. CNA reports patient informed her that she rolled out of bed. Patient was in bare feet. No injuries noted. Neuros within normal limits. Assisted back to bed. Vitals WNL. Grip socks applied and patient bed moved closer to bedside drawer to be able to reach easier from bed and prevent fall. Door ajar and call light in reach. DON notified, on-call admin aware as well. Notified (FM). On-call admin apprised on-call for (PCP ). [DATE] 05:16 AM by LVN E Resident up and down during night not sleeping well and very anxious. Resident repeatedly putting shoes on and, then, removing shoes, laying down, then getting shoes again. Resident worried about being alone in room. Resident stated that she previously fell and is now scared to be alone. Reassured resident that staff is always present if she needs anything and encouraged use of call light for assistance. Resident asking about her (FM) and when is (FM) coming. Resident Informed (FM) would be in later today. Offered resident a snack and distraction. Resident ate half chocolate muffin and drink sips of water before laying back down. Resident wanted to call (FM), we called (FM) on the phone and talked with her. [DATE] 05:29 AM by LVN E Resident continues on F/U fall monitoring with neuro assessments WNL. No C/O pain during night shift. [DATE] 09:55 AM by LVN F New fall this a.m. Patient was already on follow up fall precautions from fall last night. This a.m. patient was calling out and was observed laying on her back in her doorway with head towards the doorway and walker tipped over next to her. Notice skin tear to right elbow that was crescent in shape. Neuros WNL. No other injuries noted. ROM at baseline. Assisted up to wheelchair from floor. Skin tear cleansed with W/C and put skin back together and laid flat with Steri-Strips. Patient was last seen by this nurse at approximately three minutes before coming out of her bathroom with walker. No S/S of distress or anxiety at the time of fall. This nurse understood part of what patient was explaining to her in Spanish that she tripped on the carpet. Called and notified patient (FM) a fall. (FM) requested that psych meds to be looked into changing. (FM) informed that (Resident #1) will often get better when her meds are adjusted and then her body gets used to them and the meds stop working. On-call admin and DON at facility and aware. On-call admin notified (NP B) for PCP. NP to look into psych med changes. Patient also has order for UA to be collected. No frequent abnormal frequent urination noted by this nurse. Patient does have habit of taking self to the bathroom frequently at times when awake R/T forgetting that she just went to the bathroom. Fluids in reach and encouraged. No C/O pain. Patient at this time in W/C and is kept with staff or in staff line of sight for safety. [DATE] 03:40 PM by LVN F Patient up in wheelchair in hallway and visiting with fellow patients and upon group dispersing. Patient begin to call out in Spanish that she did not want to be alone. Patient brought to the nurses station to help keep her calm and patient repeatedly asked in Spanish what she needed to do. Staff continues to reassure. PRN APAP given this afternoon for C/O pain to right hip. Apprised (NP B) of C/O pain post fall and gave orders to x-ray. Spoke with x-ray tech and scheduled x-ray stat. [DATE] 05:23 PM by RN H Patient yelling out loud, attempting to get up from her chair, attempted to redirect patient with poor results. Patient continues to yell out loud, called (NP B), new order for Ativan 0.5 mg PO daily PRN X 14 days. Called pharmacy. Initial dose given at this time. One on one with patient at this time. Will continue to monitor. Awaiting for x-rays to be done. [DATE] 06:08 PM by RN H Mobile x-ray here, to view x-ray done at this time. Assisted patient back up in a wheelchair until patient calms down. [DATE] 09:30 PM by LVN F Right hip x-ray negative for fracture. [DATE] 03:05 AM by LVN E Resident continues on F/U fall monitoring. Resident resting in bed asleep with no S/S pain or distress. Call light in reach. [DATE] 01:53 PM by LVN D Patient remains on F/U falls and neuros R/T to patient fall on the third. Neuros within normal limits. Patient slept throughout this shift and refused meds. No C/O of pain or distress noted on the shift. [DATE] 02:45 PM by RN C Resident asleep in bed. Bed in lowest position. Call light within reach. [DATE] 04:00 PM by RN C Resident continues to sleep. Opens eyes to calling name. [DATE] 06:31 PM by RN C Awakened to administer medication, and then fell back to sleep. Gave (FM) update on the phone. [DATE] 07:30 PM by RN C (FM) at bedside. Patient opened eyes but did not respond as usual to her (FM). Notified (NP B) that resident has been sleeping since last night. [DATE] 09:30 PM by RN C No change in condition. Pulse 90 BP 156/78, respirations 16. Notified (alternate on call NP service) for PCP (NP A) responded and after updating her on condition decided to send her to ER. Called transport. Transported to local hospital at 10:20 PM. (FM) notified. DON notified through phone message. Review of neurological check documentation for Resident #1 reflected the following: [DATE] 09:15 PM within normal limits 09:30 PM within normal limits 09:45 PM within normal limits 10:00 PM within normal limits 10:30 PM Asleep 11:00 PM Asleep 12:00 AM Asleep [DATE] 01:00 AM Asleep 02:00 AM restless/agitated 03:00 AM resting in bed 07:00 AM within normal limits 10:30 AM NEW FALL unable to obtain due to tending to skin 10:45 AM within normal limits 11:00 AM within normal limits 11:15 AM within normal limits 11:45 AM within normal limits 12:15 AM within normal limits 01:15 PM within normal limits 02:15 PM within normal limits 03:15 PM within normal limits 04:15 PM within normal limits 08:15 PM Asleep [DATE] 12:15 AM Asleep 04:15 AM Asleep 08:15 AM Asleep 12:15 PM Asleep 08:15 PM Asleep [DATE] 12:15 AM Hospital Review of hospital Emergency Documentation for Resident #1 dated [DATE] at 03:54 AM reflected the following: Chief complaint - category 1 trauma multiple falls two days ago intubated. History of present illness- [AGE] year-old female presents for evaluation after multiple falls today. Reportedly had AMS and was intubated. CT showed bilateral SDH. Pt was transferred here for trauma admission. CT head without contrast - impression 1. large bilateral subdural hematomas (brain bleeds on both sides). Review of hospital History and Physical dated [DATE] at 04:39 AM reflected the following: History of Present Illness The patient is an [AGE] year-old female who has a trauma stat transferred from (other hospital) for large bilateral subdural hematomas. Patient reportedly sustained multiple ground level falls 2 to 3 days ago at her nursing home, was evaluated at (other hospital) where she had chest x-ray and pelvic x-rays. Yesterday she was noted to have slurred speech and altered mental status today for which she was taken back to (other hospital) where a CT head and C-spine was obtained showing large bilateral subdural hematomas. Patient was intubated and transferred to this hospital for higher level of care and neurosurgical evaluation. -Glasgow coma scale (a clinical scale used to reliably measure a person's level of consciousness after a brain injury.): 3T (Patients with scores of 3 to 8 are considered to be in a coma. Patients with a T next to the score are intubated.) Assessment/plan -Acute respiratory failure Intubated and sedated -Large bilateral SDH CT showed slight right to left midline shift Neurosurgery consult emergently Going to the OR emergently for craniotomy History and physical addendum [DATE] (10:45 PM) Neuro: not alert or oriented, does not awaken with noxious stimuli, does not follow commands. Observation on [DATE] at 08:37 AM in a local hospital ICU revealed Resident #1 laying in a hospital bed, ventilated and receiving IV fluids. Her head had been shaved, and there was a bandage wrapped around a portion of it. During an interview on [DATE] at 08:45 AM, the hospital RN for Resident #1 stated Resident #1 had two brain bleeds and had to have two [NAME] holes dripped into her skull to relieve pressure. She stated Resident #1 had been unresponsive to most stimuli prior to that morning, but she had been waking up for a few moments that morning. During an interview on [DATE] at 02:00 PM, LVN D stated he had worked at the facility for five months and had worked the 06:00 AM to 02:00 PM shift on [DATE], the day after Resident #1's falls. He stated protocol after a resident fall was to initiate neurological checks if there was head involvement or if