**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse, neglect, exploitation or mistreatment for 5 of 73 residents (Resident #8, Resident #12, Resident #18, Resident #20, and Resident #30) reviewed for abuse and neglect in that: The facility failed to ensure residents at the facility were provided with hot water and baths/showers for a month, that would allow them to maintain cleanliness and access to activities of daily living. The facility negelcted to provide hot water in the facility for over a month. The residents in the building had not had showers in weeks and there was no documentation to show that residents had a bed bath or a shower for the month of September. -The facility neglected to ensure residents at the facility were relieved from filth, and distress. -Resident #8 had cried to staff about her discomfort of not having a bed bath or shower in weeks. -Resident #12 was diagnosed with the need for assistance with personal care. She had a urinary tract infection and had not taken a bed bath or shower in a month. -Resident #18 had been diagnosed with a skin rash and other non-specific skin eruption and had not taken a bed bath or shower in a couple of weeks. She had been identified as having a fish like smell and a urine odor. -Resident #20 developed complications with possible bacteria in her urine during the time she went without a bath and shower. She was hospitalized for two days, 9/6/2024 to 9/8/2024 and was given medication to treat a possible urinary tract infection. She was one of 9 resdients at the facility being treated for an UTI. -Resident #30 had a shower in a month and reported his concerns to his family. On 10/15/24 at 3:07 p.m., an Immediate Jepordy (IJ) was identified. While the IJ was lowered on 10/16/24 at 3:17 p.m., the facility remained out of compliance at a a scope of pattern with the potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. This failure affected Residents #8, #12, #18, #20, and #30 and placed an additional 68 residents who were without hot water and showers at risk of skin breakdowns, infections, and illnesses which could cause a decline in health. Findings Include: Record Review of the Facility's Event Summary Report for the Infection Tracker with McGreer's Criteria dated 9/1/2024 to 9/24/2024 revealed 9 residents with urinary tract infections and possible urinary tract infections. Record review of Resident #8's Face sheet revealed a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses, anoxic brain damage (occurs when the brain is deprived of oxygen, which can lead to brain cell death), bipolar disorder, anxiety disorder, dysphagia (difficulty swallowing can have causes that aren't due to underlying disease), and oropharyngeal phase (the active phase of swallowing, which is a complex movement that involves moving food from the mouth to the throat and protecting the airway). Record review on Resident #8's admission MDS assessment dated [DATE], revealed she had a BIMS score of 14 out of 15, indicating she was cognitively intact. Further record review revealed partial/moderate assistance, for toileting hygiene, upper body dressing and lower body dressing. She needed substantial/maximal assistance for shower and bath/self and supervision or touching for oral hygiene and eating. She did not walk and used a wheelchair for mobility. She needed substantial/maximal assistance for chair to bed transfer and set-up or clean up assistance to roll left and right. Record review on of Resident #8's Baseline Plan of Care dated 9/18/2024 revealed she had a urinary tract infection, and the goal was to resolve the infection by 12/18/2024. Her care plan edited on 8/16/2024 revealed she preferred to take a bath/shower once a day on Tuesdays, Thursdays, sand Saturdays. Record Review of Resident #8's progress notes dated 09/19/24 revealed, Resident #8s family member called the facility and is upset that there is no hot water. Informed the RP that the water issue is currently being serviced. She said Resident #8 needs a shower. Informed the RP that the resident has refused showers. Staff has tried several offers to do so per the assigned CNA and the charge nurse. The RP requested to then speak to the CNA, to verify whether or not the resident did indeed, refuse her shower. The CNA informed the RP that the resident did refuse her shower. Record Review of Resident #8's progress notes on 09/22/24 Resident: Is being Monitored for an Active Infection. Transmission Based Precautions in Place: Urinary tract Infection: Antibiotic: flagyl/Macrobid. Observation and interview on 09/23/24 at 9:14a.m., with Resident #8 revealed her resting in bed. Observation and interview on 09/23/24 at 3:10p.m., with Resident #8 said she had not had a bath or shower in two weeks. She said she was independent and had been wiping herself off with wet wipes. Interview on 9/23/2024 at 5:15p.m., with LVN B, said the residents were refusing showers because they did not want to take cold showers. She said she did not have documentation to show that the residents refused to take a shower. She said she had been off, but on the Wednesday before 9/16/24, the hot water was fine. She said on Monday, 9/16/24, a family member told her Resident #8 had not had a shower and she was crying. She said she told the Administrator at that time, that there was no hot water, and they could not make the water work. She said the Administrator said maintenance was working on it. She said not having hot water in the building could spread germs and if the residents are not taking showers, it can cause skin breakdowns and infections. Observation and interview on 09/24/24 at 10:15a.m., with Resident #8 revealed her in her room and her hair was wet. She said she had a shower this morning, after making a complaint to the surveyors. She said the water was warm. Record review of Resident #12's Face sheet revealed a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses, muscle weakness (commonly due to lack of exercise, ageing, muscle injury of pregnancy), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), need for assistance for personal care (bathing, teeth and mouth care, dressing and grooming, toileting, eating, ambulation, etc.), constipation, neuromuscular dysfunction of bladder (a condition that affects the bladder's ability to function properly due to nerve damage in the brain, spinal cord, or nerves). Record review on Resident #12's admission MDS assessment dated [DATE], revealed she had a BIMS score of 15 out of 15, indicating she was cognitively intact. She needed partial/moderate assistance with toileting hygiene, upper body, lower body, and personal hygiene. She needed substantial/maximal assistance for shower/bath self and supervision or touching assistance for eating and oral hygiene. She did not walk and used a wheelchair for mobility. She needed substantial/maximal assistance for chair to bed transfer and set-up or clean up assistance to roll left and right. Record review of Resident #12's care plan edited 8/26/24 revealed she preferred to have showers on specific days of the week and her hair washed on Mondays and Fridays. Her care plan also revealed she has pressure sores/skin care, and she has thin and fragile skin. Observation and interview on 9/23/24 at 9:30a.m., with Resident #12 revealed she was in bed awake and alert. She said she did not receive assistance as needed. She said sometimes she did not get help when she needed to be changed. She had her glasses were dirty and stained with brown substances. She said she would spray her glasses from time to time. On her wall it stated she gets up during her shower time, but she said she had not received a shower and had not gotten out of bed for a while. Follow-up interview on 09/23/24 at 1:00p.m., with Resident #12, said she would get up when she had her shower, but she did not want to take a cold shower. She said the last time she took shower was over three weeks ago because there was no hot water. Observation and interview on 9/26/2024 at 3:20p.m., with Resident #12 revealed her lying in bed. She said she felt better becuase she had received a bath/shower, after the grievances she made to the surveyors about not receiving a bath/shower for a long period of time. She had a neck brace. She had a bed side table over her with a lot of items and a bag of chips. She had straps on both feet. She said when she felt yucky when she did not have a shower for a very long time. She said she needed her nails clipped. She said she complained to many people about the showers. Record review of Resident #18's Face sheet revealed a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses, rash and other nonspecific skin eruption , morbid obesity, type 2 diabetes (a long term condition in which the body has trouble controlling blood sugar and using it for energy), chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), dry eye syndrome of bilateral lacrimal glands (occurs when the lacrimal glands in the eyes don't produce enough tears), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review on Resident #18's admission MDS assessment dated [DATE], revealed she had a BIMS score of 15 out of 15, indicating she was cognitively intact. She needed substantial/maximal assistance for toilet transfer, chair/bed to chair transfer, and tub/shower transfer. She required setup or clean-up assistance to roll left and right, and partial/moderate assistance for sit to lying. Record review of Resident #18's care plan edited 7/12/24 revealed she would perform task at her highest practicable level. It revealed the care plan was edited on 9/26/24 under approach and it revealed the resident preferred to take a bath/shower once a day on Mondays, Wednesdays, and Fridays, 6:00p.m.-6:00p.m. Observation and interview on 9/23/2024 at 8:30a.m., with Resident #18 revealed her sitting on an uncovered mattress, that was soiled. Her right and left legs were swollen with red marks on both feet. She had a pile of dirty linen at her bedside. Resident #18's room smelled of urine. There were gnats by her food near the sink area. C-pap mask was hanging on her dresser drawer. She had an electric wheelchair in the corner of the room. There were cases of briefs and nutrient bottles underneath the sink. She said she had not had a bath in several weeks and was told there was an issue with the hot water. She said she was receiving bed baths by staff. Observation and interview on 9/23/2024 at 9:00a.m., with Resident #18 revealed her lying in bed and had a fish and urine odor. She said she had not had a shower in a month. Record review of Resident #20's Face sheet revealed a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses, diffuse traumatic brain injury with loss of consciousness of unspecified duration (occurs when the brain is jarred or moves around in the skull, which can happen from a penetrating injury to the skull or other trauma), bipolar disorder, diarrhea (when your stools are loose and watery), and urinary tract infection (an illness in any part of the urinary tract, the system of organs that makes urine). Record review on Resident #20's admission MDS assessment dated [DATE], revealed she had a BIMS score of 15 out of 15, indicating she was cognitively intact. She required substantial/maximal assistance for toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. She required supervision and touching assistance for oral hygiene and setup or cleanup assistance for eating. She did not walk and used a wheelchair for mobility. She needed substantial/maximal assistance for chair to bed transfer and partial/moderate assistance to roll left and right. Record review of Resident #20's care plan edited on 8/16/24 revealed she preferred to take a bath/shower on Tuesdays, Thursdays, and Saturdays. Her care plan edited on 9/9/24, revealed she had recurring UTI's. Observation and interview on 9/23/2024 at 3:09p.m., with Resident #20 revealed her eating a sandwich while sitting in her wheelchair near the nurse's station. She said she had not showered nor given a bed bath in almost a month. She said she had been having diarrhea for five weeks with no showers. She said she had no deodorant. She said at first, she refused showers because of the frequency of the diarrhea but when she was ready to take a shower she couldn't because there was no hot water in the facility. She said the only time she was cleaned is when they used wipes when changing her briefs. Follow-up observation and interview on 9/24/2024 at 10:45a.m., with Resident #20 revealed her sitting in a wheelchair, attending resident council. She said when she did not receive a bed bath or shower, she smelled a lot and went to the hospital for two days. She said she did not feel good. She said she believed she had E. Coli and bacteria in her urine. She said she was put on antibiotics. She said she believe the antibiotics caused her diarrhea. She said not having a shower while having diarrhea made her feel dirty. She said it did not make her feel good going without a shower for over a month. Record review of Resident #30's Face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, quadriplegia (a condition that causes a complete or severe loss of motor function in all four limbs), urinary tract infection (an illness in any part of the urinary tract, the system of organs that makes urine), generalized anxiety disorder (severe on going anxiety that interferes with daily activities), gross hematuria (a condition where blood is visible in the urine), need assistance for personal care (bathing, teeth and mouth care, dressing and grooming, toileting, eating, ambulation, etc.), major depressive disorder, and pressure ulcer of sacral region (a wound that forms on the lower back, tailbone, or rear of the body due to prolonged pressure on the area). Record review on Resident #30's admission MDS assessment dated [DATE], revealed he had a BIMS score of 15 out of 15, indicating he was cognitively intact. He was dependent for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. He required partial/moderate assistance for oral hygiene and eating. He could not walk and used a motorized wheelchair and a mechanical lift for mobility. Record review of Resident #30's care plan edited on 7/29/24 revealed, itching and dry skin to scalp, treatment and dosage: selenium sulfide shampoo. Approach: apply medication as ordered, notify MD if symptoms persist or worsen. Resident #30's care plan edited 9/12/2024 revealed, Recurring UTI's, have a suprapubic catheter. Edited 7/29/24, resolve infections without complications. Resident #30's care plan edited 8/19/2024 revealed, ADL functional/rehab potential, approach: bathing/hygiene amount of assistance: extensive/dependent every shift, 6:00a.m.-6:00p.m. Shift 2, 6:00p.m.-6:00a.m. Observation and interview on 9/25/2024 at 11:40a.m. with Resident #30 revealed him lying in bed watching tv. He was covered in a blanket. He has a catheter bag as well. He said he did not receive showers when there was no hot water. He said he almost got sick from the water being so cold. He said he did not have an issue with a particular staff member regarding showers. Interview on 9/26/2024 at 11:47a.m., with CNA C said she was aware that Resident #30 complained about not having a bath in a month. She said he believed he told his family about it. She said any CNA can give the residents their showers. She said it was the night shift aide that the resident was complaining about, and she is no longer at the facility. Observation on 9/23/2024 at 1:30p.m. revealed there were two shower rooms on hall 100. The water for the shower rooms was turned on for 5 minutes. The water was lukewarm at 80 degrees Fahrenheit-F. Interview on 9/23/2024 at 1:40p.m., with the Maintenance Director, said the issues with the hot water had been going on for almost two months and he had been adjusting the thermostat. He said the water was getting hot randomly on one side of the building at a time until it finally broke. He said the hot water stop working about a week ago. Interview on 9/23/2024 at 1:45p.m., with CNA K, said she was working in central supply. She said she had not given any residents showers that day. She explained how showers were provided to residents. She said the even numbered rooms were Mondays, Wednesdays, and Fridays. She said morning CNAs gives showers to A-bed and evening CNAs gives showers to the B bed on their shower days. She did not answer how long the hot water had been off. She said she did not know. She said she washed her hands with the cold water. She was not able to provide showers sheets or any documentation that showed the residents she was assigned to had been given showers for the month of September. Interview on 9/23/2024 at 2:50p.m., with the facility Administrator and the DON, the Administrator said he first heard of the hot water not working last week. He said it was an ongoing problem for over a month. He said at first, the facility thought it was the thermostat and the Maintenance Director tried adjusting the temperature. He said he thought the thermostat got broken through the back and forth of the adjustment process. He said once he noticed that the hot water was out, he contacted a local company for repair. He provided an invoice dated 09/16/24. The DON said the aides were warming up the water in the microwave to give bed baths to residents. She said she had other things going on at the facility, so she left it up to the charge nurses to make sure the aides were doing their jobs. She said she found out about the water being cold sometime last week. She did not have any documentation showing the CNAs were warming water in the microwaves nor that showers or baths were given to the residents. Observation and interview on 9/23/2024 at 4:00p.m., with the Maintenance Director revealed water temperatures, specifically for hot water temperatures in 10 different rooms, ranging from 73-84 degrees. He said he received a text from the plumber, and they would be at the facility soon. Observation and interview on 9/23/2024 at 4:30p.m., with the Administrator and the Maintenance Director, revealed the Administrator in the laundry room, washing mop heads. The Laundry Supervisor said the laundry had not been done because there was no hot water, and no one had delivered clean clothes to the residents because it would just get dirty and add to the dirty laundry barrels that were already full. Follow-up interview on 9/23/23034 at 4:45 p.m., with Administrator, said he was on medical leave from 8/1/24 to 8/26/24 and after he came back, they had started trying to adjust the water temperatures because one side would be too low, and one side would be too high. He said the thermostat broke after that, and they contacted a plumber. He said he thought maybe it broke from them trying to adjust the temperatures. Interview on 9/24/2024 at 10:50a.m., with CNA J, said he had not given showers to residents for about two weeks but only provided bed baths because the hot water was off. He said he did not know how long the water had been off because the hot water had been on and off at different times. He said he gave bed baths as needed. Interview on 9/25/2024 at 9:48a.m., with the Doctor, said if baths and showers are not given within a month it would not be proper incontinent care for the residents. He said it could cause the residents to have an infection. He said if a resident is having diarrhea and BMs without proper care, it could cause skin problems, irritation, infections, and open sores. He said not cleaning the residents could cause infections especially females. He said not having proper incontinence care could lead to a serious problem. He said it is important for residents to take baths for hygiene and to be clean. He said the Mcgreer criteria follows a specific criterion for urinary tract infections. He said even if they do not meet the criteria, they can still have the infection. He said it could still count it as a urinary tract infection especially if a resident was still complaining of the infection and taking antibiotics. Record review of the facility's policy titled Abuse, Neglect, and Exploitation revised (unknown) read in part . The facility will provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. The facility will designate an 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. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. Possible indicators of abuse include, but are not limited to: Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning . This was determined to be an Immediate Jeopardy (IJ) on 10/15/24 at 3:07 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy template on 10/15/24 at 3:20 PM. The following Plan of Removal was submitted and accepted on 10/16/24 at 10:52 AM. Plan of Removal October 16, 2024 Submission #3 Immediate action: Action: All residents were offered a shower 9/25/2024. All residents were offered showers. All other residents that were interview able were offered and if they refused it was documented in their chart. All residents who were nonverbal/non interview able were offered and given showers with no refusals. Person(s) Responsible: Clinical Staff to include Certified Nurse Aides, Charge Nurses, Assistant Director of Nurses, and Director of Nurses Date: 9/25/2024 by 10PM How the Facility Identified Other Possibly Effected Residents: How the Facility Identified Other Possibly Effected Residents: Action: All interview able residents were interviewed to address who did not receive showers on their scheduled shower days, the interviews included when they last received a shower and if they were experiencing any emotional distress due to not receiving a shower. All residents that were non/verbal or non-interview able were assessed for hygiene and cleanliness and received a shower. Behavior sheets and progress notes were reviewed for all nonverbal residents to determine if there were any signs of emotional distress. All residents were receiving incontinent care as they normally would, with prepackaged wet wipes. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee. Date: 9/25/2024 by 10PM Date: 9/25/2024 by 10PM Action: All active infections were reviewed on 9/25/2024 by the Director of Nursing. 