the fall was unwitnessed. LVN D stated he did not know the circumstances of Resident #1's falls on [DATE] and [DATE], but he could surmise that she was anxious and trying to get out of her room and slipped. LVN D stated the facility had initiated neurological checks after the first fall on [DATE]. LVN D stated when he came onto shift at 06:00 AM on [DATE], the neurological checks at that point were at a frequency of each four hours. He stated Resident #1 slept through the first neurological check and during his second neurological check, Resident #1 woke up with stimuli only to refuse her medications. He stated she had already been sleeping since bedtime the night before at that point, and he was concerned that she did not wake up. When asked if she would normally sleep that long at once, he stated it depended on her sleep pattern how long she slept. LVN D stated she often slept during the day if she was up all night. When asked at what point or at how many hours of sleep during neurological checks would he see a problem, he stated again he had gotten concerned when she refused her noon medications. He stated she still woke up at that time but was lethargic which was weird, and at that point she had already been asleep fourteen hours. When asked if he spoke to anyone about his concern, he stated he recommended to RN C, who came in to relieve him, that they increase the neurological checks to more often than every four hours. LVN D stated he would have called nurse management and the nurse practitioner by the third round of neurological check in which she was still asleep. LVN D stated he would have called at 16 or 20 hours of sleep since he knew she had been awake for 24 hours before that. During an interview on [DATE] at 02:18 PM, RN C stated she worked the 02:00 PM to 10:00 PM shift at the facility and was the charge nurse for Resident #1 on [DATE], the day after her falls. RN C stated when she started her shift, Resident #1 was sound asleep. RN C stated the nurses did hourly check on all residents to prevent falls as part of their routine supervision, and on the second check of her shift, she took Resident #1's vitals, which were all normal. RN C stated Resident #1 had a history of talking and moving around constantly and then sleeping for a long time. RN C stated it was not unusual for Resident #1 to sleep a long time, and she had gotten report that Resident #1 had woken up to get her medication, but that Resident #1 had refused the meds and gone back to sleep. RN C stated during her shift, she went in and checked on Resident #1 to make sure she was breathing and not in distress, her call light was accessible, and her bed was in low position. When asked when she became concerned enough to engage the nurse practitioner, RN C stated it was when Resident #1's FM arrived at the facility, and Resident #1 did not respond much to the FM. RN C stated Resident #1 was not talking and could not follow directions enough for RN C to conduct a neurological check on her. RN C stated she became worried at that point and left a voicemail for NP B who did not call back. RN C stated when she did not hear back, she called an alternate number for an on-call nurse practitioner service and spoke with NP A who did order that Resident #1 be sent out to the hospital. RN C stated Resident #1 was not completely asleep the entire time, and she had a history of staying up for several hours and sleeping for several hours. RN C stated she had not seen Resident #1 sleep all day before, but the resident was not completely asleep the whole time. RN C stated Resident #1 had not slept during her entire shift before, and it was potentially a sign of a head injury. RN C stated if she had hindsight, she would have called the nurse practitioner earlier. She stated the outcome for the resident was very sad. An attempt was made by telephone on [DATE] at 02:32 PM to interview NP A and voicemail left but no return contact was received. During an interview on [DATE] at 02:50 PM, the MD stated sending a resident to ER should have been the knee jerk reaction to any change in mentation, nausea, vomiting, or change in pupils. When asked if sleeping for excessively long stretches constituted a change in mentation, he stated he would want the resident to be sent out. When the circumstances of Resident #1's hospitalization were explained to him, he stated Resident #1 should have been sent out to the hospital at 12 hours of sleeping at the latest, and he should have been updated about the incident as the medical director for the facility. The MD stated he did not really have a role at the facility in training staff to make clinical decisions. He stated he spoke about any concerns he had, to the ADON and DON, but unfortunately the staff is very heterogenous and there could be little uniformity in the various staff member's assessments. He stated what had occurred with Resident #1 was very unfortunate. An attempt was made by telephone on [DATE] at 03:12 PM to interview LVN E but no return contact was received. During an interview on [DATE] at 03:20 PM, the ADON stated she did not know much about what had happened with Resident #1, because she had been off on the weekend. She stated none of her staff reached out to her on Monday while they were conducting neurological checks on Resident #1 and voiced any concerns. She stated her understanding was that Resident #1 was sent to the ER because of falls. The ADON stated she also had gotten report that Resident #1 was up for 48 hours prior to that. The ADON stated Resident #1 had a lot of anxiety on [DATE] after her falls, which was normal for her. The ADON stated she would have hoped the charge nurses would have reached out to the nurse manager or nurse practitioner after 12 hours of sleeping during the process of monitoring for head injury. The ADON stated Resident #1 stayed up and then slept for a long time regularly, but the longest she had heard of Resident #1 sleeping was the day shift after she had been up the night before. The ADON stated Resident #1 was prescribed antianxiety medications to help her rest, and they did not always work, but then all of a sudden, they would catch up with her and she would sleep deeply for hours. The ADON stated it was part of her role to train the staff to assess properly during the process of charting neurological evaluations. She stated she hoped they would have contacted the physician by 12 hours of sleeping. The ADON stated that was outside of Resident #1's baseline. When it was pointed out that Resident #1 had not been awake for 48 hours prior to falling asleep for 25 hours, she stated she would have seen the excessive sleeping as a problem if that was the case. During an interview on [DATE] at 3:32 PM, the DON stated she had worked the floor on [DATE], and she had a gut feeling that something was going to happen with Resident #1, so when she stepped away from the hall for a few minutes to the medication cart, and Resident #1 immediately fell, she was upset. The DON stated that all unwitnessed falls resulted in the neurological checks protocol. The DON stated she stayed with Resident #1 most of that day, and the resident was agitated and having some pain, so the DON assessed her hips. The DON stated there was no obvious deformity, but they ordered a STAT x-ray, which was negative for any fracture. The DON stated Resident #1 was still agitated and anxious, so they called for PRN order for Ativan and administered the medication. She stated soon after that, Resident #1 was ready to lay down. The DON stated she was off the following day on [DATE] and received a call at around 10:30 PM that they were sending Resident #1 out to the hospital. The DON stated she got an update from the family that Resident #1 had two brain bleeds. The DON stated RN C had told her Resident #1 slept all night Sunday and all day and evening Monday. The DON stated after coming back to the facility, she looked into the incident reports and neurological check sheets and realized the resident's lethargy and extended sleep should have been addressed earlier than it was. When asked at what point she would have expected the nurses call nurse management or the nurse practitioner, the DON stated it depended on the resident. The DON then said, though that if they were checking every one to two hours for signs of head injury, they were checking for a reason and needed to act when the resident was out of baseline. The DON stated the first time they could not wake up the resident or keep her awake, they should have called. The DON stated when LVN D was concerned at noon, he should not have passed that off to the next shift. The DON stated she had only been at the facility and was still identifying what systems needed improvement. She stated they were still doing a lot of training and in-servicing. During an interview on [DATE] at 3:47 PM, the ADM stated his understanding was Resident #1 had two falls over the weekend, and he was notified yesterday morning that Resident #1 had gone to the hospital and was in surgery. The ADM stated he started asking questions when he learned that, to figure out what had occurred and gather information to do the self-report. He stated when he started asking questions, he found out she fell twice, the DON was in the building most of the day [DATE], and the DON was side by side with Resident #1 all day. The ADM stated Resident #1 had been acting normally and they initiated the neurological checks. The ADM stated he had not reviewed the entire neurological check log yet, but he knew something happened [DATE] where a decline was noticed. The ADM stated Resident #1 was sent to the hospital at that point and was currently in the ICU and not expected to live. The ADM stated he had been at the facility for five weeks and did not know the entire protocol for falls and change of condition, but his thought was if there was a possibility of head injury, they should have just sent her out right away. During a text interview on [DATE] at 11:22 AM, a FM of Resident #1 stated the following: Just wanted to inform you that my MIL passed away the night of [DATE] @ 10:15pm she had been transferred to (another local nursing facility) to live out her final days . she went 10 days without being able to eat or drink because she the trauma to her brain contributed to failing her barium swallow X-ray test a few days after we first met you at the hospital. Observation on [DATE] of an automated electronic monitoring video dated [DATE] at 10:37 AM revealed the door to Resident #1's bathroom opened, and LVN F stopped at the bedroom door for Resident #1, looked in, and then kept walking by. Resident #1 became visible from the other side of the bathroom door with her walker, the door was pushed out, and then the door began to fall closed again and pushed the walker over. Resident #1 fell to the right with the walker, and the right side of her head made contact with the floor. During an interview on [DATE] at 11:09 AM, LVN F stated she was the charge nurse for Resident #1 on the weekends, and she had worked with Resident #1 for a long time. She stated Resident #1 had lots of falls, so she did not remember all the falls perfectly. After being reminded that the fall in question was the one on [DATE] after which Resident #1 was sent to the hospital, LVN F stated she remembered the fall. LVN F stated just before the fall that morning, she had peeked in on Resident #1 because LVN F was getting ready to go to lunchbreak and wanted to check on Resident #1 for safety reasons. LVN F stated they were keeping a closer eye on her after the fall on [DATE] and subsequent agitation and fidgeting, and they were trying to get a urine specimen for some changes. LVN F stated during the fall on [DATE], Resident #1 had rolled out of bed because she was fidgety and restless. LVN F stated they had realized Resident #1 was restless having more anxiety than usual, so they were trying to keep her where she could see someone. LVN F stated Resident #1 was not in direct line of sight, but they kept her where there would be more instances of seeing people, so she would be calmer. LVN F stated Resident #1 had breakfast near her doorway that morning. LVN F stated Resident #1 was more anxious in the dining room, so she usually ate in her room, but the morning of [DATE], they put in place breakfast in her doorway to keep her closer to staff. LVN F stated the whole morning with Resident #1 was like that, so on her way out to lunchbreak, LVN F stopped to check, saw Resident #1 coming out of the bathroom, and Resident #1 was fine. LVN F stated she kept walking for a couple of seconds before the CNA called her back and said Resident #1 was on the floor. LVN F stated Resident #1 frequently toileted herself, and when LVN F saw Resident #1, she was not agitated, so LVN F let the resident do her thing. When asked how they do standby assist for residents who require standby assist for all ambulation, she stated they did not stay with those residents at all moments while the residents were ambulating. LVN F stated they could manage to do one-to-one supervision, as they basically initiated that after the fall the morning of [DATE]. LVN F stated if there was an extenuating circumstance, one-to-one could be provided. LVN F stated, as far as every day, they offered toileting on a frequent basis and tried to anticipate needs when they were in there serving meals. When asked if Resident #1 required constant supervision and standby assistance during ambulation, LVN F stated it depended on the day. LVN F stated Resident #1 was very different that day, which was why LVN F was checking on Resident #1 so often. During an interview on [DATE] at 11:31 AM, Resident #1's PCP stated he had a chance to review the hospital records for Resident #1. He stated the records reflected an acute-on-chronic subdural, which meant she may have had the injuries prior to the fall on [DATE], and there was no way to tell how or when they might have been sustained. The PCP stated he would be visiting the facility on Monday [DATE] and would look closely into the records and call back with a bigger picture. A return phone call was not received as of [DATE]. Review of facility's undated policy titled Fall Prevention, undated reflected the following: 'Environmental Hazards/Facility Staff Involvement & Training. All facility employees will be involved with the prevention of falls including providing assistance to any resident who appears to be at risk for an immediate fall and by immediately reporting or resolving environmental hazards. Facility staff will be trained during orientation and as needed thereafter.' On [DATE] at 02:05 PM, the ADM was notified of an IJ due to above listed failures and an IJ Template was provided and POR requested. The facility's POR was accepted on [DATE] at 12:35 PM and included: 689 Plan of Removal Introduction: On [DATE], an Immediate Jeopardy was identified because of resident falls. Resident 1 sustained 2 falls within 13 hours, on [DATE] and on [DATE]. The Resident was hospitalized after ER sleeping for a period of 25 hours. Resident was diagnosed with 2 brain bleeds, underwent surgery for repair. On [DATE] HHS re-entered on the original complaint from [DATE]. Resident 1 was discharged from the hospital, admitted to another care center, and passed away on [DATE]. Residents care plan indicated a required intervention of Assist with one staff member for all ambulation and assist with stand-by-assist for all ambulation. An additional Immediate Jeopardy was identified regarding accidents and hazards. All current residents at (facility name) are at risk of falling and have the potential to be impacted by this deficient practice. As a result of the IJ the facility has implemented the following: 1. On [DATE] at 1430 hrs. The Administrator and DON were in-serviced by Chief Nursing Officer. The in-service covered: a. Ensure that all residents have an accurate plan of care, including fall interventions and assistance required for ambulation. b. All residents must be reviewed to ensure accurate and appropriate interventions are care-planned and in place. c. Ensure that staff follows each resident's plan of care including fall prevention measures d. Ensure that staff assess and monitor residents for any status change and report change immediately. e. Each resident's plan of care to be reviewed by interdisciplinary team for accuracy and appropriate interventions. 2. On [DATE] at 1500 hrs. The Administrator in-serviced ADON regarding following resident care plans. MDS Nurses were in-serviced by Administrator and DON. ADON in-serviced staff on duty on following resident care plans, specifically for ambulation interventions for the 7 residents who were identified as having the following interventions listed: Assist with 1 staff member for all ambulation. Assist with stand-by-assist for ambulation. All nursing staff will be in-serviced by the DON or Designee prior to the start of their next shift. Training will be conducted face to face, telephone, and by facility nurses trained to deliver the in-service to agency staff. Nursing staff must verbalize understanding and be able to identify residents who require additional assistance for ambulation. An informational binder has been created to complete the in-service. A list of residents who have been identified as needing interventions with ambulation has been placed in the binder. Care plan training will be provided to new hires during floor orientation. 