1 UTI that met McGeer's Criteria and 1 UTI being treated per the direction of the physician (indwelling catheter and colonized), 2 residents out of 72 were being treated for possible urinary tract infections. Person(s) Responsible: Director of Nursing Date: 9/25/2024 by 10PM Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Plumber Vendor serviced the boiler system on 09/23/24. The boiler was unable to be repaired so he temporarily rerouted the boiler so that the the center was able to continue to reset the boiler to have manageable temperatures to care for the residents. The new hot water system was ordered at this time. The new hot water system was installed and will be completed on 10/16/24. Person(s) Responsible: Administrator Date: 9/23/2024 by 10PM & 10/16/2024 by 12PM Action: All facility laundry was done in house using a laundry sanitation system using chemicals that were effective in cold water and not dependent on hot water. Person(s) Responsible: Administrator Date: 09/23/2024 by 12PM Action: The facility policy/procedure was reviewed for ADL Care and Monitoring and no needed changes were identified Person(s) Responsible: [NAME] President of Clinical Services Date: 10/16/2024 by 12PM Action: Education provided to Nurses & CNAs regarding the policy for ADLs and identifying residents that appear to be unkempt or have odors and actions to take if they note any issues or resident concerns, peri-care, hand hygiene, communication/reporting on maintenance issues, showers/baths & documentation, and abuse & neglect. Education was provided to the Maintenance Director on equipment maintenance and monitoring water temperatures, Person(s) Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 9/27/2024 by 10PM All identified staff will educated prior to working their next shift, facility is not utilizing temporary staff, and new staff will be educated prior to working their first shift. How the Corrective Actions Will be Monitored, by whom and for how long: Action: Shower/bath assignment sheet is being completed by the CNA and nurses to sign off that showers/baths have indeed been completed. Director of Nursing monitoring shower/bath assignment sheets M-F. Person(s) Responsible: CNAs & Charge Nurses Date: 9/30/2024 by 10PM Action: Water temperature log continued to monitor water temperature. Person(s) Responsible: Maintenance Director and/or Designee Date: 9/25/2024 by 10PM Action: Ad hoc QAPI performed with Medical Director during survey (9/25/2024) & on 10/15/2024 to inform the Medical Director of the water issue, the immediate jeopardy template, and the facility's plan to remove the immediacy. Person(s) Responsible: Administrator and Director of Nursing Date: 10/15/2024 by 3:15PM Surveyor Monitored the plan of removal as follows: On 10/15/2024 12 residents were interviewed from each hall between 11:00am to 12:00pm, about showers/baths and the presence of hot water. All 12 residents verified they are getting baths, and the water has been hot instead of lukewarm. Observation on 10/15/2024 at 12:20 p.m. in Laundry, revealed 1 staff was present. She revealed that she worked at 6:00 a.m. to 2:00 p.m. shift, and another staff member worked 2:00 p.m. to 10:00 p.m. Observation revealed clean clothes were hanging on racks, ready to be distributed to the resident's rooms, and clean linens were stacked on shelves ready to be put in linen closets. There was a clothes rack of unidentified clothing and donated clothes stacked on shelves in the corner. There were two operational washers and two operational dryers. POR Monitoring: 10/16/24 Facility POR binder has evidence via census sheet checks that all residents were offered showers on 9/25/24. If resident refused shower, it was documented in the resident's record. CNAs, charge nurses, ADON, DON implemented. ***verified by observation, interviews, record reviews 10/16/24. Facility POR binder has evidence via checked census sheet that all interviewable residents were asked when their last shower was, and fi they had any emotional distress if shower was missed. Non-interviewable residents were assessed for hygiene and cleanliness and assessed for signs of emotional distress. Completed 9/25/24. ***verified by observation, interviews, record reviews 10/16/24. Facility POR binder has evidence that all active infections were reviewed by the DON. One UTI met McGreer's criteria and was treated by MD. Two residents were treated for possible UTI. Completed 9/25/24. *** Verified by observation, interviews, record reviews 10/16/24. Facility POR binder has evidence a plumber serviced the boiler on 9/23/24. The boiler could not be repaired so water was re-routed. A new hot water system was ordered 9/23/24 and will be completed by 10/16/24. **surveyors were in facility on 9/23/24 and can verify the hot water issue on 9/23/24. Surveyors were in facility 10/16/24 and can verify the new boiler installed on that day, and water was hot by the end of the day. Facility POR binder has evidence the laundry was being done by a sanitation system with chemicals effective in cold water. ***this was verified by observations and interviews in laundry on 9/23/24 and 10/15/24. Facility POR binder has evidence of ADL policy and procedure Review and education provided to staff on ADL policy. Completed 9/25/24. ***interviews with staff on each hall verified in-services on ADL care policy was conducted regularly 10/16/24. Facility POR binder had evidence the Administrator and DON were educated on equipment, water temperatures, neglect on 9/25/24. ***verified by interviews 10/16/24. Facility POR binder had evidence nurses, CNA's were educated on ADL policy and identifying residents who appeared unkempt, and reporting issues of care or maintenance issues, on 9/25/24. ***verified by interviews with nurses, CNAs 10/16/24. Facility POR binder had evidence the Maintenance Director was educated on equipment, monitoring water temperatures on 9/25/24. ***verified by interview with Maint. Director 10/16/24. Facility POR binder has shower/bath assignment sheet for CNAs and nurses to sign off, completed 9/30/24. ***verified by interviews with CNAs, nurses 10/16/24. Facility POR binder has water temperature log, completed 9/25/24. ***verified by observation, interview 10/16/24. Facility POR binder has evidence of ad HOC QAPI meeting with Medical Director 9/25/24 and 10/15/24 to inform of water issue, IJ template and plan of removal. ***verified by interview, documentation. Observation, testing of water temperature in shower room on 200 Hall revealed it was lukewarm after running several minutes, and became hot after running 2-3 minutes longer. Per interview with the Administrator, the new boiler is being installed today 10/16/24, and water temperatures may fluctuate, but once it is installed, water temperatures would be stable. This was verified by water temp testing on 10/16/24 at 3:30p.m. The Administrator was informed the Immediate Jeporady was lowered on 10/16/24 at 3:17 p.m. The facility remained out of

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services to maintain grooming and personal care for 5 (Resident #8, Resident #12, Resident #18, Resident #20, Resident #30) of 73 residents reviewed for ADL care, in that: The facility failed to ensure residents at the facility were provided with hot water and baths/showers for a month, that would allow them to maintain cleanliness and access to activities of daily living. There had been no hot water in the facility for over a month. The residents in the building had not had showers in weeks and there was no documentation to show that residents had a bed bath or a shower for the month of September. -Resident #8 had cried to staff about her discomfort of not having a bed bath or shower in weeks. -Resident #12 was diagnosed with the need for assistance with personal care. She had a urinary tract infection and had not taken a bed bath or shower in a month. -Resident #18 had been diagnosed with a skin rash and other non-specific skin eruption and had not taken a bed bath or shower in a couple of weeks. She had been identified as having a fish like smell and a urine odor. -Resident #20 developed complications with possible bacteria in her urine during the time she went without a bath and shower. She was hospitalized for two days, 9/6/2024 to 9/8/2024 and was given medication to treat a possible urinary tract infection. She was one of 9 resdients at the facility being treated for an UTI. -Resident #30 had a shower in a month and reported his concerns to his family. On 10/15/24 at 3:07 p.m., an Immediate Jepordy (IJ) was identified. While the IJ was lowered on 10/16/24 at 3:17 p.m., the facility remained out of compliance at a a scope of pattern with the potential for more than minimal harm, due to the facility need to evaluate the effectiveness of the corrective systems. This failure affected Residents #8, #12, #18, #20, and #30 and placed an additional 68 residents who were without baths and showers, requiring assistance with incontinent care and personal hygiene, at risk of not receiving assistance with personal care, skin breakdowns, infections, and illnesses which could cause a decline in health. Findings Include: Record Review of the Facility's Event Summary Report for the Infection Tracker with McGreer's Criteria dated 9/1/2024 to 9/24/2024 revealed 9 residents with urinary tract infections and possible urinary tract infections. Record review of Resident #8's Face sheet revealed a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses, anoxic brain damage (occurs when the brain is deprived of oxygen, which can lead to brain cell death), bipolar disorder, anxiety disorder, dysphagia (difficulty swallowing can have causes that aren't due to underlying disease), and oropharyngeal phase (the active phase of swallowing, which is a complex movement that involves moving food from the mouth to the throat and protecting the airway). Record review on Resident #8's admission MDS assessment dated [DATE], revealed she had a BIMS score of 14 out of 15, indicating she was cognitively intact. Further record review revealed partial/moderate assistance, for toileting hygiene, upper body dressing and lower body dressing. She needed substantial/maximal assistance for shower and bath/self and supervision or touching for oral hygiene and eating. She did not walk and used a wheelchair for mobility. She needed substantial/maximal assistance for chair to bed transfer and set-up or clean up assistance to roll left and right. Record review on of Resident #8's Baseline Plan of Care dated 9/18/2024 revealed she had a urinary tract infection, and the goal was to resolve the infection by 12/18/2024. Her care plan edited on 8/16/2024 revealed she preferred to take a bath/shower once a day on Tuesdays, Thursdays, sand Saturdays. Record Review of Resident #8's progress notes dated 09/19/24 revealed, Resident #8 family member called the facility and is upset that there is no hot water. Informed the RP that the water issue is currently being serviced. She said Resident #8 needs a shower. Informed the RP that the resident has refused showers. Staff has tried several offers to do so per the assigned CNA and the charge nurse. The RP requested to then speak to the CNA, to verify whether or not the resident did indeed, refuse her shower. The CNA informed the RP that the resident did refuse her shower. Record Review of Resident #8's progress notes on 09/22/24 Resident: Is being Monitored for an Active Infection. Transmission Based Precautions in Place: Urinary tract Infection: Antibiotic: flagyl/Macrobid. Observation and interview on 09/23/24 at 9:14a.m., with Resident #8 revealed her resting in bed. Observation and interview on 09/23/24 at 3:10p.m., with Resident #8 said she had not had a bath or shower in two weeks. She said she was independent and had been wiping herself off with wet wipes. Interview on 9/23/2024 at 5:15p.m., with LVN B, said the residents were refusing showers because they did not want to take cold showers. She said she did not have documentation to show that the residents refused to take a shower. She said she had been off, but on the Wednesday before 9/16/24, the hot water was fine. She said on Monday, 9/16/24, a family member told her Resident #8 had not had a shower and she was crying. She said she told the Administrator at that time, that there was no hot water, and they could not make the water work. She said the Administrator said maintenance was working on it. She said not having hot water in the building could spread germs and if the residents are not taking showers, it can cause skin breakdowns and infections. Observation and interview on 09/24/24 at 10:15a.m., with Resident #8 revealed her in her room and her hair was wet. She said she had a shower this morning, after making a complaint to the surveyors. She said the water was warm. Record review of Resident #12's Face sheet revealed a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses, muscle weakness (commonly due to lack of exercise, ageing, muscle injury of pregnancy), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), need for assistance for personal care (bathing, teeth and mouth care, dressing and grooming, toileting, eating, ambulation, etc.), constipation, neuromuscular dysfunction of bladder (a condition that affects the bladder's ability to function properly due to nerve damage in the brain, spinal cord, or nerves). Record review on Resident #12's admission MDS assessment dated [DATE], revealed she had a BIMS score of 15 out of 15, indicating she was cognitively intact. She needed partial/moderate assistance with toileting hygiene, upper body, lower body, and personal hygiene. She needed substantial/maximal assistance for shower/bath self and supervision or touching assistance for eating and oral hygiene. She did not walk and used a wheelchair for mobility. She needed substantial/maximal assistance for chair to bed transfer and set-up or clean up assistance to roll left and right. Record review of Resident #12's care plan edited 8/26/24 revealed she preferred to have showers on specific days of the week and her hair washed on Mondays and Fridays. Her care plan also revealed she has pressure sores/skin care, and she has thin and fragile skin. Observation and interview on 9/23/24 at 9:30a.m., with Resident #12 revealed she was in bed awake and alert. She said she did not receive assistance as needed. She said sometimes she did not get help when she needed to be changed. She had her glasses were dirty and stained with brown substances. She said she would spray her glasses from time to time. On her wall it stated she gets up during her shower time, but she said she had not received a shower and had not gotten out of bed for a while. Follow-up interview on 09/23/24 at 1:00p.m., with Resident #12, said she would get up when she had her shower, but she did not want to take a cold shower. She said the last time she took shower was over three weeks ago because there was no hot water. Observation and interview on 9/26/2024 at 3:20p.m., with Resident #12 revealed her lying in bed. She said she felt better becuase she had received a bath/shower, after the grievances she made to the surveyors about not receiving a bath/shower for a long period of time. She had a neck brace. She had a bed side table over her with a lot of items and a bag of chips. She had straps on both feet. She said when she felt yucky when she did not have a shower for a very long time. She said she needed her nails clipped. She said she complained to many people about the showers. Record review of Resident #18's Face sheet revealed a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses, rash and other nonspecific skin eruption , morbid obesity, type 2 diabetes (a long term condition in which the body has trouble controlling blood sugar and using it for energy), chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe), dry eye syndrome of bilateral lacrimal glands (occurs when the lacrimal glands in the eyes don't produce enough tears), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review on Resident #18's admission MDS assessment dated [DATE], revealed she had a BIMS score of 15 out of 15, indicating she was cognitively intact. She needed substantial/maximal assistance for toilet transfer, chair/bed to chair transfer, and tub/shower transfer. She required setup or clean-up assistance to roll left and right, and partial/moderate assistance for sit to lying. Record review of Resident #18's care plan edited 7/12/24 revealed she would perform task at her highest practicable level. It revealed the care plan was edited on 9/26/24 under approach and it revealed the resident preferred to take a bath/shower once a day on Mondays, Wednesdays, and Fridays, 6:00p.m.-6:00p.m. Observation and interview on 9/23/2024 at 8:30a.m., with Resident #18 revealed her sitting on an uncovered mattress, that was soiled. Her right and left legs were swollen with red marks on both feet. She had a pile of dirty linen at bedside. Resident #18's room smelled of urine. There were gnats by her food near the sink area. C-pap mask was hanging on her dresser drawer. She had an electric wheelchair in the corner of the room. There were cases of briefs and nutrient bottles underneath the sink. She said she had not had a bath in several weeks and was told there was an issue with the hot water. She said she was receiving bed baths by staff. Observation and interview on 9/23/2024 at 9:00a.m., with Resident #18 revealed her lying in bed and had a fish and urine odor. She said she had not had a shower in a month. Record review of Resident #20's Face sheet revealed a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses, diffuse traumatic brain injury with loss of consciousness of unspecified duration (occurs when the brain is jarred or moves around in the skull, which can happen from a penetrating injury to the skull or other trauma), bipolar disorder, diarrhea (when your stools are loose and watery), and urinary tract infection (an illness in any part of the urinary tract, the system of organs that makes urine). Record review on Resident #20's admission MDS assessment dated [DATE], revealed she had a BIMS score of 15 out of 15, indicating she was cognitively intact. She required substantial/maximal assistance for toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. She required supervision and touching assistance for oral hygiene and setup or cleanup assistance for eating. She did not walk and used a wheelchair for mobility. She needed substantial/maximal assistance for chair to bed transfer and partial/moderate assistance to roll left and right. Record review of Resident #20's care plan edited on 8/16/24 revealed she preferred to take a bath/shower on Tuesdays, Thursdays, and Saturdays. Her care plan edited on 9/9/24, revealed she had recurring UTI's. Observation and interview on 9/23/2024 at 3:09p.m., with Resident #20 revealed her eating a sandwich while sitting in her wheelchair near the nurse's station. She said she had not showered nor given a bed bath in almost a month. She said she had been having diarrhea for five weeks with no showers. She said she had no deodorant. She said at first, she refused showers because of the frequency of the diarrhea but when she was ready to take a shower she couldn't because there was no hot water in the facility. She said the only time she was cleaned is when they used wipes when changing her briefs. Follow-up observation and interview on 9/24/2024 at 10:45a.m., with Resident #20 revealed her sitting in a wheelchair, attending resident council. She said when she did not receive a bed bath or shower, she smelled a lot and went to the hospital for two days. She said she did not feel good. She said she believed she had E. Coli and bacteria in her urine. She said she was put on antibiotics. She said she believe the antibiotics caused her diarrhea. She said not having a shower while having diarrhea made her feel dirty. She said it did not make her feel good going without a shower for over a month. Record review of Resident #30's Face sheet revealed a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses, quadriplegia (a condition that causes a complete or severe loss of motor function in all four limbs), urinary tract infection (an illness in any part of the urinary tract, the system of organs that makes urine), generalized anxiety disorder (severe on going anxiety that interferes with daily activities), gross hematuria (a condition where blood is visible in the urine), need assistance for personal care (bathing, teeth and mouth care, dressing and grooming, toileting, eating, ambulation, etc.), major depressive disorder, and pressure ulcer of sacral region (a wound that forms on the lower back, tailbone, or rear of the body due to prolonged pressure on the area). Record review on Resident #30's admission MDS assessment dated [DATE], revealed he had a BIMS score of 15 out of 15, indicating he was cognitively intact. He was dependent for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. He required partial/moderate assistance for oral hygiene and eating. He could not walk and used a motorized wheelchair and a mechanical lift for mobility. Record review of Resident #30's care plan edited on 7/29/24 revealed, itching and dry skin to scalp, treatment and dosage: selenium sulfide shampoo. Approach: apply medication as ordered, notify MD if symptoms persist or worsen. Resident #30's care plan edited 9/12/2024 revealed, Recurring UTI's, have a suprapubic catheter. Edited 7/29/24, resolve infections without complications. Resident #30's care plan edited 8/19/2024 revealed, ADL functional/rehab potential, approach: bathing/hygiene amount of assistance: extensive/dependent every shift, 6:00a.m.-6:00p.m. Shift 2, 6:00p.m.-6:00a.m. Observation and interview on 9/25/2024 at 11:40a.m. with Resident #30 revealed him lying in bed watching tv. He was covered in a blanket. He has a catheter bag as well. He said he did not receive showers when there was no hot water. He said he almost got sick from the water being so cold. He said he did not have an issue with a particular staff member regarding showers. Interview on 9/26/2024 at 11:47a.m., with CNA C said she was aware that Resident #30 complained about not having a bath in a month. She said he believed he told his family about it. She said any CNA can give the residents their showers. She said it was the night shift aide that the resident was complaining about, and she is no longer at the facility. Observation on 9/23/2024 at 1:30p.m. revealed there were two shower rooms on hall 100. The water for the shower rooms was turned on for 5 minutes. The water was lukewarm at 80 degrees Fahrenheit-F. Interview on 9/23/2024 at 1:40p.m., with the Maintenance Director, said the issues with the hot water had been going on for almost two months and he had been adjusting the thermostat. He said the water was getting hot randomly on one side of the building at a time until it finally broke. He said the hot water stop working about a week ago. Interview on 9/23/2024 at 1:45p.m., with CNA K, said she was working in central supply. She said she had not given any residents showers. She explained how showers were provided to residents. She said the even numbered rooms were Mondays, Wednesdays, and Fridays. She said morning CNAs gives showers to A-bed and evening CNAs gives showers to the B bed on their shower days. She did not answer how long the hot water had been off. She said she did not know. She said she washed her hands with the cold water. She was not able to provide showers sheets or any documentation that showed the residents she was assigned to had been given showers for the month of September. Interview on 9/23/2024 at 2:50p.m., with the facility Administrator and the DON, the Administrator said he first heard of the hot water not working last week. He said it was an ongoing problem for over a month. He said at first, the facility thought it was the thermostat and the Maintenance Director tried adjusting the temperature. He said he thought the thermostat got broken through the back and forth of the adjustment process. He said once he noticed that the hot water was out, he contacted a local company for repair. He provided an invoice dated 09/16/24. The DON said the aides were warming up the water in the microwave to give bed baths to residents. She said she had other things going on at the facility, so she left it up to the charge nurses to make sure the aides were doing their jobs. She said she found out about the water being cold sometime last week. She did not have any documentation showing the CNAs were warming water in the microwaves nor that showers or baths were given to the residents. Observation and interview on 9/23/2024 at 4:00p.m., with the Maintenance Director revealed water temperatures, specifically for hot water temperatures in 10 different rooms, ranging from 73-84 degrees. He said he received a text from the plumber, and they would be at the facility soon. Interview on 9/24/2024 at 10:50a.m., with CNA J, said he had not given showers to residents for about two weeks but only provided bed baths because the hot water was off. He said he did not know how long the water had been off because the hot water had been on and off at different times. He said he gave bed baths as needed. Interview on 9/25/2024 at 9:48a.m., with the Doctor, said if baths and showers are not given within a month it would not be proper incontinent care for the residents. He said it could cause the residents to have an infection. He said if a resident is having diarrhea and BMs without proper care, it could cause skin problems, irritation, infections, and open sores. He said not cleaning the residents could cause infections especially females. He said not having proper incontinence care could lead to a serious problem. He said it is important for residents to take baths for hygiene and to be clean. He said the Mcgreer criteria follows a specific criterion for urinary tract infections. He said even if they do not meet the criteria, they can still have the infection. He said it could still count it as a urinary tract infection especially if a resident was still complaining of the infection and taking antibiotics. Record review of the facility's policy titled Activities of Daily Living (ADLs), Supporting revised (3/2018) read in part . Residents will provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care); Mobility (transfer and ambulation, including walking); Elimination (toileting); Dining (meals and snacks); and Communication (speech, language, and any functional communication systems). Care and services to prevent and/or minimize functional decline will include appropriate pain management, as well as treatment for depression and symptoms of depression. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions: Independent - Resident completed activity with no help or staff oversight at any time during the last 7 days. Supervision - Oversight, encouragement or cueing provided 3 or more times during the last 7 days. Limited Assistance - Resident highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight bearing assistance 3 or more times during the last 7 days. Extensive Assistance - While resident performed part of activity over the last 7 days, staff provided weight-bearing support. Total Dependence - Full staff performance of an with no participation by resident for any aspect of the ADL activity. Resident was unwilling or unable to perform any part of the activity over entire 7-day look-back period . This was determined to be an Immediate Jeopardy (IJ) on 10/15/24 at 3:07 PM. The Administrator and DON were notified. The Administrator was provided the Immediate Jeopardy template on 10/15/24 at 3:20 PM. The following Plan of Removal was submitted and accepted on 10/16/24 at 10:52 AM. Plan of Removal October 16, 2024 Submission #3 Immediate action: Action: All residents were offered a shower 9/25/2024. All residents were offered showers. All other residents that were interview able were offered and if they refused it was documented in their chart. All residents who were nonverbal/non interview able were offered and given showers with no refusals. Person(s) Responsible: Clinical Staff to include Certified Nurse Aides, Charge Nurses, Assistant Director of Nurses, and Director of Nurses Date: 9/25/2024 by 10PM How the Facility Identified Other Possibly Effected Residents: o How the Facility Identified Other Possibly Effected Residents: Action: All interview able residents were interviewed to address who did not receive showers on their scheduled shower days, the interviews included when they last received a shower and if they were experiencing any emotional distress due to not receiving a shower. All residents that were non/verbal or non-interview able were assessed for hygiene and cleanliness and received a shower. Behavior sheets and progress notes were reviewed for all nonverbal residents to determine if there were any signs of emotional distress. All residents were receiving incontinent care as they normally would, with prepackaged wet wipes. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee. Date: 9/25/2024 by 10PM Date: 9/25/2024 by 10PM o Action: All active infections were reviewed on 9/25/2024 by the Director of Nursing. 1 UTI that met McGeer's Criteria and 1 UTI being treated per the direction of the physician (indwelling catheter and colonized), 2 residents out of 72 were being treated for possible urinary tract infections. Person(s) Responsible: Director of Nursing Date: 9/25/2024 by 10PM Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: o Action: Plumber Vendor serviced the boiler system on 09/23/24. The boiler was unable to be repaired so he temporarily rerouted the boiler so that the the center was able to continue to reset the boiler to have manageable temperatures to care for the residents. The new hot water system was ordered at this time. The new hot water system was installed and will be completed on 10/16/24. Person(s) Responsible: Administrator Date: 9/23/2024 by 10PM & 10/16/2024 by 12PM o Action: All facility laundry was done in house using a laundry sanitation system using chemicals that were effective in cold water and not dependent on hot water. Person(s) Responsible: Administrator Date: 09/23/2024 by 12PM o Action: The facility policy/procedure was reviewed for ADL Care and Monitoring and no needed changes were identified Person(s) Responsible: [NAME] President of Clinical Services Date: 10/16/2024 by 12PM o Action: Education provided to Nurses & CNAs regarding the policy for ADLs and identifying residents that appear to be unkempt or have odors and actions to take if they note any issues or resident concerns, peri-care, hand hygiene, communication/reporting on maintenance issues, showers/baths & documentation, and abuse & neglect. Education was provided to the Maintenance Director on equipment maintenance and monitoring water temperatures, Person(s) Responsible: Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee Date: 9/27/2024 by 10PM o All identified staff will educated prior to working their next shift, facility is not utilizing temporary staff, and new staff will be educated prior to working their first shift. How the Corrective Actions Will be Monitored, by whom and for how long: o Action: Shower/bath assignment sheet is being completed by the CNA and nurses to sign off that showers/baths have indeed been completed. Director of Nursing monitoring shower/bath assignment sheets M-F. Person(s) Responsible: CNAs & Charge Nurses Date: 9/30/2024 by 10PM o Action: Water temperature log continued to monitor water temperature. Person(s) Responsible: Maintenance Director and/or Designee Date: 9/25/2024 by 10PM o Action: Ad hoc QAPI performed with Medical Director during survey (9/25/2024) & on 10/15/2024 to inform the Medical Director of the water issue, the immediate jeopardy template, and the facility's plan to remove the immediacy. Person(s) Responsible: Administrator and Director of Nursing Date: 10/15/2024 by 3:15PM Surveyor Monitored the plan of removal as follows: On 10/15/2024 12 residents from each hall between 11:00am to 12:00pm, about showers/baths and the presence of hot water. All 12 residents verified they are getting baths, and the water has been hot instead of lukewarm. Observation on 10/15/2024 at 12:20 p.m. in Laundry, revealed 1 staff was present. She revealed that she worked at 6:00 a.m. to 2:00 p.m. shift, and another staff member worked 2:00 p.m. to 10:00 p.m. Observation revealed clean clothes were hanging on racks, ready to be distributed to the resident's rooms, and clean linens were stacked on shelves ready to be put in linen closets. There was a clothes rack of unidentified clothing and donated clothes stacked on shelves in the corner. There were two operational washers and two operational dryers. POR Monitoring: 10/16/24 Facility POR binder had evidence via census sheet checked that all residents were offered showers on 9/25/24. If resident refused showers, it was documented in the resident's record. CNAs, charge nurses, ADON, DON implemented. ***verified by observation, interviews, record reviews 10/16/24. Facility POR binder had evidence via checked census sheet that all interview able residents were asked when their last shower was, and if they had any emotional distress if their shower was missed. Non-interview able residents were assessed for hygiene and cleanliness and assessed for signs of emotional distress. Completed 9/25/24. ***verified by observation, interviews, record reviews 10/16/24. Facility POR binder had evidence that all active infections were reviewed by the DON. One UTI met McGreer's criteria and was treated by MD. Two residents were treated for possible UTI. Completed 9/25/24. *** Verified by observation, interviews, record reviews 10/16/24. Facility POR binder had evidence a plumber serviced the boiler on 9/23/24. The boiler could not be repaired so water was re-routed. A new hot water system was ordered 9/23/24 and should be completed by 10/16/24. **surveyors were in facility on 9/23/24 and can verify the hot water issue on 9/23/24. Surveyors were in facility 10/16/24 and can verify the new boiler installed on that day, and water was hot by the end of the day. Facility POR binder had evidence the laundry was being done by a sanitation system with chemicals effective in cold water. ***this was verified by observations and interviews in laundry on 9/23/24 and 10/15/24. Facility POR binder has evidence of ADL policy and procedure: Review and education provided to staff on ADL policy. Completed 9/25/24. ***interviews with staff on each hall verified in-services on ADL care policy was conducted regularly 10/16/24. Facility POR binder had evidence the Administrator and DON were educated on equipment, water temperatures, neglect on 9/25/24. ***verified by interviews 10/16/24. Facility POR binder had evidence nurses, CNA's were educated on ADL policy and identifying residents who appeared unkempt, and reporting issues of care or maintenance issues, on 9/25/24. ***verified by interviews with nurses, CNAs 10/16/24. Facility POR binder had evidence the Maintenance Director was educated on equipment, monitoring water temperatures on 9/25/24. ***verified by interview with the Maintenance Director 10/16/24. Facility POR binder had shower/bath assignment sheet for CNAs and nurses to sign off, completed 9/30/24. ***verified by interviews with CNAs, nurses 10/16/24. Facility POR binder had water temperature log, completed 9/25/24. ***verified by observation, interview 10/16/24. Facility POR binder had evidence of ad HOC QAPI meeting with Medical Director 9/25/24 and 10/15/24 to inform of water issue, IJ template and plan of removal. ***verified by interview, documentation. Observation, testing of water temperature in shower room on 200 Hall revealed it was lukewarm after running several minutes, and became hot after running 2-3 minutes longer. Per interview with the Administrator, the new boiler is being installed today 10/16/24, and water temperatures may fluctuate, but once it is installed, water temperatures would be stable. This was verified by water temp testing on 10/16/24 at 3:30p.m. The Administrator was informed the Immediate Jeporady was lowered on 10/16/24 at 3:17 p.m. The facility remained out of compliance at a scope of isolated and severity of no actual harm with potential for more than minimal harm that is not immediate threat, at a scope of pattern due to the facility'n need to evaluate the effectiveness of the corective systems that

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to obtain laboratory services when ordered by a physician in accordance with the State law, including scope of practice laws for 1 of 12 residents (CR #1) reviewed for laboratory services. 1. LVN A failed to document physician's orders and obtain weekly laboratory services (CMP, CBC, and CPK) as ordered by CR #1's infectious disease physician when she was discharged from an acute care hospital on [DATE] and resulted in re-hospitalization on 04/16/2024 with elevated WBC values, which indicated infection. 2. LVN A failed to document physician's orders and obtain weekly laboratory services (BMP and CBC) as ordered by CR #1's NP when she reconciled (the process of comparing a patient's medication orders) medication orders on 03/29/2024 and resulted in re-hospitalization on 04/16/2024. She was diagnosed with polymicrobial (multiple bacteria) skin and soft tissue infections and multifocal (having more than one location) osteomyelitis of the pelvis. On 04/25/2024 at 3:20 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/27/2024, the facility remained out of compliance at a scope of pattern with the severity level at a potential for more than minimal harm that is not immediate jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan or Removal. These findings placed residents at risk of experiencing pain, worsening of symptoms/condition, and possible death from not having vital laboratory tests completed to monitor/diagnose infection, disease, and other health conditions. Findings included: Record review of CR #1's face sheet dated 04/24/2024 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with metabolic encephalopathy (a series of neurological disorders caused by systemic illness), quadriplegia (paralysis that affects all of a person's limbs and body from the neck down), local infection of the skin and subcutaneous (under the skin) tissue, acute kidney failure (when the kidneys suddenly cannot filter waste from the blood), acute respiratory failure (sudden inability of the respiratory system to meet the oxygenation, ventilation, or metabolic requirements of the patient), sepsis (life-threatening complication of an infection; when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body) due to staphylococcus, osteomyelitis (inflammation of bone or bone marrow, usually due to infection) - multiple sites, chronic pain (persistent pain that lasts weeks to years), hypotension (low blood pressure), anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin), bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), stage 4 pressure ulcer (full thickness skin loss extends through the fascia with considerable tissue loss), and muscle wasting and atrophy (a decrease in size of muscle tissue). She was discharged from the facility to an acute care hospital on [DATE] at 3:12 a.m. Record review of CR #1's quarterly MDS, dated [DATE] revealed she had a BIMS score of 15 (cognitively intact). CR #1 did not experience hallucinations or delusions. CR #1 did not exhibit behaviors which indicated rejection of care (bloodwork, taking medications, or ADL assistance). CR #1 had functional limitations in range of motion in both upper extremities and both lower extremities. CR #1 used a motorized wheelchair for ambulation. CR #1 required substantial/maximal assistance from staff for oral hygiene, toileting, showers, upper body dressing, personal hygiene, sitting, transfers, and rolling left and right. CR #1 received pain medications. CR #1 had six unhealed stage 4 pressure ulcers upon admission and was prescribed antibiotic medications. Record review of CR #1's care plan, revised on 04/22/2024 revealed the following care areas: * CR #1 refused wound treatments and labs at times. Goals included: Resident will allow wound treatments and labs to be complete as scheduled. Approach included: Staff will encourage wound treatments and labs as scheduled. * CR #1 was at risk for pressure sore infections. CR #1 was admitted with infected pressure injuries. CR #1 had osteomyelitis with recurring infections. Goals included: CR #1's pressure ulcer will not exhibit purulent discharge, foul odor, or peri ulcer inflammation (inflammation around the ulcer). Approach included: Enhanced barrier precautions, central line care per facility policy and MD orders, and administer antibiotics as ordered. Evaluate/record/report effectiveness/adverse side effects, observe and report signs of purulent discharge, foul odor, or peri ulcer inflammation. Report signs of cellulitis (bacterial skin infection), sepsis, tachycardia (increased heart rate), and osteomyelitis. On low air-loss alternating mattress for the treatment of pressure injuries. Record review of CR #1's progress notes for March 2024 and April 2024 revealed the following: On 03/22/2024 at 6:53 p.m., LVN D wrote, Resident stated she wants to go to the hospital because she feels her wounds are infected. Writer noted yellow discharge to wound during wound care. Resident refused protein supplement because she said it is nasty. New order per NP to send resident to ED for evaluation . On 03/23/2024 at 7:41 a.m. (recorded as late entry from 03/22/2024), LVN C wrote, Received order from medical provider to transfer resident to hospital ER. Transfer order obtained from physician . Primary reason for transfer: Foul odor from wounds . Resident left the facility at 8:45 p.m. On 03/30/2024 at 1:59 p.m. (recorded as late entry from 03/29/2024), Treatment LVN B wrote, Resident arrived at facility on 03/29/2024 at 5:00 p.m. Primary admitting diagnosis: Osteomyelitis . admission orders entered into system and medication orders sent to pharmacy: 5:20 p.m. Referrals made for the following: No referrals at time of admission . Additional Notes: Resident returned to facility with new orders for IV ABT's and with IJ tunnel catheter with CVC double lumen to right chest, dressing is clean, dry, and intact, with no signs and symptoms of infection observed at this time . On 04/04/2024 at 5:15 p.m., Treatment LVN B wrote, . Transmission based precautions in place: Type: Skin/Soft Tissue Infection: osteomyelitis/wound. Resident is receiving antibiotic: Daptomycin reconstituted (recomposed) solution (500 mg) and Ceftriaxone, IV administration. Resident has received treatment for 4 days . Resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . On 04/05/2024 at 2:26 p.m., Agency LVN E wrote, IV ABT therapy in progress due to osteomyelitis. Resident afebrile (no fever) with no adverse reactions noted . Resident has received treatment for 5 days . Resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . On 04/09/2024 at 12:57 a.m., LVN F wrote, Resident is being monitored for an active infection . Resident has received treatment for 8 days . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . On 04/09/2024 at 9:48 p.m., LVN F wrote, Resident is being monitored for an active infection . Resident has received treatment for 9 days . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . On 04/11/2024 at 4:32 p.m., LVN G wrote, Resident is being monitored for an active infection . Resident has received treatment for 10 days . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . On 04/13/2024 at 5:16 p.m., Treatment LVN B wrote, Resident is being monitored for an active infection . Resident has received treatment for 14 days . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . On 04/15/2024 at 1:12 a.m., LVN F wrote, Resident is being monitored for an active infection . The resident has experienced the following signs/symptoms of infection during this shift: purulent discharge or drainage from wound . On 04/15/2024 at 5:13 p.m., LVN G wrote, Resident noted sweating and complained of not feeling well. Resident's vitals are 100.4 temperature, pulse 84, blood pressure 145/86, O2 saturation 98% on room air, respirations 18. Placed call to NP. She instructed this writer to give 500 ml of normal saline per IV. Fluids were given as ordered. On 04/16/2024 at 3:37 p.m., Treatment LVN B wrote, Weekly Skin Assessment: 04/16/2024 at 12:30 p.m. Transmission Based Precautions in place: osteomyelitis/wounds . Resident has received treatment for more than 14 days . The resident has experienced the following signs/symptoms of infection during this shift: Fever . 500 ml of normal saline per IV. Laboratory/Diagnostic: wound culture was done. Spoke to medical provider at: 04/15/2024 at 1:30 p.m. Record review of CR #1's laboratory orders, dated 04/16/2024 revealed, CR #1; Start Date: 04/16/2024; Order Choices: CBC with Auto Differential, Basic Metabolic Panel; Recurrence Schedule: Starting on Tuesday, 04/16/2024, repeat every 1 week, on Tuesday, until 05/21/2024 . Record review of CR #1's wound culture laboratory results dated [DATE] revealed, Collected: 04/15/2024 at 10:35 a.m. Received: 04/16/2024 at 3:44 p.m. Reported: 04/19/2024 at 11:55 a.m. Pathogens Detected: Acinetobacter Baumannii complex (Heavy Growth); Escherichia coli (Heavy Growth) . Record review of CR #1's laboratory results (collected at the facility) dated 04/16/2024 revealed, Collection date/Time: 04/16/2024 at 10:55 a.m. Received Date/Time: 04/16/2024 at 2:44 p.m. Reported Date/Time: 04/16/2024 at 3:57 p.m. CBC with differential - WBC: 10.6 (high; range: 4.0 - 10.0) . Record review of CR #1's Observation Details, created by LVN C, dated 04/17/2024 revealed CR #1 was transferred to an acute care hospital on [DATE] at 7:44 p.m. The document read in part, This resident was transferred to an acute care hospital. She was having severe pain, low O2 saturation, and severe shivers. She requested to go to the hospital . No vitals have been recorded for this observation . There are no associated progress notes. Record review of CR #1's hospital Nursing Note, dated 03/29/2024 revealed, Date of Service: 03/29/2024 at 4:04 p.m. Gave report to LVN A at the facility about the patient current vitals and discharge information . Record review of CR #1's hospital After Visit Summary dated 03/29/2024 (provided by facility) revealed CR #1 was admitted to the acute care hospital on [DATE] and discharged on 03/29/2024. The electronic orders listed each medication CR #1 was discharged from the hospital with. Some of the listed medications had hand-written notes beside them, indicating they were new medications from the hospital which CR #1 did not take at the facility before she was discharged to the hospital. The document read in part, Sodium Chloride 100 ml with Daptomycin 500 mg Solution 500 mg . Last dose taken: 03/29/2024 at 2:25 p.m. New. CBC/BMP Once (per) week was hand-written in the box next to the listed medication. Record review of CR #1's hospital discharge records sent to the facility from the hospital (provided by facility) dated 03/29/2024 revealed, . [AGE] year-old female with past medical history significant for gunshot wound complicated by quadriplegia complicated by sacral and lateral left buttock decubitus ulcers now complicated by polymicrobial (multiple bacteria) skin and soft tissue infections and multifocal (having more than one location) osteomyelitis of the pelvis . Will treat for 6 weeks with empiric Ceftriaxone and Daptomycin to minimize dosing complications and monitoring. Patient has historic venous access difficulty due to anatomic reasons and requires tunneled CVC catheter for IV antibiotic administration outpatient. She will need a SNF committed to turning her, aggressive wound care, and appropriate administration of IV antibiotics and lab monitoring as ordered . Overall plan will be . 