3. Completion date for care plan in-services [DATE] 10am. 4. Resident Care plans were reviewed by members of the IDT Team on [DATE]. A comparison was made to the MDS. The cross comparison identified 7 residents who could require stand-by-assist for ambulation or assist with 1 staff member for all ambulation. Reassessments by rehab and nursing were conducted on these 7 residents and completed on [DATE] 5. Facility Census was reviewed by Director of Rehab for other potential residents to be reassessed. Rehab Director identified 4 additional residents for consideration of additional supervision. These residents require assistance with set up of assistive devices. Including but not limited to ensuring wheelchairs and/or walkers are positioned close to the resident for transfer. These residents do not require stand by or 1:1 assistance with ambulation. 6. Facility reviewed resident care plans who have been care planned to have the following interventions: Assist with 1 staff member for all ambulation. Assist with stand-by-assist for ambulation. Residents were reviewed and in some cases a reassessment as completed to ensure proper fall interventions were implemented. A review of the individual residents fall history determined residents who received an updated fall assessment. Criteria included resident gait, resident changes of condition in the past 90 days, related to mobility. 7. Residents were reviewed by nursing and PT/OT staff. Upon completing of the review, Resident care plans were updated to reflect current interventions for residents who require assistance with ambu[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care including but not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident needs for one of ten residents (Resident #1) reviewed for assessment of change in condition. The facility failed to ensure Resident #1 received timely intervention following assessment when she slept for 25 hours after an unwitnessed fall, and she required intubation and two craniotomies (a surgical procedure that involves the removal of a part of the bone from the skull or cranium to expose the brain) because of injuries sustained. This failure resulted in the identification of an IJ on 09/06/23 at 05:20 PM. IJ template was provided to the facility on [DATE] at 05:26 PM. While the immediacy was removed on 09/09/23 at 09:45 AM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate due to the facility's need to continue training and monitoring of change in condition assessments. This failure resulted in two craniotomies for Resident #1 and placed residents at risk of brain injury after falls. Findings included: Review of the face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of depression, iron deficiency anemia, anxiety disorder, dementia, hypothyroidism, gastroesophageal reflux disease, mild protein-calorie, malnutrition, Alzheimer's disease, abnormalities of gait and mobility, history of falling, muscle weakness, repeated falls, and cognitive communication deficit. Review of the quarterly MDS for Resident #1 dated 07/12/23 reflected a BIMS score of 3, indicating a severe cognitive impairment. The section of the MDS for function status reflected Resident #1 required the limited assistance of one person for bed mobility and transfers. The section that assessed health conditions reflected she had sustained two or more falls since admission and that one fall had resulted in a minor injury. Review of a care plan item for Resident # dated 07/05/23 reflected the following: Care Plan Description- Falls: History of Falling Care Plan Goal- Injury from falls will not occur Care Plan Interventions- Refer to physical therapy for evaluation. Remind to ask staff for assistance with ambulation. Monitor for changes in condition that may warrant increased supervision/assistance and notify the physician. Keep walker within reach at all times. Assist with one staff member for all ambulation. Review of a nurse practitioner exam note dated 08/15/23 reflected the following : Neurologic physical exam: cranial nerves: grossly intact. Sensation: grossly intact. Assessment and Plan: 2. Domiciliary services - patient will get assistance with ADLs, supervision when walking, assistance with meals, and medication is managed. Review of an incident report for Resident #1 dated 09/02/23 reflected the following: CNA heard resident calling out for help at (09:30 PM) Found resident bedside her bed, sitting. Resident stated she rolled out of bed. Educated resident on the importance of calling for help. Provided call light. Head to toe assessment complete- no injuries. Informed MD and family. Neuros have initiated. Review of an incident report for Resident #1 dated 09/03/23 reflected the following: Patient calling out and was observed laying on the floor on her back in doorway of her room with head towards hallway and walker tipped over on the ground next to her. Skin tear to right elbow. Neuros within normal limits. Assisted to wheelchair. Review of nursing progress notes for Resident #1 reflected the following: 09/02/23 10:08 PM by LVN F At approximately (09:15 PM) patient was observed sitting on the floor on bottom next to bed and in center of room between beds. CNA reported a few minute (sic) before PT was observed, leaning over in her bed and fidgeting with her belongings in her drawer. CNA reports patient informed her that she rolled out of bed. Patient was in bare feet. No injuries noted. Narrows within normal limits. Assisted back to bed. Vitals WNL. Grip socks applied and patient bed moved closer to bedside drawer to be able to reach easier from bed and prevent fall. Door ajar and call light in reach. DON notified, on-call admin aware as well. Notified ((FM)). On-call admin apprised on-call for (PCP). 09/03/23 05:16 AM by LVN E Resident up and down during night not sleeping well and very anxious. Resident repeatedly putting shoes on and then, removing shoes, laying down, then getting shoes again. Resident worried about being alone in room. Resident stated that she previously fell and is now scared to be alone. Reassured resident that staff is always present if she needs anything and encouraged use of call light for assistance. Resident asking about her (FM) and when is (FM) coming. Resident Informed (FM) would be in later today. Offered resident a snack and distraction. Resident ate half chocolate muffin and drink sips of water before laying back down. Resident wanted to call (FM), we called (FM) on the phone and talked with her. 09/03/23 05:29 AM by LVN E Resident continues on F/U fall monitoring with neuro assessments WNL. No C/O pain during night shift. 09/03/23 09:55 AM by LVN F New fall this a.m. Patient was already on follow up fall precautions from fall last night. This a.m. patient was calling out and was observed laying on her back in her doorway with head towards the doorway and walker tipped over next to her. Notice skin tear to right elbow that was crescent in shape. Neuros WNL. No other injuries noted. ROM at baseline. Assisted up to wheelchair from floor. Skin tear cleansed with W/C and put skin back together and laid flat with Steri-Strips. Patient was last seen by this nurse at approximately three minutes before coming out of her bathroom with walker. No S/S of distress or anxiety at the time of fall. This nurse understood part of what patient was explaining to her in Spanish that she tripped on the carpet. Called and notified patient (FM) a fall. (FM) requested that psych meds to be looked into changing. (FM) informed that (Resident #1) will often get better when her meds are adjusted and then her body gets used to them and the meds stop working. On-call admin and DON at facility and aware. On-call admin notified (NP B) for PCP. NP to look into psych med changes. Patient also has order for UA to be collected. No frequent abnormal frequent urination noted by this nurse. Patient does have habit of taking self to the bathroom frequently at times when awake R/T forgetting that she just went to the bathroom. Fluids in reach and encouraged. No C/O pain. Patient at this time in W/C and is kept with staff or in staff line of sight for safety. 09/03/23 03:40 PM by LVN F Patient up in wheelchair in hallway and visiting with fellow patients and upon group disbursement. Patient begin to call out in Spanish that she did not want to be alone. Patient brought to the nurses station to help keep her calm and patient repeatedly asked in Spanish what she needed to do. Staff continues to reassure. PRN APAP given this afternoon for C/O pain to right hip. Apprised (NP B) of C/O pain post fall and gave orders to x-ray. Spoke with x-ray tech and scheduled x-ray stat. 09/03/23 05:23 PM by RN H Patient yelling out loud, attempting to get up from her chair, attempted to redirect patient with poor results. Patient continues to yell out loud, called (NP B), new order for Ativan 0.5 mg PO daily PRN X 14 days. Called pharmacy. Initial dose given at this time. One on one with patient at this time. Will continue to monitor. Awaiting for x-rays to be done. 09/03/23 06:08 PM by RN H Mobile x-ray here, to view x-ray done at this time. Assisted patient back up in a wheelchair until patient calms down. 09/03/23 09:30 PM by LVN F Right hip x-ray negative for fracture. 09/04/23 03:05 AM by LVN E Resident continues on F/U fall monitoring. Resident resting in bed asleep with no S/S pain or distress. Call light in reach. 09/04/23 01:53 PM by LVN D Patient remains on F/U falls and neuros R/T to patient fall on the third. Narrows within normal limits. Patient slept throughout this shift and refused meds. No C/O of pain or distress noted on the shift. 09/04/23 02:45 PM by RN C Resident asleep in bed. Bed in lowest position. Call light within reach. 09/04/23 04:00 PM by RN C Resident continues to sleep. Opens eyes to calling name. 09/04/23 06:31 PM by RN C Awakened to administer medication, and then fell back to sleep. Gave (FM) update on the phone. 09/04/23 07:30 PM by RN C (FM) at bedside. Patient opened eyes but did not respond as usual to her (FM). Notified (NP B) that resident has been sleeping since last night. 09/04/23 09:30 PM by RN C No change in condition. Pulse 90 BP 156/78, respirations 16. Notified (alternate on call NP service) for PCP (NP A) responded and after updating her on condition decided to send her to ER. Called transport. Transported to local hospital at 10:20 PM. (FM) notified. DON notified through phone message. Review of neurological check documentation for Resident #1 reflected the following: 09/02/23 09:15 PM within normal limits 09:30 PM within normal limits 09:45 PM within normal limits 10:00 PM within normal limits 10:30 PM Asleep 11:00 PM Asleep 12:00 AM Asleep 09/03/23 01:00 AM Asleep 02:00 AM restless/agitated 03:00 AM resting in bed 07:00 AM within normal limits 10:30 AM NEW FALL unable to obtain due to tending to skin 10:45 AM within normal limits 11:00 AM within normal limits 11:15 AM within normal limits 11:45 AM within normal limits 12:15 AM within normal limits 01:15 PM within normal limits 02:15 PM within normal limits 03:15 PM within normal limits 04:15 PM within normal limits 08:15 PM Asleep 09/04/23 12:15 AM Asleep 04:15 AM Asleep 08:15 AM Asleep 12:15 PM Asleep 08:15 PM Asleep 09/05/23 12:15 AM Hospital Review of Emergency Documentation for Resident #1 dated 09/05/23 at 03:54 AM reflected the following: Chief complaint - category 1 trauma multiple falls two days ago intubated. History of present illness- [AGE] year-old female presents for evaluation after multiple falls today. Reportedly had AMS and was intubated. CT showed bilateral SDH. Pt was transferred here for trauma admission. CT head without contrast - impression 1. large bilateral subdural hematomas (brain bleeds on both sides). Review of hospital History and Physical dated 09/05/23 at 04:39 AM reflected the following: History of Present Illness The patient is an [AGE] year-old female who has a trauma stat transferred from (other hospital) for large bilateral subdural hematomas. Patient reportedly sustained multiple ground level falls 2 to 3 days ago at her nursing home, was evaluated at (other hospital) where she had chest x-ray and pelvic x-rays. Yesterday she was noted to have slurred speech and altered mental status today for which she was taken back to (other hospital) where a CT head and C-spine was obtained showing large bilateral subdural hematomas. Patient was intubated and transferred to this hospital for higher level of care and neurosurgical evaluation. -Glasgow coma scale (a clinical scale used to reliably measure a person's level of consciousness after a brain injury.): 3T (Patients with scores of 3 to 8 are considered to be in a coma. Patients with a T next to the score are intubated.) Assessment/plan -Acute respiratory failure Intubated and sedated -Large bilateral SDH CT showed slight right to left midline shift Neurosurgery consult emergently Going to the OR emergently for craniotomy History and physical addendum 09/05/23 (10:45 PM) Neuro: not alert or oriented, does not awaken with noxious stimuli, does not follow commands. Observation on 08/06/23 at 08:37 AM in a local hospital ICU revealed Resident #1 laying in a hospital bed, ventilated and receiving IV fluids. Her head had been shaved, and there was a bandage wrapped around a portion of it. During an interview on 08/06/23 at 08:45 AM, the hospital RN for Resident #1 stated Resident #1 had two brain bleeds and had to have two [NAME] holes dripped into her skull to relieve pressure. She stated Resident #1 had been unresponsive to most stimuli prior to that morning, but she had been waking up for a few moments that morning. During an interview on 08/06/23 at 02:00 PM, LVN D stated he had worked at the facility for five months and had worked the 06:00 AM to 02:00 PM shift on 09/04/23, the day after Resident #1's falls. He stated protocol after a resident fall was to initiate neurological checks if there was head involvement or if the fall was unwitnessed. LVN D stated he did not know the circumstances of Resident #1's falls on 09/02/23 and 09/03/23, but he could surmise that she was anxious and trying to get out of her room and slipped. LVN D stated the facility had initiated neurological checks after the first fall on 09/02/23. LVN D stated when he came onto shift at 06:00 AM on 09/04/23, the neurological checks at that point were at a frequency of each four hours. He stated Resident #1 slept through the first neurological check and during his second neurological check, Resident #1 woke up with stimuli only to refuse her medications. He stated she had already been sleeping since bedtime the night before at that point, and he was concerned that she did not wake up. When asked if she would normally sleep that long at once, he stated it depended on her sleep pattern how long she slept. LVN D stated she often slept during the day if she was up all night. When asked at what point or at how many hours of sleep during neurological checks would he see a problem, he stated again he had gotten concerned when she refused her noon medications. He stated she still woke up at that time but was lethargic which was weird, and at that point she had already been asleep fourteen hours. When asked if he spoke to anyone about his concern, he stated he recommended to RN C, who came in to relieve him, that they increase the neurological checks to more often than every four hours. LVN D stated he would have called nurse management and the nurse practitioner by the third round of neurological check in which she was still asleep. LVN D stated he would have called at 16 or 20 hours of sleep since he knew she had been awake for 24 hours before that. During an interview on 09/04/23 at 02:18 PM, RN C stated she worked the 02:00 PM to 10:00 PM shift at the facility and was the charge nurse for Resident #1 on 09/04/23, the day after her falls. RN C stated when she started her shift, Resident #1 was sound asleep. RN C stated the nurses did hourly check on all residents to prevent falls as part of their routine supervision, and on the second check of her shift, she took Resident #1's vitals, which were all normal. RN C stated Resident #1 had a history of talking and moving around constantly and then sleeping for a long time. RN C stated it was not unusual for Resident #1 to sleep a long time, and she had gotten report that Resident #1 had woken up to get her medication, but that Resident #1 had refused the meds and gone back to sleep. RN C stated during her shift, she went in and checked on Resident #1 to make sure she was breathing and not in distress, her call light was accessible, and her bed was in low position. When asked when she became concerned enough to engage the nurse practitioner, RN C stated it was when Resident #1's FM arrived at the facility, and Resident #1 did not respond