2. 6 weeks IV abx and smoking cessation with monitoring of labs, ESR, CRP . quadriplegia secondary to gunshot wound, complicated by sepsis secondary to acute on chronic, multifocal polymicrobial osteomyelitis of the pelvis . [NAME] Instructions: . Obtain weekly CMP, CBC with differential and Creatine Kinase. Fax lab results to hospital: Attention Infectious Disease Doctor . Recommendations Summary: . When preparing for discharge, [NAME] instructions below: . Obtain weekly CMP, CBC with differential and Creatine Kinase. Fax lab results to hospital: Attention Infectious Disease Doctor . Labs: CBC with differential - Collection time: 03/28/2024 at 6:17 a.m. Result: WBC - 8.90 (normal range) . CBC with differential - Collection time: 03/29/2024 at 5:12 a.m. Result WBC - 7.95 (normal range) . admission Date: 03/22/2024. discharge date : [DATE] . Record review of CR #1's hospital records dated 04/24/2024 revealed, Date of Service: 04/16/2024 at 8:34 p.m. Emergency Department Note: . History of Present Illness: Resident is a [AGE] year-old female presents today with a chief complaint of weakness and wound (multiple sacral). Patient endorses that she has a fever taken yesterday temporarily of 100 degrees Fahrenheit. Has had nausea without emesis (vomiting) yesterday as well. Today has been having shaking chills . Physical Exam: Blood Pressure - 137/97 . Temperature - 99 degrees Fahrenheit . Skin: Skin is pale . Lab Results: CBC with differential - Abnormal. WBC - 12.32 (high) . Diagnosis/Impression: Chills, pain associated with wound, sepsis due to unspecified organism . Laboratory Results - . Erythrocyte sedimentation rate (monitored for the detection of inflammation in the body): 03/24/2024 - 127 (elevated); 04/16/2024 - 127 (elevated) . Record review of CR #1's physician's orders for March 2024 and April 2024 revealed the following order: * RN may access Central Line and perform blood draw as needed. Start Date: 03/29/2024. End Date: Open Ended. Further review of CR #1's physician's orders for March 2024 and April 2024 revealed no documentation of any routine laboratory orders. In an interview with Treatment LVN B on 04/24/2024 at 10:45 a.m., she stated CR #1 was not compliant with care and she liked to stay in her wheelchair all the time. She said if she was not able to get to CR #1's wounds right when she wanted them done, CR #1 would tell her to come back, or she said she would get them done on the night shift (the staff worked 12-hour shifts, 7:00 a.m. - 7:00 p.m. and 7:00 p.m. - 7:00 a.m.). She said sometimes, the night shift nurse did not get a chance to do CR #1's wound care because she stayed in her wheelchair until 2:00 a.m. She said CR #1 complained of pain in her joints, so sometimes, she did not want to be turned or bothered. She said she sometimes talked to CR #1 about staying in the same position all the time, but she said her joints felt better in that position. She said on 04/15/2024, CR #1 was in the bed and the wound doctor did a culture on her wounds himself because they were milky and opaque. She said the wound doctor cleaned the wounds out. She said CR #1's wounds did not have an odor, but CR #1 always complained they did have an odor. She said the wounds did not smell foul, but they smelled like it would if a female left a menstrual pad on too long, like old blood, but not an infected smell. She said CR #1 was already on two oral antibiotics at that time and the wound doctor said maybe those were not the right antibiotics for CR #1's wounds. She said CR #1 was on antibiotics for her wounds since she was admitted to the facility in September 2024. She said the wound culture results came back after CR #1 was already gone. She said the only weekly lab orders she knew about were the CBC and CMP the NP ordered for every Tuesday. She said she was the nurse who put the orders into the computer system for the weekly draws on 04/15/2024 (to be drawn on 04/16/2024). Treatment LVN B looked through CR #1's MAR and said she did not see the order for the weekly labs. She said she did not know why it was not there. She said on 04/15/2024, LVN G called CR #1's NP and said she was not feeling well. She said the NP asked LVN G to put in orders for a CBC and BMP. Observation and interview with CR #1 at a local acute care hospital on [DATE] at 3:30 p.m. revealed she was alert and oriented. CR #1 was on contact isolation. CR #1's hands were contracted but she could move her arms enough to operate her cellular phone. She said her wounds had an odor at the facility, but they did not stink at the hospital. She said she knew she was supposed to get weekly labs done after she left the hospital in March (03/29/2024) but she never had any labs drawn until right before she left. In a telephone interview with the hospital's infectious disease doctor on 04/24/2024 at 7:10 p.m., he stated whenever he sent a patient out (discharge from the hospital to a SNF) for IV antibiotic therapy, he always put all the details in the patient's orders. He stated all instructions for CR #1's weekly lab orders were in his notes. He said he went to the hospital's case manager and asked her what they needed to send to the facility to make sure they got the instructions. He said the case manager told him she was sending everything to the facility. He said a hospital nurse always called the facility before discharge, so CR #1's orders should have been communicated very well. He said the type of antibiotics he prescribed for CR #1 could have caused Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), so CR #1's Creatine Kinase levels needed to be monitored for this. He said failure to monitor CR #1's blood chemistry could have resulted in renal failure, Rhabdomyolysis, sludge in the gallbladder, and increased liver enzymes, which were adverse effects of the antibiotics. He said CR #1 was oriented and she told him the facility did not check any of her labs. He said CR #1's pressure ulcers developed infections that went into her bone. He said he was surprised to see her back at the hospital on [DATE] and her wounds were smelly with pus. He said CR #1's inflammatory markers (erythrocyte sedimentation rate), which tracked the bone infection were exactly the same when she returned to the hospital on [DATE] as when she discharged on 03/29/2024. He said he expected at least a small decrease based on the amount of time she was on the antibiotics. In an interview with the DON on 04/25/2024 at 9:00 a.m., she said the facility did not usually get a resident's discharge summary from the hospital which documented everything that happened in the hospital. She said the hospital usually sent clinical updates and progress notes, which were very seldom completed by the actual doctor. She said she did not see any orders for labs on CR #1's discharge paperwork. She said the lab orders were not listed on the signed electronic orders. She said normally, the hospital called in report before the resident was discharged from the hospital. After review of the handwritten notes on the electronic hospital orders the facility received from the hospital, which read, New. CBC/BMP once (per) week, the DON said she assumed the handwritten notes were written by one of their (facility) nurses. She said she could not say the facility nurse who wrote the notes on the electronic orders was aware CR #1 was supposed to have weekly labs. She said she could not speak on what the nurse's handwriting meant or what she knew, but she would find out which nurse completed CR #1's admission on [DATE]. In a telephone interview with CR #1's physician (who was also the facility's medical director) on 04/25/2024 at 10:49 a.m., he stated he was familiar with CR #1 because she had very bad wounds and to his understanding, she was non-compliant with treatments. He said facility staff usually reconciled medications for residents who discharged from the hospital, but he did not reconcile CR #1's medications. He said the NP reconciled CR #1's medications and he was aware of CR #1's order for weekly labs (the labs ordered by the NP), either through conversations with the NP or reading her notes. He said he thought the labs were supposed to be done because he was concerned about the infection getting worse. He said part of it was to see if the infection got better or if it was the same or worse. He said it was usual protocol for them (him or his NP's) to request weekly labs on all residents on IV antibiotics. He said he was not aware the weekly labs were not being done. He said he assumed the labs were being done but never saw any results. He said some infectious disease doctors do not care to see the lab results, but they request the labs. In a telephone interview with the NP on 04/25/2024 at 11:00 a.m., she stated a facility nurse (she could not recall which nurse) reconciled CR #1's medications with her on 03/29/2024. The NP said she ordered weekly labs (CBC and BMP) for CR #1 on 03/29/2024 based on the antibiotics she was prescribed at the hospital. She said the weekly labs she ordered would have showed her if CR #1's infection was getting better and her kidney function. The NP said she asked for CR #1's lab results each time she visited the facility (she visited weekly), but she thought the facility nurses said CR #1 refused the labs. The NP said she did not think it was unusual because refusals were not uncommon for CR #1. She said she did not recall the nurse telling her that the hospital doctor requested weekly labs. She said it was normal to order weekly labs for residents on IV antibiotics like the ones CR #1 was prescribed, to make sure the kidneys functioned properly and to track the infection. She said she requested weekly labs on 03/29/2024 and on 04/15/2024 or 04/16/2024. In an interview with LVN A on 04/27/2024 at 11:45 a.m., she stated she normally worked the 7:00 a.m. - 7:00 p.m. shift. She said CR #1 was admitted to the hospital on [DATE] for infection symptoms. She said she was on shift when CR #1 returned to the facility on [DATE]. LVN A said she did not receive report from the hospital on [DATE]. She said CR #1 returned to the facility an hour before her shift ended. She said nobody from the hospital called her ahead of CR #1's return. She said CR #1 just showed up at the facility and she (LVN A) did not talk to anybody from the hospital at all that day. She said if the hospital had her name listed as the person, they gave report to, then it had been a while since that day, and she could not recall if she got report or not. She stated report sheets were handwritten and if she did not have a form, she wrote on a blank sheet of paper. She said the report sheet should go into the resident's admission packet and sent to medical records. She said eventually the report sheet would be scanned and put in the computer system for that resident. She said she did not recall if she did or did not do a report sheet for CR #1. She said she could have done a sheet for CR #1, but she did not recall. She said she recalled calling the NP to reconcile CR #1's medication. She said she got CR #1's discharge medications (from the hospital) from the packet the resident brought with her from the hospital. She said when she reconciled medications for readmitting residents from the hospital, she let the doctors know if anything was new, and they either approve the new medication or discontinue it. She said she also asked the doctors if they wanted to continue the medications the resident was on before they left the facility. She said she usually tried to read every page of the discharge packet sent from the hospital. She said she usually looked for the diagnosis to determine why the resident went to the hospital and if they started anything new at the hospital. She said usually, recurrent orders for labs were not on the electronic orders from the hospital. She said when she called the doctor to reconcile medications, they would usually add recurrent orders then. She said it was unusual for the hospital doctors to order recurring labs. She said she called the NP to reconcile CR #1's medication when she returned from the hospital on [DATE]. She said she informed the NP that CR #1 had two new IV antibiotics and the NP ordered a weekly CBC and BMP. She said she thought she wrote the requested labs on a piece of paper. She said after she got off the phone with the NP, she started reconciling the medications and entered the new medication orders into the computer system. She said she wrote the requested labs on the hospital discharge paperwork and on a little piece of paper. She said the little piece of paper probably got lost in the shuffle (possibly lost in a stack of paperwork). She said she forgot to enter the NP's requested orders for weekly labs. She said she was the admitting nurse, and it was her responsibility to enter the orders into the computer system. She said she guessed the requested labs were to determine if CR #1 still had infection, or something like that because the NP really did not say why she wanted the orders. She said it was important to get the labs done because the labs told you everything going on in the body and if something was off, it would tell you. She said it was easy to get distracted while admitting residents because she still had residents asking for PRN medications and other things. In an interview with an RN at a local acute care hospital on [DATE] at 10:30 a.m., she stated she was the hospital nurse who called to give report to the facility when CR #1 was discharged on 03/29/2024. She said she wrote the nurse's name on the discharge paperwork (LVN A), and she specifically gave thorough instructions regarding CR #1's wounds. She said she could not recall if they talked about the labs the infectious disease doctor requested, but she knew about the labs because the infectious disease doctor always requested labs in CR #1's circumstances. In an interview with the DON on 04/30/2024 at 11:45 a.m., she stated she was the facility's interim DON and had only been working at the facility for a few days. She said she did not know if the facility's previous DON or the ADON (the facility recently hired a new ADON who had not started working at the facility yet) completed quarterly audits of physician's orders as referenced in the facility's Laboratory Tracking System policy (see below). She stated she did not find any documentation, as of 04/30/2024 to verify the audits were being done. She said it was important to carry out all physician's orders for the safety and well being of the residents. She said the nurses were supposed to read each page of the hospital discharge record if it was available. In an interview with the Administrator on 04/30/2024 at 1:19 p.m., he stated it was important to make sure physician's orders were carried out because following orders was how they cared for their residents. Record review of the facility's undated policy titled, Laboratory, Radiology, and Diagnostic Testing Services revealed, Policy Statement: This facility will provide the appropriate diagnostic services (laboratory and radiology) required to maintain the overall health of its residents and in accordance with State and Federal guidelines. Policy Interpretation and Implementation: 1. The facility must provide or obtain laboratory, radiology, and other diagnostic services to meet the needs of its residents. 2. The facility is responsible for the timeliness of the services. 3. The facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders. No diagnostic tests will be performed without specific physician, physician assistant, nurse practitioner or clinical nurse specialist orders in accordance with State law to include scope of practice laws . Record review of the facility's policy titled, Medication Orders revised November 2014 revealed, Purpose: The purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication order. Supervision by a Physician: . 2. A current list of orders must be maintained in the clinical record of each resident. 3. Orders must be written and maintained in chronological order . 5. Intravenous Orders - When recording orders for IV solutions, specify the type of solution, rate of flow and volume to be infused. 6. Treatment Orders - When recording treatment orders, specify the treatment, frequency, and duration of the treatment . This was determined to be an Immediate Jeopardy (IJ) on 04/25/2024 at 3:20 p.m. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 04/25/2024 at 3:20 p.m. The following Plan of Removal submitted by the facility was accepted on 04/25/2024 at 8:56 p.m.: PLAN OF REMOVAL: Laboratory Services, F-773 Name of Facility Date: 4/25/2024 The facility failed to obtain laboratory services as ordered by a physician in accordance with the State law, including scope of practice laws. The facility failed to obtain weekly laboratory services (CMP, CBC, and CPK) as ordered by a hospital infectious disease doctor for CR #1, who was diagnosed with sepsis secondary to acute on chronic multifocal polymicrobial osteomyelitis of the pelvis, when she was discharged from an acute care hospital on [DATE]. The facility failed to obtain weekly laboratory services (CMP and CBA) as ordered by CR #1's NP when LVN A reconciled medication orders on 03/29/2024. Immediate Action: Action: CR#1 is currently in the hospital and is not returning to the facility Person(s) Responsible: Charge Nurse Date/Time: 4/16/2024 at 7:44 p.m. Facilities Plan to Ensure Compliance Quickly: Action: Lab audit performed facility wide to ensure no other labs were missed. If any other labs are identified the physician will be notified and the facility will follow orders. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date/Time: 4/25/2024 by 10:00 p.m. Action: Residents who have been admitted /readmitted in the past 30 days will have their admission/readmission orders reviewed to ensure lab orders, if present, were transcribed appropriately into the orders, we have the lab results, the MD has been notified, and new orders, if any, have been followed. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date/Time: 4/25/2024 by 10:00 p.m. Action: Laboratory, Radiology, and Diagnostic Testing Service Policy reviewed by Director of Clinical Operations and no changes are identified as needed at this time. Person(s) Responsible: Director of Clinical Operations Date/Time: 4/25/2024 by 10:00 p.m. Action: Director of Nursing and Assistant Director of Nursing have been educated regarding reviewing admission/readmission paperwork, transcribing orders (such as labs), lab communication to the MD and/or their extender

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure each resident received adequate supervision to prevent accidents for 4 of 17 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for smoking. 1. The facility failed to ensure Resident #1 had proper supervision after her smoke assessment stated she was careless with smoking materials and dropped ashes on herself. Her care plan stated she needed an extender and apron to be safe. She was observed without supervision, an apron or extender. 2. The facility failed to ensure Resident #2 had proper supervision after he was found smoking in his room located in the memory care unit. He was supposed to be supervised by his family member. His family member was not supervising him upon observation. 3. The facility failed to ensure Resident #3 had supervision after she was deemed non-compliant with smoking and had placed a half-smoked cigarette, she had just extinguished into a brown paper bag. 4. The facility failed to ensure Resident #4 was observed to be smoking without supervision when her smoking assessment stated she did not smoke. An immediate jeopardy (IJ) was identified on 2/29/2024 at 2:39 p.m. The IJ template was provided to the facility on 2/29/2024 at 3:01p.m. While the IJ was removed on 3/3/2024 at 11:22 a.m., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents who smoke and their roommates at risk of harm from burns or fires, explosions, hospitalization, and death. Findings Included: Resident #1 Record review of Resident #1's face sheet dated 2/28/2024 revealed she was a [AGE] year-old female who was admitted on [DATE]. She was diagnosed with anoxic brain damage(a brain injury due to restriction on the oxygen supplied to the brain), acute respiratory disease(a life-threatening lung injury that allows fluid to leak into lungs), muscle wasting and atrophy(is the decrease in size and wasting of muscle tissue), multiple sites; hereditary and idiopathic neuropathy(an illness where sensory and motor nerves of the peripheral nervous system are affected), unspecified; other lack of coordination, dysphagia oropharyngeal phase(problems with chewing and preparing food to be swallowed), bipolar disorder (mental disorder marked by extreme changes in mood, thought or behavior) and major depressive disorder (when an individual has persistently low or depressed mood). Record review of Resident 1's quarterly MDS dated [DATE] revealed C0500- BIM summary score was 04, which represented severe cognitive impairment. Section GG Functional abilities and goals had upper extremities such as shoulder, elbow, wrist, and hand were coded (1)- which meant Impairment on one side. Record review of smoking assessment dated [DATE] revealed she was careless with smoking materials-Drop cigarette butts/matches on the floor, furniture, self or others; smoked near oxygen. Coded at (3)- severe problem. Further review revealed the smoking risk at bottom of form stated she was scored at 6- follow facility policy. Scores of 0-9 was deemed safe to smoke. Record review of smoking assessment dated [DATE] revealed she was to use a smoke apron for safety & extender provided to help promote functional ability when smoking with supervision. Record review of care plan dated 1/10/2024 and updated 2/28/2024 stated Resident #1 has smoking extender provided during smoking to hold and ash cigarettes. Observation of Resident #1 on 2/28/2024 at 9:52am revealed she was smoking a cigarette in the smoking area. Resident #1 was observed without supervision, extender or apron to be safe while smoking. Resident #2 Record review of Resident #2's face sheet dated 2/28/2024 revealed he was a [AGE] year-old male who was admitted on [DATE]. He was diagnosed with unspecified intercranial injury without loss of consciousness (a brain injury without losing consciousness), need for assistance with personal care, unspecified injury at C6 level of cervical spinal cord (an injury with paralysis from the chest down, in hands and partially in the wrists), conversion disorder with seizures or convulsion( a condition in which a person experiences physical and sensory problems), schizoaffective disorder a mental health disorder including schizophrenia and mood disorder), dementia (group of thinking and social symptoms that interferes with daily functioning), shortness of breath, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and cognitive communication deficit(problems speaking, hearing, understanding, reading and writing). Record review of Resident #2's quarterly MDS dated [DATE] revealed C0500 was scored at 09 represented moderately impaired. Record review of Resident #2's smoke assessment dated [DATE] revealed it was safe for him to smoke. His smoking risk was 0. A score of 0-9 was deemed a safe smoker. No supervision was deemed necessary. Record review of Resident #2's care plan dated 2/14/2024 read in part: Problem: I am a smoker; I must be supervised. I have smoked in my room. Intervention: Smoking paraphernalia will be kept by nursing and activity department. Observation of Resident #2 on 2/28/2024 at 9:52am revealed he was smoking a brown cigarette without staff supervision. An interview with the ADON on 2/28/2024 at 10:01am, she stated the residents are independent smokers. She said they are allowed to keep cigarettes and lighters on their person as this was their home. She stated Resident #2 was the only resident must have supervision. She stated he only smokes when his RP was there to supervise him. She said otherwise he does not smoke. She was informed Resident #2's RP was not observed in the designated smoking area with him, and he was smoking a cigarette. The ADON stated Resident #2's RP arrived earlier in the morning and must have stepped away from him briefly. She said all other residents can smoke when they want and do not require staff supervision. An interview with Resident #2's RP on 2/28/2024 at 12:37pm, revealed she usually take Resident #2 out of the memory care unit to smoke. She said she visit him at least 3 to 4 times per week. She said she was approached by the ADON, who told her she was not supposed to leave Resident #2 unsupervised. She said she apologized and did not want any trouble for Resident #2. She said she usually do not leave his side. She did not say where she was when he was observed unsupervised this morning at 9:52am. She said he had smoked in his room once and she made sure she takes all cigarettes and lighters with her when she leaves the facility. She said she could understand how that could be dangerous because he was in the memory care due to both short and long-term memory loss and wandering. She said and another memory care resident might wander into his room and get a hold of his cigarettes. She said she understands the facility concern. An interview with MA A on 2/28/2024 at 12:53pm, revealed she mostly work on the secured memory care unit. She said Resident #2's RP took him out to smoke. She said he does not understand English very well and have memory impairment. She said Resident #2's RP usually stayed with him while he smoked and walk him back to the memory care unit. She said she was not sure why she was not with him upon my observation. She said she observed her walking him out to the designated smoking area this morning around 9:30am. She said she had heard Resident #2 smoked in his room recently. She said this was dangerous because most of the residents are wanderers. If they were to get a hold of cigarettes and lighters, this could be dangerous for the entire facility. Resident #2 was observed to be smoking unsupervised on 2/28/2024 at 9:52am. Resident #2 was supposed to be supervised by his family member but was not being supervised upon observation. Resident #3 Record review of Resident #3's face sheet dated 2/28/2024 revealed she was a 62- year-old female that was admitted to the facility on [DATE]. She had diagnosed with unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), paranoid schizophrenia(is a mental disorder characterized by reoccurring episodes of psychosis), cognitive communication deficit (difficulty thinking and how someone uses language), and dysphagia(difficulty or discomfort in swallowing). Record review of Resident #3's smoke assessment dated [DATE] revealed it was safe for her to smoke. She had a score of 0. A score of 0-9 were deemed a safe smoker. Record review of Resident #3 MDS dated [DATE] revealed BIMS summary score was 14 which represented cognitively intact. Record review of Resident #3's care plan dated 5/26/2023 and edited on 12/19/2023 read in part: Problem: I am not compliant with smoking policy. Goal: I will smoke only during smoke times. Approach: I will be monitored to only smoke in designated smoking areas and times or might lose my privileges. This care plan did not match the smoking assessment which revealed she was a safe smoker with a score of 0. A score of 0-9 were deemed a safe smoker. Observation of Resident #3 on 2/28/2024 at 9:52am, revealed she was smoking a cigarette without staff supervision. Further observation revealed Resident #3 left the smoke area and went inside to the lobby area. She had placed her half-smoked cigarette and a lighter inside a brown paper bag. Resident #4 Record review of Resident #4 face sheet dated 2/28/2024 revealed she was a [AGE] year-old female. She was diagnosed with: Chronic obstructive pulmonary disease(a group of lung disease that block air flow and causes difficulty in breathing), acute or chronic diastolic congestive heart failure (left ventricle muscle becomes stiff or thickened), pneumonia(infection that flames air sacs in one or both lungs, which may fill with fluid) unspecified, Sepsis unspecified organism(a life-threatening complication of an infection), acute upper respiratory infection, muscle wasting and atrophy(the decrease in size and wasting of muscle tissue), and bipolar disorder (episodes of mood swings ranging from depressive lows and manic highs) Record review of smoke assessment dated [DATE] revealed description: Resident quit smoking. Smoking assessment- Does resident smoke? No, was checked. Record review of care plan dated 2/29/2024 revealed a Problem start date: 2/29/2024 Category: Smoking: Resident #4 wants to smoke. I am a smoker. I require the following supervision. Goal: I will safely smoke in designated area(s) at scheduled times through next review. I will be assisted with smoking cessation as applicable. The care plan did not match the smoking assessment which stated she was not a smoker. Observation of Resident #4 on 2/28/2024 at 9:52am revealed she was sitting in her wheelchair smoking a cigarette without staff supervision. Further observation on 2/28/2024 at 3:28 p.m. revealed her to be sitting in her wheelchair in her room. There was an oxygen tank inside of her room. An interview with Resident #4 on 2/28/2024 at 3:28pm, she stated that she has been a smoker for over 50 years. She said she has never attempted to stop smoking. She said she enjoyed smoking and found it difficult to get through the day without smoking. She denied smoking in her bedroom. She stated she had her cigarettes and lighter in a plastic bag. She pointed to the plastic bag that was on her end table. She stated the facility smoke policy has changed numerous times. She said at one point they wanted to keep all cigarettes and lighters. She said that did not work because all smokers wanted to keep their own. She said she can keep all of her smoking paraphernalia on her person. She said she understand some residents that smoke might need supervision. She said she does not require supervision as she has her faculties and quite capable of keeping her own smoking paraphernalia. An interview with the traveling DON on 2/28/2024 at 10:06a.m., revealed she has been working at the facility for about 5-6 weeks. She said she had taken the brown paper bag from Resident #3. She said inside of the bag was a half-smoked cigarette and a lighter. She said she took it from Resident #3 because it could have caused a fire. She stated she believed the Activity Assistant was supervising the residents who were outside smoking. She was informed no staff was supervising the four residents observed to be smoking. She said the company smoke policy was in the process of being changed to keeping all resident's paraphernalia in locked boxes and they would be kept at the nursing station. She said trying to change this procedure/policy has been met with a lot of pushbacks from the residents as they have rights. She said they are waiting for lockboxes to be delivered and all residents cigarettes and smoke devices will be locked. She said not keeping residents' paraphernalia made her a little uneasy because she knows what can happen. She said unsafe smoking habits of one resident could cause a disaster for the entire facility. She denied any of the residents of this facility smoked near oxygen. She denied any residents smoked in their room. An interview with the Administrator on 2/28/2024 at 10:17a.m., revealed residents are allowed to smoke safely without supervision. They can have cigarettes and lighters in their rooms. However, they are transitioning to lockboxes to store cigarettes mostly due to complaints about cigarettes being stolen. He denied any unsafe smoking habits by the four residents observed outside smoking without supervision. He denied residents had smoked inside their rooms. He stated no staff had to provide supervision and that was why no one was supervising the resident as they smoked today (2/28/2024). He was informed the care plans and smoking assessments for the residents did not contain the same information. He said he would have his nurses investigate the discrepancies. He provided the facility smoking policy, smoke times and a census of all smokers. An interview with the Activity Assistant on 2/28/2024 at 10:55 a.m., she said she was not scheduled to supervise the residents smoking, but she would have helped, if asked by management. She said residents can keep their smoking items on their person and they do not have to be supervised, as far as she was aware. She said all the residents observed smoking today (2/28/2024) were capable of smoking unsupervised. An interview with an anonymous staff on 2/28/2024 at 1:17pm revealed Resident #2 has smoked in his room about 1 month ago. He was not a safe smoker and should not have cigarettes or lighters in his room. The anonymous staff stated Resident #4 also smoked in her room recently and uses oxygen. Residents are allowed to keep cigarettes and lighters in their rooms. The anonymous staff stated this was very unsafe and have voiced this concern to the Administrator. The anonymous staff stated the smoking policy has changed multiple times. At one point, staff were told the residents were not allowed to keep cigarettes on their person. They were supposed to turn in to the nursing station. The anonymous staff also stated the residents smoked at any time they wanted including some that go out late at night. An interview with ADON on 2/28/2024 at 2:08pm, revealed the residents that are deemed to be safe smokers can keep their cigarettes and lighters with them and do not require supervision as this is their home. She said only Resident #1 required a smoking extender utensil to catch the cigarette ashes due to her dexterity issues. She said the facility had purchased a cigarette extender for Resident #1 to use. The ADON was informed Resident #1 was not observed with an extender today (2/28/2024 at 9:52 a.m.) and Resident #2's RP was not observed to be supervising him. She said Resident #2's RP must have stepped away for a minute. She was not sure why his RP did not stay with him the whole time. She was not sure why Resident #1 was not using her extender at the time. An interview with SW on 2/29/2024 at 12:22pm, revealed she has been employed for 1 year. She said the facility is in the process of changing their smoking policy. She said currently residents can keep their cigarettes and lighters, but they will be keeping all smoking paraphernalia in lock boxes when they are delivered. She said staff are not currently supervising smoking. She stated that she is not responsible for smoking assessments. She said the MDS nurse/ ADON does the smoking assessments. She said 2 residents that will need supervision is Residents #1 and #2. She said Resident #1 has an extension stick that is used to dump her ashes. An interview with HR on 2/29/2024 at 12:36pm, she stated residents can currently smoke independently. She said the facility will be changing the policy soon to have all smokers supervised. She said she is responsible for new admissions. She stated the admission packet she provided was the facility's most current packet given to new residents and included their smoking policy. Record review of the facility's smoking census revealed there were 17 residents listed. Record review of the facility's smoke schedule updated on 2/1/2024 were as follow: 8:30 am- Maintenance Director 11am- Laundry/Housekeeping 1:00pm- North Hall nurse or designee 3:00pm- South Hall Nurse or designee 6:30pm- North Hall nurse or designee 8:00pm- South Hall nurse or designee At the bottom of smoking schedule, it stated smokers are to be observed for safety and until the last cigarette is extinguished and smoking materials are all locked up. No residents are allowed to keep smoking materials or have keys to lock boxes. Violations of policies will result in suspension & potential termination of smoking privileges. Record review of smoking policy dated 10/2023 read in part: This facility shall establish and maintain safe resident smoking practices. 1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 6. The resident will be evaluated on admission to determine if he or she is a safe smoker or non-smoker. If a smoker, the evaluation will include current level, method of tobacco consumption, desire to quit smoking, and ability to smoke safely with or without supervision. 11. Any residents with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possessions. Only disposable safety lighters are permitted. All other forms of lighters and matches are prohibited. Record review of an undated facility admission packet Attachment K-smoking read in part: Our facility provides our residents and our employees with a smoke-free environment. While we recognize the need of many of our residents and employees to work and live in a smoke-free environment, we must also respect the rights of those residents and employees who choose to smoke. 2. Residents and Visitors -Certain smoking restrictions apply to our residents and visitors. 19.7.4 (2). This facility will supervise all resident smoking for the safety of all residents and employees. Supervised smoking times for residents are scheduled and limited to 15-minute increments. All resident smoking paraphernalia must be checked in with the nurse. Resident smoking paraphernalia will be secured at the nurse's station and provided to the resident at specified smoking times. An immediate jeopardy (IJ) was identified on 2/29/2024 at 2:39 p.m. The Administrator and traveling DON were notified. The Administrator was provided with the IJ template on 2/29/2024 at 3:01p.m. A Plan of Removal was requested at that time. The following Plan of Removal submitted by the facility was accepted on 02/29/2024 at 4:58pm. and included: 2 /29/2024 - F689 Immediate Actions: Identification Action: All smoking residents will be reassessed. Observations to be completed in the medical records. Residents' care plans will match the residents' smoking assessments. Person(s) Responsible: Assistant Director of Nursing, Clinical Case Manager (MDS Coordinator), Clinical Resource Nurse, and/or Designee Date Completed: 2/29/2024 by 5PM Immediate/Prevention Action: All smoking residents will be educated on the facility's smoking policy , which has been changed to supervised smoking, with emphasis on smoking paraphernalia shall not be on their persons and smoking must be supervised by assigned staff. Person(s) Responsible: Social Services, Assistant Director of Nursing, and/or Designee Date Completed: 2/29/2024 by 5:30PM Immediate/Prevention Action: All staff educated over the facility's smoking policy, (which has been changed to supervised smoking, with emphasis on smoking paraphernalia shall not be on their persons and smoking must be supervised by assigned staff), reporting smoking non-compliance to the administrator, and intervening with residents that are noted smoking with no supervision (immediately begin supervising the resident(s) smoking). Assigned staff/smoking schedule (times the staff are responsible for smoking supervision)- staff will know to communicate with coworkers if unable to fulfill scheduled monitoring time and an alternate staff member will fill in. During routine nursing/CNA rounds, room cleanings (housekeeping), department head Angel Rounds staff will know to check for signs of unauthorized smoking via smell and visually checking for smoking paraphernalia being out/butts being in the trash cans, and the actual act of the residents smoking. All staff will be educated prior to working their next shift. All new/temporary (agency) staff will be educated prior to working their first/next shift. Person(s) Responsible: Administrator and/or Designee Date Completed: 3/1/2024 by 10AM Immediate/Prevention Action: Sign posted on the entrance doors to read, All smoking paraphernalia will be taken to the nurses' station, residents are not to have any cigarettes, lighters, and electronic smoking devices/vapes. Person(s) Responsible: Administrator and/or Designee Date Completed: 2/29/2024 by 5PM Immediate/Prevention Action: Binder of residents needing interventions while smoking (such as a smoking apron) will be placed outside each smoking area for staff reference to ensure residents interventions are in place while smoking. Smoking schedule/Assignments will be posted by binder. There are 4 smoking aprons on-site and are only required for residents that are assessed and deemed necessary to utilize the apron for safety. Person(s) Responsible: Administrator and/or Designee Date Completed: 2/29/2024 by 6:30PM Immediate/Monitor Action: Administrative Personnel and/or Designees will monitor/observe smoking areas, at minimum, twice daily, x4 weeks, to ensure safe smoking practices. Any residents noted to be non-compliant with the smoking policy will be re-educated. At this time the monitor will check for binder placement and ensure the intervention list is updated (see above action item). Monitors will be educated regarding their roles prior to observing. Person(s) Responsible: Administrator and/or Designee Date Completed: 2/29/2024 by 630PM Immediate/Monitor Action: At minimum, each occupied room will be checked once, daily, x4 weeks and as needed for signs of unauthorized smoking (through smell and visual checks-see education action above). Monitors will be educated regarding their roles prior to observing. Person(s) Responsible: Administrator and/or Designee Date Completed: 3/1/2024 by 11AM QAPI Action: Ad Hoc QAPI performed with Medical Director informing him of the IJ template and Seabreeze's plan to remove the immediacy. Person(s) Responsible: Administrator and/or Designee Date Completed: 2/29/2024 by 630PM Monitoring of the plan of removal from 3/3/2024 to 3/6/2024 included: Observation on 3/1/2024 at 10:00 a.m. revealed a sign on the entrance door that read, All smoking paraphernalia will be taken to the nurses' station, residents are not to have any cigarettes, lighters, and electronic smoking devices/vapes. Observation on 3/1/2024 at 11:05 a.m. of 2 white smoke aprons located in a cabinet in the designated smoking area for Resident #1 to use for ash droppings. Observation on 3/1/2024 at 1:10 p.m., revealed Resident #1 was wearing a smoking apron and supervision by staff. Observation on 3/2/2024 at 11:10am, staff was observed to be supervising the residents as they smoked. Interviews with Residents who smoked began on 3/1/2024 at 12:47 p.m. Residents #4, #15, #16, #17, #18 all were able to state the new policy in which staff are to supervise all residents. Cigarettes, lighters, chewing tobacco and vapes are to be kept at the nursing stations and all smoke times were to be adhered to. Interviews with Regional Nurse Consultant on 3/1/2024 at 10:32 a.m., revealed a room sweep had been conducted on 2/29/2024 and all cigarettes, lighters, vapes, and chewing tobacco was confiscated and placed in Ziplock bags with the residents' names on them and inside a locked box kept at the nursing station or medication room. She said she was still putting the binder together with all the updated smoking assessments. Interviews with CNA's B and F, Housekeeping Supervisor, Housekeepers A and B, LVN E, LVN F and RN A between 3/1/2024 at 9:35 a.m.- 3/2/2024 at 1:30 p.m., were able to explain the new policy in which staff are to supervise all residents that smoked, all paraphernalia was kept in locked boxes, and no residents are to keep cigarettes and lighters in their rooms or on their personal. An interview with the Regional Nurse Consultant on 3/3/2024 at 10:30 a.m., she stated the ADON texted all staff and had everyone come in for the mandatory training concerning smoking on 2/29/2024. She said all training was completed for staff prior to working a shift. She said all rooms have been checked at least once daily, a written notice that a telephone call was placed informed the Medical Director of the IJ template and the facility's plan to remove the immediacy. An interview with MDS Nurse on 3/5/2024 at 3:21p.m., revealed Resident #1 is doing well with the use of the apron. She said Resident #1 has dexterity concerns and have already had therapy to try to improve. She is not capable of holding cigarettes properly. She stated that she was responsible for the updated smoking assessments and care plans. She stated Resident #2 was the only resident that required supervision because of his memory loss. She stated that she was not sure why the care plans did not match the smoking assessments. She added that the policy had changed a few times and that might be why. She said she and the ADON were both responsible for the smoking assessments and care plans. Record review for smoking assessments for 21 residents were completed and had updated care plans. Record review of the updated smoking policy provided on 3/1/2024 revealed in part: This facility shall establish and maintain safe resident smoking practices. 9. All residents shall have direct supervision of a staff member while smoking. 11. All residents smoking paraphernalia must be checked in with the nurse. 12. Resident smoking paraphernalia will be stored in a secure location and provided to the resident at specified smoking times. Record review of the new smoking contract dated 2/29/2024 revealed 19 residents had signed the new smoking contract. According to census, two residents were in the hospital. The Administrator did not return to the facility after 2/29/2024. Therefore, no further interviews took place concerning the facility admission packet which stated that the facility was a smoke-free facility. The Regional Nurse Consultant was informed the Immediate Jeopardy was removed on 3/3/24 at 11:22 a.m. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to follow their own established smoking policy for 3 of 21 residents (Resident #1, Resident #2, and Resident #3) reviewed for smoking and compliance. 1. The facility failed to effectively intervene or follow their own smoking policy when Resident #1 was known to drop cigarette ashes on herself. 2. The facility failed to implement their own policy when resident #2, a memory care resident had smoked in his room. 3. The facility failed to implement their own policy when Resident #3 was known to be non-compliant and placed a half-smoked cigarette that she had just extinguished into a paper bag. These failures placed smoking residents at risk for injury from burns and fires caused by hazardous smoking behaviors. Findings Included: Record review of Resident #1's face sheet dated 2/28/2024 revealed she was a [AGE] year-old female who was admitted on [DATE]. She was diagnosed with anoxic brain damage(a brain injury due to restriction on the oxygen supplied to the brain), acute respiratory disease(a life-threatening lung injury that allows fluid to leak into lungs), muscle wasting and atrophy(is the decrease in size and wasting of muscle tissue), multiple sites; hereditary and idiopathic neuropathy(an illness where sensory and motor nerves of the peripheral nervous system are affected), unspecified; other lack of coordination, dysphagia oropharyngeal phase(problems with chewing and preparing food to be swallowed), bipolar disorder (mental disorder marked by extreme changes in mood, thought or behavior) and major depressive disorder . Record review of Resident 1's quarterly MDS dated [DATE] revealed C0500- BIM summary score was 04, which represented severe cognitive impairment. Section GG Functional abilities and goals had upper extremities such as shoulder, elbow, wrist, and hand were coded (1)- which meant Impairment on one side. Record review of smoking assessment dated [DATE] revealed she was careless with smoking materials-Drop cigarette butts/matches on the floor, furniture, self or others; smoked near oxygen. Coded at (3)- severe problem. However, smoking risk at bottom of form stated she was scored at 6- follow facility policy. Scores of 0-9 was deemed safe to smoke. Record review of smoking assessment dated [DATE] revealed she was to use a smoke apron for safety & extender provided to help promote functional ability when smoking with supervision. Record review of care plan dated 1/10/2024 and updated 2/28/2024 stated Resident #1 has smoking extender provided during smoking to hold and ash cigarettes. Observation of Resident #1 on 2/28/2024 at 9:52 a.m. revealed she was smoking a cigarette in the smoking area with Resident #2, Resident #3 and Resident #4 without staff supervision or an assistive device to catch the cigarette ashes. Resident #2 Record review of Resident #2's face sheet dated 2/28/2024 revealed he was a [AGE] year-old male who was admitted on [DATE]. He was diagnosed with unspecified intercranial injury without loss of consciousness, need for assistance with personal care, unspecified injury at C6 level of cervical spinal cord, conversion disorder with seizures or convulsion, schizoaffective disorder, dementia, shortness of breath and peripheral vascular disease and cognitive communication deficit. Record review of Resident #2's quarterly MDS dated [DATE] revealed C0500 was scored at 09 represented moderately impaired. Record review of Resident #2's smoke assessment dated [DATE] revealed it was safe for him to smoke. His smoking risk was 0. A score of 0-9 was deemed a safe smoker. No supervision was deemed necessary. Record review of Resident #2's care plan dated 2/14/2024 read in part: Problem: I am a smoker; I must be supervised. I have smoked in my room. Intervention: Smoking paraphernalia will be kept by nursing and activity department. Observation of Resident #2 on 2/28/2024 at 9:52am revealed he was smoking a brown cigarette without staff supervision. Resident #3 Record review of Resident #3's face sheet dated 2/28/2024 revealed she was a 62- year-old female that was admitted to the facility on [DATE]. She had diagnosed with unspecified dementia, paranoid schizophrenia, Type 2 diabetes, cognitive communication deficit, dysphagia, presence of a cardiac pacemaker and atherosclerotic heart disease. Record review of Resident #3's smoke assessment dated [DATE] revealed it was safe for her to smoke. She had a score of 0. A score of 0-9 were deemed a safe smoker. Record review of Resident #3's care plan dated 5/26/2023 and edited on 12/19/2023 read in part: Problem: I am not compliant with smoking policy. Goal: I will smoke only during smoke times. Approach: I will be monitored to only smoke in designated smoking areas and times or might lose my privileges. Observation of Resident #3 on 2/28/2024 at 9:52 a.m., revealed she was smoking a cigarette without staff supervision. Further observation revealed Resident #3 left the smoke area and went inside to the lobby area. She had placed her half-smoked cigarette and a lighter inside a brown paper bag. An interview with the ADON on 2/28/2024 at 10:01a.m., she stated the residents are independent smokers. She said they are allowed to keep cigarettes and lighters on their person as this is their home. She stated Resident #2 is the only resident must have supervision. She stated he only smokes when his RP is there to supervise him. She stated that their policy would soon be changed, and all smokers would be supervised. An interview with the traveling DON on 2/28/2024 at 10:06 a.m., revealed she had been working at the facility for about 5-6 weeks She said the company smoke policy is in the process of being changed. All of the residents' paraphernalia would be kept in locked boxes and would be kept at the nursing station. She said trying to change this procedure/policy has been met with a lot of pushbacks from the residents as they have rights. She said they are waiting for lockboxes to be delivered and all residents cigarettes and smoke devices will be locked. She said unsafe smoking habits of one resident could cause a disaster for the entire facility. An interview with the Administrator on 2/28/2024 at 10:17a.m., revealed him to state for clarity, residents are allowed to smoke safely without supervision. They can have cigarettes and lighters in their rooms. However, they are transitioning to lockboxes to store cigarettes mostly due to complaints about cigarettes being stolen. He denied any unsafe smoking habits by the four residents observed outside smoking without supervision. He said the facility would be changing their policy to all smokers having supervision. He provided the facility smoking policy, smoke times and a census of all smokers. Record review of the facility's smoking census revealed there were 17 residents listed. Record review of the facility's smoke schedule updated on 2/1/2024 were as follow: 8:30 am- Maintenance Director 11am- Laundry/Housekeeping 1:00pm- North Hall nurse or designee 3:00pm- South Hall Nurse or designee 6:30pm- North Hall nurse or designee 8:00pm- South Hall nurse or designee At the bottom of smoking schedule, it stated smokers are to be observed for safety and until the last cigarette is extinguished and smoking materials are all locked up. No residents are allowed to keep smoking materials or have keys to lock boxes. Violations of policies will result in suspension & potential termination of smoking privileges. Record review of the facility's smoking policy dated April 2023 read in part: This facility shall establish and maintain safe resident smoking practices. 1. Prior to, and upon admission, residents shall be informed of the facility smoking policy, including designated areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 6. The resident will be evaluated on admission to determine if he or she is a safe smoker or non-smoker. If a smoker, the evaluation will include current level, method of tobacco consumption, desire to quit smoking, and ability to smoke safely with or without supervision. 11. Any residents with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 12. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possessions. Only disposable safety lighters are permitted. All other forms of lighters and matches are prohibited. Record review of an undated facility admission packet Attachment K-Smoking read in part: Our facility provides our residents and our employees with a smoke-free environment. While we recognize the need of many of our residents and employees to work and live in a smoke-free environment, we must also respect the rights if those residents and employees who choose to smoke. 2. Residents and Visitors -Certain smoking restrictions apply to our residents and visitors. 19.7.4 (2). This facility will supervise all resident smoking for the safety of all residents and employees. Supervised smoking times for residents are scheduled and limited to 15-minute increments. All resident smoking paraphernalia must be checked in with the nurse. Resident smoking paraphernalia will be secured at the nurse's station and provided to the resident at specified smoking times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 resident (Resident #70) of 18 reviewed for abuse. The facility failed to ensure Resident #70, who was cognitively impaired, had a history of aggressive behaviors, and resided in the facility's memory care unit, was free from abuse when she was observed yelling and screaming for TNA A and TNA B to stop when they were twisting her around naked in her wheelchair with her feet up in the air on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:40 p.m. The IJ template was provided to the facility on [DATE] at 5:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed cognitively impaired residents at risk of physical harm, emotional distress, mental anguish and death from possible abuse and neglect. Findings include: Record review of Resident #70's undated face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Diffuse Lewy Body (protein deposits which develop in nerve cells in the brain), psychotic disturbance (a mental disorder characterized by a disconnection from reality), mood disturbance (feelings of distress, sadness or symptoms of depression, and anxiety), muscle wasting and atrophy (muscles that lose their nerve supply can decrease in size and waste away), chronic skin ulcers (ulcers that do not heal well after 12 weeks), dysphagia- oropharyngeal phase (difficulty initiating a swallow and generally due to structural , anatomical or neuromuscular abnormalities), cognitive communication deficit (difficulty with thinking and how someone uses language), restlessness and agitation (a common symptom of anxiety that makes someone have an uncomfortable urge to move), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), and chronic pain of the right hip joint. Resident #70 died on [DATE]. Record review of Resident #70's MDS dated [DATE] revealed she had a BIMS of 00 (severe cognitive impairment); she did not have hallucinations or delusions; she did not exhibit physical, verbal, or other behavioral symptoms towards others and she did not reject care. Resident #70 required extensive physical assistance from at least two staff for bed mobility, dressing, toilet use, and bathing; she required extensive physical assistance from one staff for transfers, walking, locomotion, eating, and personal hygiene; used a wheelchair for mobility and required substantial/maximum assistance; had an unsteady gait and was only able to stabilize with staff assistance; was always incontinent of bowel and bladder; had a history of falls; had skin tears; and was prescribed antianxiety and antidepressant medications. Record review of Resident #70's care plan revised [DATE] revealed the following care areas: *Resident #70 had pustules (a bulging patch of skin that is full of a yellowish fluid called pus) to the right ankle and left pinky toe. Goals included: Resident will not develop complications from foot problems as evidenced by not exhibiting infection or pain. Approach included: Apply dressing with topical medication. *ADLs Functional Status/Rehabilitation Potential. Goals Included: Resident will achieve maximum functional mobility. Approach included: Ambulation/Transfers amount of assist: Extensive. Bathing/hygiene amount of assist: Extensive. Dressing/Grooming amount of assist: Extensive. Eating amount of assist: Extensive. Toileting amount of assist: Extensive. Consult PT, OT, ST as needed. Personal care as per facility protocol. *Behavioral Symptoms. Resident did not adjust well to change. Resident was verbally and physically aggressive. At times, Resident crawled on the floor and over beds, and was not always easily redirected. Goals included: Resident will have fewer episodes of verbal and physical aggression. Approach included: Always ask for help if resident becomes abusive/resistive. Convey acceptance of acceptance during periods of inappropriate behavior. Encourage diversional activities. Keep environment calm and relaxed. Remove from public area when behavior is unacceptable. *Cognitive Loss/Dementia. Goals included: Resident will be as alert and oriented as possible. Approach included: Anticipate needs and observe for non-verbal cues. Approach in calm manner. Explain what you intend to do while providing care. Introduce self. Orient PRN to person, place, and time. *Communication. Goals included: Resident needs/wants will be met at all times. Approach included: Ask simple yes/no questions and allow adequate time to respond. Do not pretend to understand, request clarification when needed. Speak directly to resident in a clear voice facing him/her. *Mood State. Goals included: Resident will express/exhibit satisfaction. Approach included: Assess, monitor, and document mood. Be reassuring and listen to concerns. Encourage group activities. Medications as ordered. Social Services to visit 1:1. *Pressure Ulcer/Injury/Skin Care. Resident had thin and fragile skin. Resident got skin tears often and could not remember what caused the skin tears. Goals included: Prevent/heal pressure sores and skin breakdown. Approach included: Follow facility skin care protocol. Preventative Measures. Report to charge nurse any redness or skin breakdown immediately. Treatment as ordered. *Psychotropic Drug Use. Alprazolam, Paxil, Trazodone, Depakote. Goals included: Benefit without side effects. Approach included: Anti-Anxiety Medication Use - Observe resident closely for significant side effects: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash. Anti-Depressant Medication Use - Observe resident closely for significant side effects: Common - sedation, drowsiness, dry mouth, blurred vison, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity (skin), excess weight gain. Gradual dose reduction. Monitor for side effects per psychotropic flowsheet. Monitor target behaviors per psychotropic flowsheets. *Behavioral Symptoms. Resident had socially inappropriate/disruptive behavioral symptoms as evidenced by: resident pinched, hit, scratched, and bit at staff. Goals included: Resident will not exhibit socially inappropriate/disruptive behavior. Approach included: Assess resident for placement in a specially designed therapeutic unit. Resident was on memory care unit for personal safety. Maintain a calm environment and approach to resident. Observation and interview with Resident #70 on [DATE] at 10:30 a.m. revealed Resident #70 was in bed alert and yelling, Help, Help!. Resident #70 had bruises on her right leg, and she was observed scratching the bruises. There was an unidentified staff member sitting beside her. Interview with the unidentified staff member revealed Resident #70 was always restless after breakfast but fell asleep after some time. The unidentified staff member said she was watching Resident #70 to make sure she did not attempt to get up and fall. Record review of facility document entitled Concern Form dated [DATE] and signed by the Administrator revealed, Date received: [DATE]. Concern initiated by: Staff. Individual's name: [Housekeeper C] Concern reported to: DON, NHA nursing home administrator . Employee report concerns of yelling and screaming back in memory care unit . Individuals designated to take action on this concern: NHA/DON. Date assigned: [DATE]. Date to be resolved by: [DATE]. Was a group meeting held: No . Results of action taken: Resident screaming identified, care plan and behaviors reviewed, verbal education of employee due to behaviors and memory care unit, dementia, Alzheimer's . Was concern resolved? Yes, describe resolution. Employee stated she understood that dementia/Alzheimer's residents have behaviors that may include yelling, screaming, panicking, confusion, agitation, etc. Identify method used to notify the complainant of resolution: One-to-one discussion. Date: [DATE]. Was complainant satisfied with the resolution? Yes. Employee stated she understood behaviors. This form was completed by: NHA (Administrator). In an interview with the Administrator, DON, and ADON on [DATE] at 11:15 a.m., the Administrator said there was a recent incident involving a resident who passed away in the facility on the previous day, Resident #70, but the staff member, Housekeeper C, did not tell them everything that happened. The DON stated Housekeeper C said she had concerns regarding Resident #70 because she was screaming. The DON said she told Housekeeper C that screaming in the memory care unit was not unusual. The DON said regarding the incident that was reported, the aides (she did not name the aides) were trying to transfer Resident #70 to her bed and calm her down. The DON said Resident #70 was confused and combative. The DON said the staff member took it (the incident with Resident #70) personally, and thought it was abuse. The Administrator said they (administration) looked into the incident involving Resident #70 and they did not think it was abuse. The Administrator said all Housekeeper C said was that Resident #70 was yelling. The Administrator said Housekeeper C never said abuse, just that the resident was yelling. The DON said Housekeeper C quit earlier that morning ([DATE]). The ADON said Housekeeper C never mentioned that she saw or heard anybody drop Resident #70, or that she fell. The ADON said Housekeeper C said Resident #70 was yelling and she had concerns. The ADON said Housekeeper C did not name the staff, but she did try to describe the staff. The DON stated they (administration) never figured out which staff Housekeeper C was talking about. The DON said Housekeeper C came back a second time after she voiced concerns, and she still could not identify the staff involved. The ADON said Housekeeper C expressed her concerns to her supervisor, the Housekeeping Supervisor. The ADON said the Housekeeping Supervisor did not notify them (administration) until the next day, which was last week. The ADON could not recall the day administration was notified by the Housekeeping Supervisor. The Administrator said they had good continuity of care in the memory care unit, so they kept the same staff in there for each shift. The Administrator said no staff from the memory care unit had been reassigned to work another area of the building. In an interview with the Housekeeping Supervisor on [DATE] at 1:00 p.m., she stated Housekeeper C expressed concerns about Resident #70 to her on [DATE]. The Housekeeping Supervisor stepped out of the room twice at the beginning of the interview and kept saying, they (administration) were watching the door and keeping track of who entered the conference room to speak to the state surveyor about the incident. The Housekeeping Supervisor said Housekeeper C said she heard Resident #70 yelling down the hallway on [DATE], and it was concerning to her. The Housekeeping Supervisor said she explained to Housekeeper C that it was Resident #2 who always yelled in memory care, not resident #70. The Housekeeping Supervisor said Housekeeper C was fairly new to the facility and did not know residents' names. The Housekeeping Supervisor said Resident #2 always yelled, Help me! all day. The Housekeeping Supervisor initially said Housekeeper C did not say she saw anything, just that she heard yelling, and it made her uncomfortable. She said Housekeeper C was not able to say who the staff members were, just that the resident was yelling. The Housekeeping Supervisor said Resident #70 always yelled out, Stop, leave me alone. I do not want to sit down! The Housekeeping Supervisor said Housekeeper C sent a text message on Thursday, [DATE], at 10:27 p.m. saying it had been a rough and emotional day. She said when she saw the text message the next day, [DATE], she texted Housekeeper C asking her what happened and then she called Housekeeper C. The Housekeeping Supervisor said she reported the incident to the Administrator, DON, and ADON on the next day, [DATE]. In an interview with the Staffing Coordinator on [DATE] at 2:00 p.m., she stated she heard a few rumors regarding the incident involving Resident #70, but she did not know anything about it personally. She stated other staff (she would not name the staff) told her the incident involved Resident #70 and 2-3 aides, but she did not know who those aides were. She said staff had concerns because there was an incident with Resident #70 last week ([DATE]) and then she died over the weekend. She said other staff told her two aides were taking care of Resident #70 and they were swinging her around and she fell. The Staffing Coordinator said the fall was not reported and over the weekend Resident #70 was sick and vomited blood. She said the same staff always worked in the memory care unit and the same staff worked on the same days (the same staff always worked together and were off on the same days). The Staffing Coordinator said there was a lady who wanted to talk to the state surveyors about the incident, but she was scared and feared retaliation from administration. The Staffing Coordinator said the lady who wanted to talk said she saw some things but did not want to lose her job. She said recently, both TNA A and TNA B had been calling in sick, which was unusual. The Staffing Coordinator said one (TNA A or TNA B) was pregnant (she could not say which one). She said she did not know if anybody mentioned or questioned them about the incident regarding Resident #70. The Staffing Coordinator stated Housekeeper C was the original source of the information, but the person who wanted to talk to the state surveyors was a different person. In a telephone interview with TNA A on [DATE] at 2:22 p.m., she stated she often cared for Resident #70, who was confused. She said Resident #70 tried to walk but could not. She said Resident #70 was sweet some days, but some days, she did not want to be bothered. She said Resident #70 had her days when she did not want anybody to touch her. TNA A said Resident #70 had a witnessed fall in the dining room ([DATE]) and when she returned from the hospital, she was strong like super woman and tried to walk. She said she worked with Resident #70 last week (she could not recall the day) and after that, she was moved around to work on another hall. She said on that last day with Resident #70, she was really just being herself, talking and trying to get out of bed. TNA A said she sat in the room with Resident #70 on that night around 8:00 p.m. or 9:00 p.m. She said on that night, after Resident #70 got her medication, she was antsy (anxious) and she did not want Resident #70 to get out of bed, so she sat with her until she fell asleep for about 15 minutes. TNA A said Resident #70 was not aggressive or combative that night. She said Resident #70 was wheeled into her room and she was given her medications. She said she heard Resident #70 moving around on the baby monitor at nurse' station. She said it sounded like Resident #70 was talking and had a regular conversation with somebody. TNA A said Thursday, [DATE] was like a normal night and nothing unusual happened. In a telephone interview with TNA B on [DATE] at 2:44 p.m., she stated she worked nights in the memory care unit. She said Resident #70 could not walk but she tried. She said Resident #70 sometimes got fussy when she tried to provide care. TNA B said she gave Resident #70 some time when she got fussy and then came back and Resident #70 would allow her to give care. She said she was off Friday thru Sunday ([DATE] - [DATE]). TNA B said on [DATE], nothing unusual happened. She said Resident #70 had a lot of sores and she scratched them a lot. She said sometimes, nurses had to give Resident #70 first aide because she scratched the sores until they bled. She said Resident #70 never had a fall during her shifts. She said she worked on the North part of the building (not memory care) yesterday ([DATE]). Record review of facility sign-in sheets for [DATE] revealed the following: [DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: TNA A and TNA B, indicating TNA A and TNA B worked that shift. [DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: TNA A. TNA B's name was scratched out and listed under Call Ins, indicating TNA A worked the shift, but TNA B called in for that shift. [DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: Both TNA A and TNA B's names were crossed out. TNA B's name was listed under Call Ins. TNA A's name was written in under 6:00 p.m. - 6:00 a.m. North Nursing Station but it was crossed out and, and went home was written under her crossed out name. In an interview with the DON and ADON on [DATE] at 3:25 p.m., the DON said there should not have been any housekeepers on night shift that she knew of (6:00 p.m. - 6:00 a.m.). The ADON said the Housekeeping Supervisor told them it was Resident #70 that Housekeeper C was talking about. The DON had a small stack of papers and stated they were complaints the facility's administration had submitted to their corporate office against the Housekeeping Supervisor. The DON said they had issues with the Housekeeping Supervisor's performance for some time and she was aware. In a telephone interview with Housekeeper C on [DATE] at 3:45 p.m., she stated she worked as a housekeeper in the facility for approximately one month and a couple of weeks, so she was familiar with Resident #70, and she would not confuse her for Resident #2. She said she worked all over the building and her normal shift was 6:00 a.m. until 12:00 p.m., but she also worked nights sometimes from 3:00 p.m. - 8:00 p.m. She said she was cleaning in the memory care unit on [DATE] and she heard a lady, Resident #70, screaming. She said earlier that day, Resident #70 was perfectly fine. She said at 7:12 p.m. exactly, two of the night shift girls (TNA A and TNA B) had Resident #70 stripped naked with no brief, twirling her. She said Resident #70 was in her wheelchair and one of the staff was sitting in a regular chair behind the resident. She said the staff had her foot on the back of Resident #70's wheelchair like she was popping a wheelie with Resident #70's legs up in the air. She said the staff was moving Resident #70's wheelchair side to side and Resident #70 was screaming and hollering for her to stop. She said the screaming was what got her attention and she rolled her housekeeping cart to the very end of hall, where Resident #70's room was. She said another resident was walking by and told the staff to stop when she saw what the aides were doing to Resident #70. Housekeeper C said the aides were laughing during the incident. She said one of the aides was pregnant and the other was not. She said Resident #70 was bleeding, but she could not see where the blood was coming from. She said one of the aides wiped Resident #70's blood with her bed sheet. She said the pregnant aide saw her in the doorway and told her to get the bloody sheet. Housekeeper C said she picked up the bloody sheet, took it to laundry, then she went and clocked out. Housekeeper C said Resident #70's legs were still up in the air when she (Housekeeper C) walked out of the room with the bloody sheet. She said Resident #70 let out a very loud scream when she (Housekeeper C) was walking out of the room, but she did not know if that was when the staff let Resident #70's wheelchair down to the floor because she (Housekeeper C) did not turn around to look. She said she had a video of the incident that was only audio and no visual (she started recording with her phone when she heard Resident #70 screaming), but the DON made her delete it out of her phone when she was called in to report the incident. Housekeeper C said she initially reported the incident to her supervisor, the Housekeeping Supervisor, and then the DON told her to come into the office (the DON's office) and tell what her happened on Sunday, [DATE]. She said she had initially texted her supervisor the night of [DATE], but her (Housekeeping Supervisor) phone was off, and she did not see the message until the next day. She said the Administrator, DON, ADON, and the Housekeeping Supervisor were all present in the room when she reported what happened. She said there were six people in the room;, her, the Administrator, DON, ADON, Housekeeping Supervisor, and she could not name the last person. She said the video slipped her mind at first, so she did not mention it during the first meeting. She said the DON said sometimes they had to restrain residents when the residents tried to harm them. She said they told her she was too emotionally involved for that job. She said she told the DON and the Housekeeping Supervisor she thought Resident #70 was being abused because she was being abused. She said she also showed the video/audio to two other staff members (CNA K and TNA Y, but she did not say when this happened). Housekeeper C said CNA K and TNA Y asked her if she was going to report the incident to Resident #70's family member when she visited. She said CNA K told her Resident #70's leg was purple, and it looked like they (TNA A and TNA B) broke her leg. Housekeeper C said when Resident #70's family member visited her (she did not say what day this was), the family member said Resident #70 was perfectly fine when she ate lunch with her Tuesday ([DATE]). She said on her last day at the facility, Sunday, or Monday ([DATE] or [DATE]), Resident #70's family member was basically there saying her good-[NAME] to Resident #70. She said the DON called her into her office a second time on the same day and asked her who she had shown the video/audio to. She said she did not know how the DON found out about the video/audio, but after she played it for the DON, she made her air drop it to her (the DON) phone and then made her delete it from the phone and trash (in the phone). She said the DON said the voice in the audio was the lady who hollered all the time, Resident #2, but Housekeeper C said it was not Resident #2, it was Resident #70. She said they (administration) told her to think really hard about what she wanted to do at the facility and then they had her clock out. Housekeeper C said she quit when they told her to get out of the office and clock out. She said she tried to go to the facility and get paperwork to resume her state benefits earlier that morning ([DATE]) but they (administration) would not allow her into the building. She said she assumed it was because state was in the building, and they did not want her to talk. In an interview with the DON on [DATE] at 4:15 p.m., she stated Housekeeper C never sent her a video or audio and she never heard one regarding the alleged incident with Resident #70. The DON said there was talk around the facility about a video or audio, but she never told Housekeeper C to delete it. In a telephone interview with the Housekeeping Supervisor on [DATE] at 7:35 a.m. she said she was ready to tell the truth about what she knew regarding the incident with Resident #70. She said before she went to the conference room to speak with the state surveyor on [DATE], the DON texted her and told her to go to her (DON) office. She said the DON asked her what she was going to say to the state surveyor. She said she told the DON she was going to tell the state surveyor what Housekeeper C told her. She said the DON said please do not do that. She said the DON asked her to not tell the state surveyor everything. She said the DON told her to say Housekeeper C said she heard someone yelling down the hallway. The Housekeeping Supervisor said she was previously scared to talk to the state surveyor for fear of retaliation by administration. She said the Staffing Coordinator told her the DON called her into the office before she spoke to the state surveyor on [DATE] and told her the same thing, not to tell state the truth. She said Housekeeper C texted her on [DATE] at 10:27 p.m. and said she had an emotional day. She said she saw the text on Friday, [DATE] at 9:39 a.m. She said she called Housekeeper C on [DATE], after their 10:00 a.m. morning meeting. She said Housekeeper C told her that the pregnant girl at night and another one with her were involved. She said Housekeeper C said she was walking down the hall and saw Resident #70 naked in her wheelchair. She said Housekeeper C told her Resident #70 was trying to get up, but the staff were leaning the chair back and they started turning and twisting her in the air. She said Housekeeper C told her everybody kept coming up to her and asked who she reported the incident to and why she did not report it to them. She said Housekeeper C said she was scared to lose her job. The Housekeeping Supervisor said she reported the incident to the Administrator, DON, and ADON after she spoke to Housekeeper C on [DATE]. She said the Administrator and DON had her call Housekeeper C into the DON's office on Sunday, [DATE] at 3:08 p.m. because they said they needed to talk to her. She said they all talked together, then the Administrator and DON asked the Housekeeping Supervisor to leave. She said they called Housekeeper C back into the office and the DON said there was a video. She said the DON found out about the video because Housekeeper C showed it to CNA K and TNA Y. She said Housekeeper C also told her that CNA K said Resident #70's ankle was broken. The Housekeeping Supervisor said she did not know about the video when they initially walked into the office. She said the DON asked her (Housekeeping Supervisor) to have Housekeeper C come back into the office. She said the Administrator and DON asked her (Housekeeping Supervisor) to leave out of the office. She said Housekeeper C came out crying and saying she was about to lose her job. She said she told Housekeeper C she was not supposed to be on the phone. She said she thought Housekeeper C recorded the video/audio because she was already on a video call while working that night. The Housekeeping Supervisor said they (administration) made her send Housekeeper C home because state was in the building. The Housekeeping Supervisor said she never saw the video/audio because the DON made Housekeeper C send the video/audio to her (DON) phone and then made Housekeeper C delete it. She said Housekeeper C said she thought Resident #70 was being mistreated to everyone in the DON's office. She said Housekeeper C told her the staff were spinning her around and that was not right. She said Housekeeper C said one resident in the hall told them to stop when she saw what they were doing to Resident #70. Record review of a screenshot of a text message thread between the DON and the Housekeeping Supervisor's phone revealed, DON (Work) at the top of the text thread. On Wednesday, [DATE], at 12:39 p.m., the DON sent a text message that reflected, Need you to come to my office plz, and the Housekeeping Supervisor responded, On my way. In an interview with the Administrator on [DATE] at 12:35 p.m., he stated there was no evidence Resident #70 was abused and employees denied it. He said the two people (Housekeeping Supervisor and Housekeeper C) who made the accusations did it in retaliation because he made them do their jobs. He said there was an ulterior motive to the allegations. He said the first they heard of the abuse was when the HHSC complaint came in ([DATE]). The Administrator said the only time Housekeeper C came to him about any concerns was on [DATE] when she had concerns about residents yelling in memory care. In a follow up telephone interview with Housekeeper C on [DATE] at 1:00 p.m., she said on [DATE] at 7:12 p.m., she knew Resident #70 was being mistreated by the two staff (TNA A and TNA B) in the room, so she did not know what else to do but turn her video on her phone and put it (her phone) in her pocket. She said she went to the room so the video could pick up the audio of the resident yelling Stop It!, Help!. She said the resident was stripped naked, in a wheelchair with it propped back in a wheelie, and the staff members were laughing. She said another resident went by and told the staff members to stop and leave her alone, and the staff members told her to shut up and go to your room. Housekeeper C said she started to walk off and one of the staff members called her back and gave her a sheet with blood on it to take. She said she took it and walked away to put the sheet in the laundry, then she clocked out. She said when she was walking away, she heard a loud scream from the same resident that she had never heard before. She said she knew something was wrong but was too afraid to turn around at that point and she clocked out and left. She said she called the Housekeeping Supervisor as soon as she clocked out, but her phone was turned off. She said when she got to work the next day on [DATE], she told the Housekeeping Supervisor about what happened, and the Housekeeping Supervisor went to tell the Administrator and DON. She said she was called into the DON's office and told them that Resident #70 was being mistreated and what happened. She said they asked the Housekeeping Supervisor to leave the room and continued to talk to her (Housekeeper C). She said the DON said the staff could have been trying to use some kind of restraint with the resident. She said the Administrator asked her to send the video to him, but she was unable to, so the DON said to airdrop it to her. She said after she sent the video to the DON, she told her to delete it from her phone. She said her last day of work was on [DATE]. She said they (administration) told her she was too emotional and to think about what she really wanted to do. She said she went back up to the facility on [DATE] to try to get papers for her benefits and the ADON kicked her out of the facility and said she was not allowed back in the facility. She stated she never filled out a concern form or was even at the facility on [DATE]. She said she did not have a backup of the video and did not send it to anyone else besides CNA K and TNA Y. Housekeeper called back on [DATE] at 1:15 p.m. crying and said that her cellular phone maker told her if the video was deleted from the phone, there was nothing they could do. In an interview with TNA Y on [DATE] at 1:23 p.m., he stated he did not see a video (regarding Resident #70), but he heard about it from Housekeeper C and other staff in the facility. He said he was never told to not say anything or hide anything. He said when he heard about what was on the recording, he thought it was horrible. In an interview with the Staffing Coordinator on [DATE] at 3:05 p.m., she stated she received a call on [DATE] in the evening, after she was at home from the ADON. She said the ADON asked if TNA A and TNA B were on the schedule for [DATE], and she said no. She said when she came to work on [DATE], one of the aides (she did not say who) was really upset because Resident #70 had passed away. She said the anonymous aide stated, If it had anything to do with what I am hearing about, I am not comfortable. The Staffing Coordinator stated Housekeeper C was not the one who gave her the anonymous note to show the state surveyors (the Staffing Coordinator was given an anonymous note to show the state surveyors on [DATE], saying they had concerns about a resident who passed away. The anonymous person never approached the state surveyors in fear of retali[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations of abuse or mistreatment were thoroughly investigated and prevent further potential abuse or mistreatment while the investigation was in progress for 1 of 18 residents (Resident #70) reviewed for abuse. The Administrator, who was the facility's abuse coordinator and was responsible for investigating and reporting abuse incidents, failed to thoroughly investigate and report an allegation of abuse in the facility's locked memory care unit when Resident #70, who was cognitively impaired and had a history of aggressive behaviors, was observed yelling and screaming for TNA A and TNA B to stop when they were twisting her around naked in her wheelchair with her feet up in the air on [DATE]. The facility's administration failed to initiate protective interventions and continued to allow TNA A to provide care for Resident #70 ([DATE]) after the abuse incident. An Immediate Jeopardy (IJ) was identified on [DATE] at 5:40 p.m. The IJ template was provided to the facility on [DATE] at 5:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents involved in abuse incidents at risk of continued abuse, further injury, pain, and physical and emotional distress. Findings included: Record review of Resident #70's undated face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Diffuse Lewy Body (protein deposits which develop in nerve cells in the brain), psychotic disturbance (a mental disorder characterized by a disconnection from reality), mood disturbance (feelings of distress, sadness or symptoms of depression, and anxiety), muscle wasting and atrophy (muscles that lose their nerve supply can decrease in size and waste away), chronic skin ulcer (ulcers that do not heal well after 12 weeks), dysphagia- oropharyngeal phase (difficulty initiating a swallow and generally due to structural , anatomical or neuromuscular abnormalities), cognitive communication deficit (difficulty with thinking and how someone uses language), restlessness and agitation (a common symptom of anxiety that makes someone have an uncomfortable urge to move), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), and chronic pain of the right hip joint. Resident #70 died on [DATE]. Record review of Resident #70's MDS dated [DATE] revealed she had a BIMS of 00 (severe cognitive impairment); did not have hallucinations or delusions; did not exhibit physical, verbal, or other behavioral symptoms towards other; did not reject care; required extensive physical assistance from at least two staff for bed mobility, dressing, toilet use, and bathing; she required extensive physical assistance from one staff for transfers, walking, locomotion, eating, and personal hygiene; used a wheelchair for mobility and required substantial/maximum assistance; had an unsteady gait and was only able to stabilize with staff assistance; was always incontinent of bowel and bladder; had a history of falls; had skin tears; and she was prescribed antianxiety and antidepressant medications. Record review of Resident #70's care plan revised [DATE] revealed the following care areas: *Resident #70 had pustules (a bulging patch of skin that is full of a yellowish fluid called pus) to the right ankle and left pinky toe. Goals included: Resident will not develop complications from foot problems as evidenced by not exhibiting infection or pain. Approach included: Apply dressing with topical medication. *ADLs Functional Status/Rehabilitation Potential. Goals Included: Resident will achieve maximum functional mobility. Approach included: Ambulation/Transfers amount of assist: Extensive. Bathing/hygiene amount of assist: Extensive. Dressing/Grooming amount of assist: Extensive. Eating amount of assist: Extensive. Toileting amount of assist: Extensive. Consult PT, OT, ST as needed. Personal care as per facility protocol. *Behavioral Symptoms. Resident did not adjust well to change. Resident was verbally and physically aggressive. At times, Resident crawled on the floor and over beds, and was not always easily redirected. Goals included: Resident will have fewer episodes of verbal and physical aggression. Approach included: Always ask for help if resident becomes abusive/resistive. Convey acceptance of acceptance during periods of inappropriate behavior. Encourage diversional activities. Keep environment calm and relaxed. Remove from public area when behavior is unacceptable. *Cognitive Loss/Dementia. Goals included: Resident will be as alert and oriented as possible. Approach included: Anticipate needs and observe for non-verbal cues. Approach in calm manner. Explain what you intend to do while providing care. Introduce self. Orient PRN to person, place, and time. *Communication. Goals included: Resident needs/wants will be met at all times. Approach included: Ask simple yes/no questions and allow adequate time to respond. Do not pretend to understand, request clarification when needed. Speak directly to resident in a clear voice facing him/her. *Mood State. Goals included: Resident will express/exhibit satisfaction. Approach included: Assess, monitor, and document mood. Be reassuring and listen to concerns. Encourage group activities. Medications as ordered. Social Services to visit 1:1. *Pressure Ulcer/Injury/Skin Care. Resident had thin and fragile skin. Resident got skin tears often and could not remember what caused the skin tears. Goals included: Prevent/heal pressure sores and skin breakdown. Approach included: Follow facility skin care protocol. Preventative Measures. Report to charge nurse any redness or skin breakdown immediately. Treatment as ordered. *Psychotropic Drug Use. Alprazolam, Paxil, Trazodone, Depakote. Goals included: Benefit without side effects. Approach included: Anti-Anxiety Medication Use - Observe resident closely for significant side effects: sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash. Anti-Depressant Medication Use - Observe resident closely for significant side effects: Common - sedation, drowsiness, dry mouth, blurred vison, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity (skin), excess weight gain. Gradual dose reduction. Monitor for side effects per psychotropic flowsheet. Monitor target behaviors per psychotropic flowsheets. *Behavioral Symptoms. Resident had socially inappropriate/disruptive behavioral symptoms as evidenced by: resident pinched, hit, scratched, and bit at staff. Goals included: Resident will not exhibit socially inappropriate/disruptive behavior. Approach included: Assess resident for placement in a specially designed therapeutic unit. Resident was on memory care unit for personal safety. Maintain a calm environment and approach to resident. Observation and interview with Resident #70 on [DATE] at 10:30 a.m. revealed Resident #70 was in bed alert and yelling, Help, Help!. Resident #70 had bruises on her right leg, and she was observed scratching the bruises. There was an unidentified staff member sitting beside her. Interview with the unidentified staff member revealed Resident #70 was always restless after breakfast but fell asleep after some time. The unidentified staff member said she was watching Resident #70 to make sure she did not attempt to get up and fall. Record review of facility document entitled Concern Form dated [DATE] and signed by the Administrator revealed, Date received: [DATE]. Concern initiated by: Staff. Individual's name: [Housekeeper C]. Concern reported to: DON, NHA . Employee report concerns of yelling and screaming back in memory care unit . Individuals designated to take action on this concern: NHA/DON. Date assigned: [DATE]. Date to be resolved by: [DATE]. Was a group meeting