much to the FM. RN C stated Resident #1 was not talking and could not follow directions enough for RN C to conduct a neurological check on her. RN C stated she became worried at that point and left a voicemail for NP B who did not call back. RN C stated when she did not hear back, she called an alternate number for an on-call nurse practitioner service and spoke with NP A who did order that Resident #1 be sent out to the hospital. RN C stated Resident #1 was not completely asleep the entire time, and she had a history of staying up for several hours and sleeping for several hours. RN C stated she had not seen Resident #1 sleep all day before, but the resident was not completely asleep the whole time. RN C stated Resident #1 had not slept during her entire shift before, and it was potentially a sign of a head injury. RN C stated if she had hindsight, she would have called the nurse practitioner earlier. She stated the outcome for the resident was very sad. An attempt was made by telephone on 09/09/23 at 02:32 PM to interview NP A and voicemail left but no return contact was received. An attempt was made by telephone on 09/09/23 at 02:34 PM to interview the PCP for Resident #1 and voicemail left but no return contact was received. During an interview on 09/06/23 at 02:50 PM, the MD stated sending a resident to ER should have been the knee jerk reaction to any change in mentation, nausea, vomiting, or change in pupils. When asked if sleeping for excessively long stretches constituted a change in mentation, he stated he would want the resident be sent out. When the circumstances of Resident #1's hospitalization were explained to him, he stated Resident #1 should have been sent out to the hospital at 12 hours of sleeping at the latest, and he should have been updated about the incident as the medical director for the facility. The MD stated he did not really have a role at the facility in training staff to make clinical decisions. He stated he spoke about any concerns he had to the ADON and DON, but unfortunately the staff is very heterogenous and there could be little uniformity in the various staff member's assessments. He stated what had occurred with Resident #1 was very unfortunate. An attempt was made by telephone on 09/09/23 at 03:12 PM to interview LVN E but no return contact was received. An attempt was made by telephone on 09/09/23 at 02:13 PM to interview LVN F and voicemail left but no return contact was received. During an interview on 09/06/23 at 03:20 PM, the ADON stated she did not know much about what had happened with Resident #1, because she had been off on the weekend. She stated none of her staff reached out to her on Monday while they were conducting neurological checks on Resident #1 and voiced any concerns. She stated her understanding was that Resident #1 was sent to the ER because of falls. The ADON stated she also had gotten report that Resident #1 was up for 48 hours prior to that. The ADON stated Resident #1 had a lot of anxiety on 09/03/23 after her falls, which was normal for her. The ADON stated she would have hoped the charge nurses would have reached out to the nurse manager or nurse practitioner after 12 hours of sleeping during the process of monitoring for head injury. The ADON stated Resident #1 stayed up and then slept for a long time regularly, but the longest she had heard of Resident #1 sleeping was the day shift after she had been up the night before. The ADON stated Resident #1 was prescribed antianxiety medications to help her rest, and they did not always work, but then all of a sudden, they would catch up with her and she would sleep deeply for hours. The ADON stated it was part of her role to train the staff to assess properly during the process of charting neurological evaluations, but she did not have any of this training documented. She stated she hoped they would have contacted the physician by 12 hours of sleeping. The AODN stated that was outside of Resident #1's baseline. When it was pointed out that Resident #1 had not been awake for 48 hours prior to falling asleep for 25 hours, she stated she would have seen the excessive sleeping as a problem if that was the case. During an interview on 09/06/23 at 3:32 PM, the DON stated she had worked the floor on 09/03/23, and she had a gut feeling that something was going to happen with Resident #1, so when she stepped away from the hall for a few minutes to the medication cart, and Resident #1 immediately fell, she was upset. The DON stated that all unwitnessed falls result in the neurological checks protocol. The DON stated she stayed with Resident #1 most of that day, and the resident was agitated and having some pain, so the DON assessed her hips. The DON stated there was no obvious deformity, but they ordered a STAT x-ray, which was negative for any fracture. The DON stated Resident #1 was still agitated and anxious, so they called for PRN order for Ativan and administered the medication. She stated soon after that, Resident #1 was ready to lay down. The DON stated she was off the following day on 09/04/23 and received a call at around 10:30 PM that they were sending Resident #1 out to the hospital. The DON stated she got an update from the family that Resident #1 had two brain bleeds. The DON stated RN C had told her Resident #1 slept all night Sunday and all day and evening Monday. The DON stated after coming back to the facility, she looked into the incident reports and neurological check sheets and realized the resident's lethargy and extended sleep should have been addressed earlier than it was. When asked at what point she would have expected the nurses call nurse management or the nurse practitioner, the DON stated it depended on the resident. The DON then said, though that if they are checking every one to two hours for signs of head injury, they were checking for a reason and needed to act when the resident was out of baseline. The DON stated the first time they could not wake up the resident or keep her awake, they should have called. The [NAME] stated when LVN D was concerned at noon, he should not have passed that off to the next shift. The DON stated she had only been at the facility and was still identifying what systems needed improvement. She stated they were still doing a lot of training and in-servicing. During an interview on 09/06/23 at 3:47 PM, the ADM stated his understanding was Resident #1 had two falls over the weekend, and he was notified yesterday morning that Resident #1 had gone to the hospital and was in surgery. The ADM stated he started asking questions when he learned that to figure out what had occurred and gather information to do the self-report. He stated when he started asking questions, he found out she fell twice, the DON was in the building most of the day 09/03/23, and the DON was side by side with Resident #1 all day. The ADM stated Resident #1 had been acting normally and they put the neurological checks. The ADM stated he had not reviewed the entire neurological check log yet, but he knew something happened 09/04/23 where a decline was noticed. The ADM stated Resident #1 was sent to the hospital at that point and was currently in the ICU and not expected to live. The ADM stated he had been at the facility for five weeks and did not know the entire protocol for falls and change of condition, but his thought was if there was a possibility of head injury, they should have just sent her out right away. Review of undated facility policy titled Acute Condition Changes- Clinical Protocol reflected the following: Assessment and recognition 1.During the initial assessment, the nurse shall assess and document/report the following baseline information: vital signs; i. Neurological status; j. Current level of pain; k. Level of consciousness l. Cognitive and emotional status m. Residence, age and six; n. History of psychiatric disturbances, mental illness, depression, etc. o. All active diagnoses; and p. All current medications. 4. Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician; a. Phone calls to attending or on-call physician should be made by an adequately prepared nurse, who has collected and organized, pertinent information, including the residence current symptoms, symptoms, and status. 5. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately 1/2 hour or less). 6. The Attending Physician, or a practitioner, providing back up coverage, will respond in a timely manner to notification of problems or changes in condition and status. a. The staff will notify the medical Director for additional guidance and consultation if they do not receive a timely or appropriate response. 