held: No . Results of action taken: Resident screaming identified, care plan and behaviors reviewed, verbal education of employee due to behaviors and memory care unit, dementia, Alzheimer's . Was concern resolved? Yes, describe resolution. Employee stated she understood that dementia/Alzheimer's residents have behaviors that may include yelling, screaming, panicking, confusion, agitation, etc. Identify method used to notify the complainant of resolution: One-to-one discussion. Date: [DATE]. Was complainant satisfied with the resolution? Yes. Employee stated she understood behaviors. This form was completed by: NHA (Administrator). Record review of facility sign-in sheets for [DATE] revealed the following: [DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: TNA A and TNA B, indicating TNA A and TNA B worked that shift. [DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: TNA A. TNA B's name is scratched out and listed under Call Ins, indicating TNA A worked the shift, but TNA B called in for that shift. [DATE] - 6:00 a.m. - 6:00 p.m. Memory Care Unit: Both TNA A and TNA B's names were crossed out. TNA B's name was listed under Call Ins. TNA A's name was written in under 6:00 p.m. - 6:00 a.m. North Nursing Station but it was crossed out and, went home was written under her crossed out name. In an interview with the Administrator, DON, and ADON on [DATE] at 11:15 a.m., the Administrator said there was a recent incident involving a resident who passed away in the facility on the previous day (Resident #70 died on [DATE]), but the staff member (Housekeeper C) did not tell them everything that happened. The DON stated Housekeeper C said she had concerns regarding Resident #70 because she was screaming. The DON said she told Housekeeper C that screaming in the memory care unit was not unusual. The DON said Resident #70 had recently declined and she had a history of falls prior to admission. The DON said regarding the incident that was reported, the aides were trying to transfer her (Resident #70) to her bed and calm her down. The DON said Resident #70 was confused and combative. The DON said the staff member probably took it (the incident with Resident #70) personally, and thought it was abuse. The Administrator said they (administration) looked into it (the incident with Resident #70) and they did not think it was abuse and was not reported to HHSC. The Administrator said all Housekeeper C said was that the resident (Resident #70) was yelling. The Administrator said Housekeeper C never said abuse, just that the resident was yelling. The DON said Housekeeper C quit earlier that morning ([DATE]). The ADON said Housekeeper C never mentioned that she saw or heard anybody drop Resident #70, or that she fell. The ADON said Housekeeper C said Resident #70 was yelling and she had concerns. The ADON said Housekeeper C did not name the staff, but she did try to describe the staff. The DON stated they (administration) never figured out which staff Housekeeper C was talking about. The DON said Housekeeper C came back a second time after she voiced concerns, and she still could not identify the staff involved. The ADON said Housekeeper C expressed her concerns to her supervisor, Housekeeping Supervisor. The ADON said the Housekeeping Supervisor did not notify them (administration) until the next day, which was last week (she could not recall the day administration was notified by the Housekeeping Supervisor). The Administrator said they have had really good continuity of care in the memory care unit, so they kept the same staff in there for each shift. The Administrator said no staff from the memory care unit had been reassigned to work another area of the building. In an interview with the Housekeeping Supervisor on [DATE] at 1:00 p.m., she stated Housekeeper C expressed concerns about Resident #70 to her on [DATE]. The Housekeeping Supervisor stepped out of the room twice at the beginning of the interview and kept saying, they (administration) were watching the door and keeping track of who entered the conference room to speak to the state surveyor about the incident. The Housekeeping Supervisor said Housekeeper C said she heard Resident #70 yelling down the hallway, and it was concerning to her. The Housekeeping Supervisor said she explained to Housekeeper C that Resident #2 always yelled in memory care, not Resident #70. The Housekeeping Supervisor said Housekeeper C was fairly new to the facility and did not know residents' names. The Housekeeping Supervisor said Resident #2 always yelled, Help me! all day. The Housekeeping Supervisor initially said Housekeeper C did not say she saw anything, just that she heard yelling, and it made her uncomfortable. She said Housekeeper C was not able to say who the staff members were, just that the resident was yelling. The Housekeeping Supervisor said Resident #70 always yelled out, Stop, leave me alone, I do not want to sit down! The Housekeeping Supervisor said Housekeeper C sent a text message on Thursday, [DATE], at 10:27 p.m. saying it had been a rough and emotional day. She said when she saw the text message the next day, [DATE], she texted Housekeeper C, asking her what happened and then she called Housekeeper C. The Housekeeping Supervisor said she reported the incident to the Administrator, DON, and ADON on the next day, [DATE]. In an interview with the Staffing Coordinator on [DATE] at 2:00 p.m., she stated she heard a few rumors regarding the incident with Resident #70, but she did not know anything about it personally. She stated other staff (she would not name the staff) told her the incident involved Resident #70 and 2-3 aides, but she did not know who those aides were. She said staff had concerns because there was an incident with Resident #70 last week ([DATE]) and then she died over the weekend. She said other staff told her two aides were taking care of Resident #70 and they were swinging her around and she fell. The Staffing Coordinator said the fall was not reported and over the weekend Resident #70 was sick and vomited blood. She said the same staff always worked in the memory care unit and the same staff worked on the same days (the same staff always worked together and were off on the same days). The Staffing Coordinator said there was a lady who wanted to talk to the state surveyors about the incident, but she was scared and feared retaliation from administration. The Staffing Coordinator said the lady who wanted to talk said she saw some things but did not want to lose her job. She said recently, both TNA A and TNA B had been calling in sick, which was unusual. The Staffing Coordinator said one (TNA A or TNA B) was pregnant (she could not say which one). She said she did not know if anybody mentioned or questioned them about the incident with Resident #70. The Staffing Coordinator stated Housekeeper C was the original source of the information, but the person who wanted to talk to the state surveyors was a different person. In a telephone interview with TNA A on [DATE] at 2:22 p.m., she stated she often cared for Resident #70, who was confused. She said Resident #70 tried to walk but could not. She said Resident #70 was sweet some days, but some days, she did not want to be bothered. She said Resident #70 had her days when she did not want anybody to touch her. TNA A said Resident #70 had a witnessed fall in the dining room ([DATE]) and when she returned from the hospital, she was strong like super woman and tried to walk. She said she worked with Resident #70 last week (she could not recall the day) and after that, she was moved around to work on another hall. She said on that last day with Resident #70, she was really just being herself, talking and trying to get out of bed. TNA A said she sat in the room with Resident #70 on that night around 8:00 p.m. or 9:00 p.m. She said on that night, after Resident #70 got her medication, she was antsy (anxious) and she did not want Resident #70 to get out of bed, so she sat with her until she fell asleep for about 15 minutes. TNA A said Resident #70 was not aggressive or combative that night. She said Resident #70 was wheeled into her room and she was given her medications. She said she heard Resident #70 moving around on the baby monitor at nurse' station. She said it sounded like Resident #70 was talking and had a regular conversation with somebody. TNA A said Thursday, [DATE] was like a normal night and nothing unusual happened. In a telephone interview with TNA B on [DATE] at 2:44 p.m., she stated she worked nights in the memory care unit. She said Resident #70 could not walk but she tried. She said Resident #70 sometimes got fussy when she tried to provide care. TNA B said she gave Resident #70 some time when she got fussy and then came back and Resident #70 would allow her to give care. She said she was off Friday thru Sunday ([DATE] - [DATE], which was confirmed by the sign-in sheets). TNA B said on [DATE], nothing unusual happened. She said Resident #70 had a lot of sores and she scratched them a lot. She said sometimes, nurses had to give Resident #70 first aide because she scratched the sores until they bled. She said Resident #70 never had a fall during her shifts. She said she worked on the North part of the building (not memory care) yesterday ([DATE]). In an interview with the DON and ADON on [DATE] at 3:25 p.m., the DON said there should not have been any housekeepers on night shift that she knew of (6:00 p.m. - 6:00 a.m.). The ADON said the Housekeeping Supervisor told them it was Resident #70 that Housekeeper C was talking about. The DON had a small stack of papers and stated they were complaints the facility's administration had submitted to their corporate office against the Housekeeping Supervisor. The DON said they had issues with the Housekeeping Supervisor's performance for some time and she was aware. The DON said the facility used the state provider letter (Long-Term Care Regulatory Provider Letter 19-17 dated [DATE]) to let them know which incidents to report to HHSC. In a telephone interview with Housekeeper C on [DATE] at 3:45 p.m., she stated she worked as a housekeeper in the facility for approximately one month and a couple of weeks, so she was familiar with Resident #70, and she would not confuse her for Resident #2. She said she worked all over the building and her normal shift was 6:00 a.m. until 12:00 p.m., but she also worked nights sometimes from 3:00 p.m. - 8:00 p.m. She said she was cleaning in the memory care unit on [DATE] and she heard a lady, Resident #70, screaming. She said earlier that day, Resident #70 was perfectly fine. She said at 7:12 p.m. exactly, two of the night shift girls (TNA A and TNA B but she did not know their names) had Resident #70 stripped naked with no brief, twirling her. She said Resident #70 was in her wheelchair and one of the staff was sitting in a regular chair behind the resident. She said the staff had her foot on the back of Resident #70's wheelchair like she was popping a wheelie with Resident #70's legs up in the air. She said the staff was moving Resident #70's wheelchair side to side and Resident #70 was screaming and hollering for her to stop. She said the screaming is what got her attention and she rolled her housekeeping cart to the very end of hall, where Resident #70's room was. She said another resident was walking by and told the staff to stop when she saw what the aides were doing to Resident #70. Housekeeper C said the aides were laughing during the incident. She said one of the aides was pregnant and the other was not. She said Resident #70 was bleeding, but she could not see where the blood was coming from. She said one of the aides wiped Resident #70's blood with her bed sheet. She said the pregnant aide saw her in the doorway and told her to get the bloody sheet. Housekeeper C said she picked up the bloody sheet, took it to laundry, then she went and clocked out. Housekeeper C said Resident #70's legs were still up in the air when she (Housekeeper C) walked out of the room with the bloody sheet. She said Resident #70 let out a very loud scream when she (Housekeeper C) was walking out of the room, but she did not know if that was when the staff let Resident #70's wheelchair down to the floor because she (Housekeeper C) did not turn around to look. She said she had a video of the incident that was only audio and no visual (she started recording with her phone when she heard Resident #70 screaming), but the DON made her delete it out of her phone when she (Housekeeper C) was called in to report the incident. Housekeeper C said she initially reported the incident to her supervisor, Housekeeping Supervisor, and then the DON told her to come into the office (the DON's office) and tell what happened. She said she had initially texted her supervisor the night of [DATE], but her (Housekeeping Supervisor) phone was off, and she did not see the message until the next day. She said the Administrator, DON, ADON, and the Housekeeping Supervisor were all present in the room when she reported what happened. She said there were six people in the room, her, the Administrator, DON, ADON, Housekeeping Supervisor, and she could not name the last person. She said the video slipped her mind at first, so she did not mention it during the first meeting. She said the DON said sometimes they had to restrain residents when the residents tried to harm them. She said they told her she was too emotionally involved for that job. She said she told the DON and the Housekeeping Supervisor she thought Resident #70 was being abused because she was being abused. She said she also showed the video/audio to two other staff members, (CNA K and TNA Y). Housekeeper C said CNA K and TNA Y asked her if she was going to report the incident to Resident #70's family member when she visited. She said CNA K told her Resident #70's leg was purple, and it looked like they (TNA A and TNA B) broke her leg. Housekeeper C said when Resident #70's family member visited her (she did not say what day this was), the family member said Resident #70 was perfectly fine when she ate lunch with her Tuesday ([DATE]). She said on her last day at the facility, Sunday, or Monday ([DATE] or [DATE]), Resident #70's family member was basically there saying her good-[NAME] to Resident #70. She said the DON called her into her office a second time on the same day and asked her who she had shown the video/audio to. She said she did not know how the DON found out about the video/audio, but after she played it for the DON, she made her air drop it to her (the DON) phone and then made her delete it from the phone and trash (in the phone). The DON said the voice in the audio was the lady who hollered all the time, Resident #2. Housekeeper C said it was not Resident #2, it was Resident #70. She said they (administration) told her to think really hard about what she wanted to do at the facility and then they had her clock out. Housekeeper C said she quit when they told her to get out of the office and clock out. She said she tried to go to the facility and get paperwork to resume her state benefits earlier that morning ([DATE]) but they (administration) would not allow her into the building. She said she assumed it was because state was in the building, and they did not want her to talk. In an interview with the DON on [DATE] at 4:15 p.m., she stated Housekeeper C never sent her a video or audio and she never heard one regarding the alleged incident with Resident #70. The DON said there was talk around the facility about a video or audio, but she never told Housekeeper C to delete it. In a telephone interview with the Housekeeping Supervisor on [DATE] at 7:35 am., she said she was ready to tell the truth about what she knew regarding the incident with Resident #70. She said before she went to the conference room to speak with the state surveyor on [DATE], the DON texted her and told her to go to her (DON) office. She said the DON asked her what she was going to say to the state surveyor. She said she told the DON she was going to tell the state surveyor what her staff (Housekeeper C) told her. She said the DON said please do not do that. She said the DON asked her to not tell the state surveyor everything. She said the DON told her to say Housekeeper C said she heard someone yelling down the hallway. The Housekeeping Supervisor said she was previously scared to talk to the state surveyor for fear of retaliation by administration. She said the Staffing Coordinator told her the DON called her into the office before she spoke to the state surveyor on [DATE] and told her the same thing, not to tell state the truth. She said Housekeeper C texted her on [DATE] at 10:27 p.m. and said she had an emotional day. She said she saw the text on Friday, [DATE] at 9:39 a.m. She said she called Housekeeper C on [DATE], after their 10:00 a.m. morning meeting. She said Housekeeper C told her that the pregnant girl at night and another one with her were involved. She said Housekeeper C said she was walking down the hall and saw Resident #70 naked in her wheelchair. She said Housekeeper C told her Resident #70 was trying to get up, but the staff were leaning the chair back and they started turning and twisting her in the air. She said Housekeeper C told her everybody kept coming up to her and asked who she reported the incident to and why she did not report it to them. She said Housekeeper C said she was scared to lose her job. The Housekeeping Supervisor said she reported the incident to the Administrator, DON, and ADON after she spoke to Housekeeper C on [DATE]. She said the Administrator and DON had her call Housekeeper C into the DON's office on Sunday, [DATE] at 3:08 p.m. because they said they needed to talk to her. She said they all talked together, then the Administrator and DON asked the Housekeeping Supervisor to leave. She said they called Housekeeper C back into the office and the DON said there was a video. She said the DON found out about the video because Housekeeper C showed it to CNA K and TNA Y. She said Housekeeper C also told her that CNA K said Resident #70's ankle was broken. The Housekeeping Supervisor said she did not know about the video when they initially walked into the office. She said the DON asked her (Housekeeping Supervisor) to have Housekeeper C come back into the office. She said the Administrator and DON asked her (Housekeeping Supervisor) to leave out of the office. She said Housekeeper C came out crying and saying she was about to lose her job. She said she told Housekeeper C she was not supposed to be on the phone (she thought Housekeeper C recorded the video/audio because she was already on a video call while working that night). The Housekeeping Supervisor said they (administration) made her send Housekeeper C home because state was in the building. The Housekeeping Supervisor said she never saw the video/audio because the DON made Housekeeper C send the video/audio to her (DON) phone and then made Housekeeper C delete it. She said Housekeeper C said she thought Resident #70 was being mistreated to everyone in the DON's office. She said Housekeeper C told her the staff were spinning her around and that was not right. She said Housekeeper C said one resident in the hall told them to stop when she saw what they were doing to Resident #70. Record review of a screenshot of a text message thread between the DON and the Housekeeping Supervisor's phone revealed, DON (Work) at the top of the text thread. On Wednesday, [DATE], at 12:39 p.m., the DON sent text message, Need you to come to my office plz, and the Housekeeping Supervisor responded, On my way. In a follow up telephone interview with the Housekeeping Supervisor on [DATE] at 12:00 p.m., she stated on [DATE], she, Housekeeper C, the DON, ADON, and the Administrator were in the DON's office when Housekeeper C told them about the mistreatment she saw. She said the administration told her (The Housekeeping Supervisor step out. She said after the meeting they told Housekeeper C to go home because she was too emotional to work. She said the DON and ADON called her into the office on [DATE], before she spoke to the state surveyor. She said the DON asked her what she was going to say to state. The Housekeeping Supervisor said she did not want to tell the state anything because she was afraid she would get in trouble if she said the correct thing and afraid she would get in trouble if she said the wrong thing. She said she told the DON she was going to say the staff were swinging the resident around. She said the DON said no, no, no do not say that. She said the DON told her to say the resident was yelling and to not say the resident was being swung around. The Housekeeping Supervisor said they (administration) did not want her to go talk to the second state surveyor on [DATE]. Later on, [DATE], the DON called her into the office and the DON said, You got me an IJ and it is your fault! She said the DON, ADON, and Administrator were in the room and they all followed her out of the office. She said the DON cursed her out in front of residents, families, and other staff, calling her A stupid bitch! She said they followed her outside, calling her names and cursing and the Administrator slammed the door in her face. She said the ADON followed her outside cursing at her. The Housekeeping Supervisor said she was in fear for her own safety. She said the DON told her she was not fired, but she could not go to work. She said she was removed from of the facility's text message thread. In an interview with the Administrator on [DATE] at 12:35 p.m., he stated there was no evidence Resident #70 was abused and employees denied it. He said the two people (Housekeeping Supervisor and Housekeeper C) who made the accusations did it in retaliation because he made them do their jobs. He said there was an ulterior motive to the allegations. He said the first they heard of the abuse was when the HHSC complaint came in ([DATE]). The Administrator said the only time Housekeeper C came to him about any concerns was on [DATE] when she had concerns about residents yelling in memory care. In a follow up telephone interview with Housekeeper C on [DATE] at 1:00 p.m., she said on [DATE] at 7:12 p.m., she knew Resident #70 was being mistreated by the two staff (TNA A and TNA B) in the room, so she did not know what else to do but turn her video on her phone and put it (her phone) in her pocket. She said she went to the room so the video could pick up the audio of the resident yelling Stop It!, Help! She said the resident was stripped naked, in a wheelchair with it propped back in a wheelie, and the staff members were laughing. She said another resident went by and told the staff members to stop and leave her alone, and the staff members told her to shut up and go to your room. Housekeeper C said she started to walk off and one of the staff members called her back and gave her a sheet with blood on it to take. She said she took it and walked away to put the sheet in the laundry, then she clocked out. She said when she was walking away, she heard a loud scream from the same resident that she had never heard before. She said she knew something was wrong but was too afraid to turn around at this point and she clocked out and left. She said she called the Housekeeping Supervisor as soon as she clocked out, but her phone was turned off. She said when she got to work[TRUNCATED]