7. The Nurse and Physician will discuss and evaluate the situation. a. The physician should ask questions to clarify the situation; for example, vital signs, physical findings, and a description of symptoms. Treatment/Management 3. The physician will help identify and authorize appropriate treatments. 4. If it is decided, after sufficient review, the care or observation cannot reasonably prove be provided in the facility, the attending physician will authorize transfer to an acute hospital, emergency room, or another appropriate setting. On 09/06/23 at 05:20 PM, the ADM was notified of an IJ due to above listed failures and an IJ Template was provided. The facility's POR was accepted on 09/08/23 at 05:08 PM and included: 726 Plan of Removal Introduction: On September 6, 2023, an immediate Jeopardy was identified because of resident falls. Resident 1 sustained two falls within 13 hours, was hospitalized after sleeping for a period of 25 hours. Resident was diagnosed with two brain bleeds, underwent surgery for repair. Resident 1 remains on a ventilator and may not recover. All current residents at Cypress Healthcare and Rehabilitation center are at risk of falling and have the potential to be impacted by this deficient practice. 12. As a result of the IJ, the facility has implemented the following. Administrator, DON, were in serviced by chief nursing officer, as well as regional nurse: healthcare, regarding resident changes in condition, follow up, incident and accident, monitoring staff, staff, reporting of incidents and changes in condition/neurochecks. Admin and DON in serviced on the need for increased staff education and monitoring new hires and agency staff. Both verbalized understanding. 13. ADON was in serviced by corporate/regional nurse: regarding Resident changes in condition, follow up, incidents and accidents, monitoring staff, staff reporting of incidents and changes in condition/neurochecks. Admin and DON in-serviced on the need for increased staff education and monitoring, including new hires and agency staff. Both verbalized understanding. 14. As a result of the two falls Resident 1 sustained the facility, DON & ADON on 9/6/23 at 6 PM implemented the following: d. all on duty nursing staff were in serviced on the following by DON and a DOM. vi. MD notification of change in condition, including change in mental status/alertness vii. Notification of DON/administrator of any change in condition viii. Resident and Falls, and follow up monitoring ix. Completion of neurological checks, including waking resident to complete assessment and signs/symptoms of subdural hematoma x. Monitoring residents for change in condition, including sleeping for abnormal periods of time. e. Signs/symptoms of resident change of condition to include, but not limited to: vi. Mental status vii. Unarousable while sleeping viii. Changes to pupils ix. Changes to normal behavior patterns x. Inability to/or refusing to eat, drink, or take medications f. These in-services were completed on 9/7/23 15. All other nurses will be in service prior to starting their next scheduled shift. The DON, or designee will train the nurses. 16. All nurses will be tested for understanding in these areas and re-educated if they do not score 100% on the test. 17. The facility will add additional falls and neurological check training for the nurses. DON, ADON, will provide training and in-service training to nurses upon higher, and then semiannually and staff in-services. 18. Additionally, DON/ADON have in-serviced nurses by phone prior to the start of their next shift. 19. A reference binder has been set up for nursing staff to quickly access policy on incidents and accidents and neurological checks. New hires, agency, staff, and existing stuff will be oriented to the location of the information. And will complete the in-service and related test 20. Completion date, 9/7/2023 at 7 AM 21. The facility completed an internal review and audit of falls for the past 90 days. The review was completed by administrator, corporate/regional nurse, and DON/ADON. All resident falls were reviewed for the potential of head injury. Files that were identified a sustaining a head injury were audited for compliance with the fall policy. e. The facility identified 101 total incidents in the review. Period 86 of which were false. f. Facility reviewed all 86 falls and identified 15 initially identified as head injuries or potential head injuries. A review of the other 71 Falls was conducted. The review found 63 where neurological checks were performed. Instances of incomplete documentation were noted. No adverse were identified during the review. g. Additional in servicing was initiated, to reinforce earlier and service on documentation, and the requirement on documentation completion and follow up. h. This review was completed on 9/7/23. The review identified additional in-services completed regarding incident reporting a neurological checks. 22. The facility completed an ad hoc QAPI, regarding the incident resulting in the IJ. QAPI committee will add Resident Falls with, and without head injuries to the agenda, and will review data for eight weeks. Additionally falls will be reviewed in the morning QA, a specific file review has been added to the daily QA meeting. The POR was monitored in the following ways: Observation on 09/09/23 at 08:30 AM revealed the DON in-servicing two agency medication aides. The DON went over the detailed information in the in-service including protocol for MD notification of change in condition, including change in mental status/alertness, notification of DON/administrator of any change in condition, resident falls, and follow up monitoring, completion of neurological checks, including waking resident to complete assessment and signs/symptoms of subdural hematoma, and monitoring residents for change in condition, including sleeping for abnormal periods of time. She checked for understanding from both medication aides and observed as they signed the in-service. During interviews on 09/07/23 between 04:30 PM and 05:15 PM, one RN, three LVNs, and two CNAs stated they had be in-serviced on protocol for MD notification of change in condition, including change in mental status/alertness, notification of DON/administrator of any change in condition, resident falls, and follow up monitoring, completion of neurological checks, including waking resident to complete assessment and signs/symptoms of subdural hematoma, and monitoring residents for change in condition, including sleeping for abnormal periods of time. She checked for understanding from both medication aides and observed as they signed the in-service. The RN and LVNs stated they had also been in-serviced on the signs and symptoms that should be reported during neurological checks: mental status, unarousable while sleeping, changes to pupils, changes to normal behavior patterns, and inability to/or refusing to eat, drink, or take medications. During an interview on 09/08/23 at 07:55 AM, an overnight LVN stated she had been in-serviced on protocol for MD[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards, in that: The facility failed on 08/09/23 to identify Resident #1 as a missing resident until they were notified that he had arrived at the hospital with facial abrasions, fractured teeth, and an inter-cranial hemorrhage (bleeding within the skull). This deficient practice placed residents at risk for unsafe elopements, falls, injuries, and hospitalization. An Immediate Jeopardy (IJ) existed from 08/09/23 - 08/09/23. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. Findings included: Review of Resident #1's undated face sheet reflected a[AGE] year old male who was admitted to the facility on [DATE] with diagnoses including history of TIA (stroke), type II diabetes, anxiety disorder, and unspecified dementia. Review of Resident #1's quarterly MDS assessment, dated 05/04/23, reflected a BIMS of 3, indicating a severe cognitive impairment. Section E (Behavior) reflected he had not shown signs of wandering. Section G (Functional Status) reflected he could ambulate independently. Section J (Health Conditions) reflected he had not had any falls since admission. Review of Resident #1's quarterly care plan, dated 08/04/23, reflected he was at risk for elopement with an intervention of having secured/coded exit doors. He also had poor safety awareness with an intervention of monitoring for changes in condition that may warrant increased supervision/assistance. Review of Resident #1's admission Elopement Risk Assessment, dated 09/22/22 , reflected that he did wander aimlessly but had not attempted to leave the facility. Review of Resident #1's nursing notes in his EMR, dated 08/09/23 and documented by LVN A, reflected the following: This nurse was notified that [Resident #1] had eloped and was in the hospital around 11:00 AM. This nurse last saw [Resident #1] at 8:15 AM. A nurse from (hospital) called and reported that [Resident #1] had been brought in around 10:00 AM and was in A-FIB . [Resident #1] being assessed at this time. Review of Resident #1's hospital records, dated 08/09/23, reflected the following: This is a [AGE] year-old male with history of dementia, diabetes, who presented to the emergency room after being found down. According to the ER physician [Resident #1] eloped from his nursing home and was found lying on the ground by a fire truck passing by. There is concern for possible syncope (fainting) and [Resident #1] was found with to be in atrial fibrillation upon arriving to the emergency room. [Resident #1] is amnesic to the events and does not know any events of today or where he lives . He does have an abrasion to his left cheek. [Resident #1] is on Plavix, per emergency room physician for CAD. CT imaging was concerning for a possible IVH and neurosurgery was consulted for evaluation. Impression: 1. Findings concerning for a small amount of intraventricular hemorrhage. 2. Multiple fractured teeth. Review of Resident #1's hospital records, dated 08/10/23, reflected the following: [Resident #1] found to have facial abrasions, multiple teeth fx, and IVH. Observation made of the facility's video surveillance of the front lobby, on 08/10/23 at 8:30 AM, revealed Resident #1 standing by the front door of the facility on 08/09/23 at 8:46 AM. Shortly after, PT B was seen pushing another resident in his wheelchair, bringing him in from the outdoor patio. Resident #1 was seen leaving through the open door. PT B acknowledged the wander guard alarm, looked back towards the door, and continued pushing the resident to the nurse's station. During an interview on 08/10/23 at 8:42 AM, the ADM stated he was notified immediately of Resident #1's elopement by LVN A around 11:00 AM on 08/09/23. He stated he and the DON immediately made sure all residents at the facility were accounted for, all wander guards were tested to ensure they were working properly on residents that had them, all residents were being checked and signed off on their whereabouts every two hours, a list of residents with wander guards were placed at the nurses' station and on all medication carts, a new sign was made for the front door that was neon green and had a red STOP sign, reminding staff and visitors to not let any residents exit the facility , and an Ad Hoc QAPI meeting was held on 08/09/23 with himself, the DON, ADON, and the MD. He stated all staff that were working on 08/09/23 were in-serviced on elopements, missing residents, and wander guards. He stated the staff that were not in attendance or unable to work the floor until they were in-serviced, including PRN and agency staff. He stated after he watched the surveillance camera video footage, he recognized there were several chances for the incident to have been diverted, such as PT B checking to see if Resident #1 had a wander guard on, or LVN C looking up his physician orders. During an interview on 08/10/23 at 9:24 AM, PT B stated the wander guard alarm did sound the previous day (8/09/23). He stated the resident he was working with used to have a wander guard and figured that was what set the alarm off. He stated he immediately went to the nurse's station and asked LVN C for the code to turn off the alarm. He stated he also informed LVN C that Resident #1 had gone outside and LVN C told him he was allowed to go outside by himself, and the alarm sounded because of the wander guard his resident had on. He stated he normally identified residents with a wander guard by checking their wheelchair or ankle, but he did not yesterday. He stated Resident #1 always walked around the facility, but he had never saw him attempting to exit the facility. He stated he was in-serviced yesterday on elopement, exit-seeking, wander guard alarm, and the list of residents with wander guards that was now posted at the nurse's station and on medication carts. During an interview on 08/10/23 at 9:35 AM, LVN C stated he had never worked as Resident #1's nurse, so he was not completely familiar with him. He stated Resident #1 was always walking around the facility and had never seen him exit-seek or attempt to leave the facility, so he did not know he had a wander guard. He stated he was in-serviced yesterday on elopement, the wander guard system, and documenting residents' whereabouts every two hours. He stated there was now an accessible list with the residents that required a wander guard. During an interview on 08/10/23 at 9:43 AM, LVN A stated he worked on Resident #1's hall on 08/09/23. He stated he almost always worked that hall, so he was very familiar with Resident #1. He stated he had a wander guard because he was ambulatory and liked to walk around the facility, but he had never seen him exit-seek or try to leave the facility. He stated on 08/09/23, he administered Resident #1 his morning medications. He stated he last saw him around 8:15 AM when he was leaving the dining room after breakfast. He stated he was no agitated or anxious, he was at his baseline. He stated he received a call from the hospital around 11:00 AM and was informed he had been brought into the ER and was going to be admitted into the ICU for further evaluation because he hit his head and was on blood thinners. He stated he was in-serviced yesterday (08/09/23) on elopement, exit-seeking behaviors, missing residents, wander guard alarms, and checking on resident whereabouts every two hours. Interviews conducted on 08/10/23 from 10:02 AM - 11:08 AM, three nurses, three aides, and one med aide were able to answer questions appropriately regarding elopement, exit-seeking behaviors, missing residents, and wander guard alarms. The nurses knew where to document resident whereabouts every two hours. All were able to describe exit-seeking behaviors such as agitation or constant pushing on exit door handles. Observations were made on 08/10/23 from 10:35 AM - 10:52 AM revealing a list of residents with wander guards on the nurses' station ad on all medication carts. Review of the resident observation check-off list, on 08/10/23, reflected all residents had been monitored from 08/09/23 at 11:00 AM - 08/10/23 at 11:00 AM every two hours. Review of the facility's Ad Hoc QAPI meeting, dated 08/09/23, reflected the following: QA initiated as follows: - Census checks every two hours by charge nurse of each hall - 100, 200, 400, and 500. - Wander guard checks on every resident on and working. - Administrator made rounds throughout the day and night. - Physician orders in place for the residents with wander guards. Review of the facility's in-service, dated 08/09/23 and ongoing, reflected staff were educated on every two-hour census checks on all residents - Check mark if present, or OOP if at appointment or signed out with family. They were all also in-serviced on exit-seeking behaviors, immediately going to see which resident left the facility if the wander guard alarm sounded, and the facility policies on resident elopement risks and the procedure when a resident went missing. Review of the facility's undated Elopement Risk policy reflected the following: The facility will make every attempt to provide adequate supervision to all residents. However, even when all precautions are taken, a resident who is independently mobile may be able to leave the facility grounds without being observed by the staff. . 3. The facility may maintain a locking door system whereby an at-risk resident would wear a safety device that activates a door alarm. Review of the facility's undated Elopement/Missing Residents policy reflected the following: As soon as a resident is determined to be missing, the Charge Nurse will immediately do the following: 1. Assign all available staff to systematically search the entire premises, both inside and outside, patient rooms, bathrooms, closets, kitchen, lobby, and offices. 2. Notify the Administrator and/or Director of Nursing. 3. Assign someone to speak to all staff present to determine when the resident was last seen. . 8. The Administrator will be responsible to review the safety procedures of the facility for needed changes.