**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide respiratory care, including tracheostomy care and tracheal suctioning consistent with professional standards of practice, the resident's care plan, and the resident's preferences, for 2 of 3 residents (Resident #1 and Resident #2) reviewed for respiratory care. The facility failed to ensure LVN C assessed Resident #1 when he exhibited abdominal retractions (a sign of respiratory distress) while breathing on 09/24/25. The facility failed to ensure LVN A, LVN C, LVN D, and the Interim DON used sterile technique while performing tracheotomy suctioning on Resident #1. The facility failed to ensure RN B used sterile technique while performing tracheotomy care on Resident #2 on 09/29/25. The facility failed to follow the tracheotomy care and suctioning policy and procedure. The facility failed to provide competency check offs for LVN A, LVN C and LVN D on tracheotomy care and suctioning. Immediate jeopardy (IJ) was identified on 09/30/25 at 04:00 PM. The IJ template was provided to the facility on [DATE] at 04:38 PM. While the IJ was removed on 10/02/25 at 05:13 PM, the facility remained out of compliance at a scope of a patterned and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been provided education on the policy and procedure for sterile tracheotomy care and suctioning. These failures could place residents at risk of respiratory complications, infections and death.Findings included: 1. Record review of a face sheet dated 09/29/25 indicated Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of tracheostomy status. Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #1 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #1 did not have BIMS score, which indicated Resident #1 was unable to complete the assessment. The MDS assessment indicated Resident #1 was dependent on staff for all ADLs. The MDS assessment indicated Resident #1 had a tracheotomy. Record review of Resident #1's care plan dated 04/16/25 with a target date of 10/21/25 indicated he had a tracheotomy with a goal indicating he would be relieved of secretions and congestion within five minutes of suctioning and no occurrence of infection. Record review of Resident #1's Order Summary Report dated 09/29/25 indicated: Change tracheotomy dressing with tracheotomy care every day and PM with a start date of 06/27/25. Record review of Complaint/Grievance dated 08/12/25 indicated Resident #1's family member complained the staff was not providing tracheotomy care and suctioning using sterile technique. Resident #1's family member provided videos of staff providing tracheotomy care without using sterile technique. The grievance indicated the resolution was all nurses on North Hall were in serviced on tracheotomy care and suctioning using sterile technique. Record review of Resident #1's electronic medical record did not indicate a re-assessment was performed by LVN C after 09/24/25 at 09:29 AM when Resident's #1 was showing signs and symptoms of respiratory distress . Record review of a nursing progress note dated 09/25/25 at 01:42 PM written by LVN C indicated [family member] called stated the hospital called and informed her that patient needed to go back to the hospital. I attempted to call the hospital and get more information but no luck. Doctor making rounds per his advice to send resident out to the hospital for further treatments since he was positive gram. Called [family member] informed of the situation of him going back to the hospital. Called EMS no estimated time of arrival on pick up time. ADON, DON aware of situation. Record review of a nursing progress note dated 09/25/25 at 05:20 PM indicated family at facility inquiring why resident was not yet transferred to hospital, this nurse explained that transportation had been set up but facility was waiting on non emergent EMS. Call placed to EMS for updated ETA. EMS stated that they had not received a call for transport. This nurse relayed that resident was needing to be transported to [name] Hospital. EMS stated that they would be on they way to transport. Record review of the admission hospital records dated 09/25/25 indicated Resident #1 was admitted with chronic respiratory failure with tracheostomy in place. Laboratory results indicated Resident #1 had bacteremia (bacteria is present in the bloodstream), staph hominis (gram positive bacteria in the bloodstream), and pseudomonas (gram positive bacteria found in lungs, skin, ears) During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/16/25 at 05:09 AM, LVN A entered Resident #1's room wearing gloves and carrying a pitcher of water. LVN A flushed Resident #1's PEG tube (a feeding tube inserted into the abdomen into the stomach) and then provided incontinent care. LVN A did not change gloves or perform hand hygiene. LVN A proceeded to grab the suction catheter from the bedside table and suctioned Resident #1. LVN A did not change her gloves or use sterile technique during the suctioning procedure. LVN A repositioned Resident #1 in the bed, took off her gloves and exited the room. During an interview on 09/30/25 at 1:13 PM, LVN A stated LVN A stated tracheostomy care and suctions was considered a sterile procedure. LVN A stated the tracheostomy was direct airway into the lungs. LVN A stated the night of 09/15/25 into the morning of 09/16/25 was her last days as full time at the facility. LVN A stated she was unable to remember the care she provided to Resident #1. LVN A stated it was important to ensure sterile technique was maintained during tracheostomy care and suctioning to protect the staff and residents from infection. During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/23/25 at 11:09 AM, LVN C entered into Resident #1's room and put on non-sterile gloves. LVN C repositioned Resident #1's bedcovers. LVN C did not change her gloves or perform hand hygiene. Then LVN C grabbed the suction catheter from the bedside table drawer and unraveled Resident #1's TV control cord from the suction tubing. LVN C proceeded to suction Resident #1. LVN C took off her gloves and exited Resident #1's room. LVN C did not apply sterile gloves or use sterile technique for the suctioning procedure. During an observation on 09/29/25 at 02:19 PM of a video, date stamped 09/23/25 at 09:30 PM, LVN D was in Resident #1's room and had a sterile field set up on the bedside table. LVN D appeared to be wearing sterile gloves. LVN D touched the suctioning machine with her dominant hand and proceed to suction Resident #1. After LVN D touched the suction machine contaminating her dominant hand. LVN D failed to follow sterile technique for the suctioning procedure. LVN D removed her gloves, discarded the used supplies and exited the room. During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/24/25 at 09:29 AM, LVN C and Resident #1's family member entered the Resident #1's room. Resident #1's family member was heard stating he needs an assessment done. LVN C stated she already completed an assessment earlier and was not going to do it again. Resident #1''s family member told LVN C, it's obvious Resident #1 is having difficulty breathing - can you assess him. LVN C stated, and then what do you want me to do after I assess him - you are not a nurse - where do you work? Resident #1 was observed in his bed exhibiting abdominal retractions (a sign of respiratory distress) and gurgling was audible during the video. LVN C argued with Resident's #1's family member and refused to assess Resident #1's respiratory status. LVN C continued to argue and refused to provide tracheal suction. LVN C exited Resident #1's room without the necessary care provided. During an interview on 09/30/25 at 2:26 PM, LVN C stated she normally worked 6 AM - 2 PM shift on Monday through Friday. LVN C stated tracheostomy care and suctioning was a sterile procedure and sterile technique was required. LVN C stated she did not always have sterile tracheostomy care kits. LVN C stated sometimes she had to perform tracheostomy care without PPE or sterile supplies. LVN C stated supplies were unavailable on a regular basis. LVN C stated it was important to ensure sterile technique was used to prevent infection. LNV C stated everyone had issues with Resident #1's family member. LVN C stated on 09/24/25 she went into Resident #1's room during her morning rounds. LVN C stated she had performed a respiratory assessment, tracheostomy care, and suctioning. LVN C stated Resident #1 had some wet sounds that cleared after he was suctioned. LVN C stated later on the family called her in the room and stated Resident #1 had a temperature. LVN C stated she checked his temperature which was approximately 97.1. LVN C stated she attempted to remove the sheet, but did not perform another respiratory assessment as she was busy with another resident. LVN C stated she did not notice if Resident #1 was having trouble breathing. LVN C stated she did not obtain vital signs or an oxygen level. LVN C stated she notified the Interim DON because the family did not want her in the room. LVN C stated she notified the doctor, and a chest x-ray was ordered STAT (immediately). LVN C stated the family believed Resident #1 needed to be sent to the emergency room, so she called the doctor back and he gave the order to send to the emergency room. LVN C stated she was unable to recall if she called emergency transport. LVN C stated there was a lot going on that day. LVN C stated the Interim DON provided care to Resident #1 after she was asked to leave the room. During an observation on 09/29/25 at 02:19 PM of a video, date stamped 09/24/25 at 09:54 AM, the Interim DON and Resident #1's family member entered Resident #1's room. The Interim DON performed an assessment by taking Resident #1's temperature, checked his oxygen levels with the pulse oximetry (device use the measure the amount of oxygen in the blood), and listened to his lungs. The Interim DON removed the suction catheter from the bedside table drawer and suctioned Resident #1. Resident #1's family member asked the Interim DON why she was not using sterile gloves. The Interim DON said, the facility did not have the correct size to fit her hands in stock. The Interim DON did not apply sterile gloves or use sterile technique for the suctioning procedure. During an interview on 09/30/25 at 2:08 PM, the Interim DON stated tracheostomy care and suctioning was considered a sterile procedure. The Interim DON stated sterile technique was required. The Interim DON stated it was important to maintain sterile technique during tracheostomy care and suctioning to decrease the risk of infection. The Interim DON stated on 09/24/25 she performed unsterile tracheostomy suctioning because the facility did not have any sterile gloves that fit her. The Interim DON stated Resident #1 needed to be assessed and had obvious signs of respiratory distress. The Interim DON stated Resident #1's family had reported that LVN C refused to assess Resident #1, which was why she was in the room. The Interim DON stated she expected the nursing staff to perform a focused assessment for any change of condition. The Interim DON stated she expected the nurses to utilize the nursing judgment and prioritize care. The Interim DON stated airway and breathing were the two top priorities. The Interim DON stated an assessment was performed to ensure patient safety and maintain well-being. 2. Record review of a face sheet dated 09/30/25 indicated Resident #2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included anoxic (lack of oxygen) brain damage acute respiratory failure, and tracheostomy (surgical procedure that creates an opening in the front of the neck (trachea) and inserts a tube to help a person breath). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #2 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #2 did not have BIMS score, which indicated Resident #2 was unable to complete the assessment. The MDS assessment indicated Resident #2 was dependent on staff for all ADLs. The MDS assessment indicated Resident #2 had a tracheotomy. Record review of Resident #2's care plan [dated 06/29/25 with a target date of 10/14/25 indicated he had a tracheotomy with a goal of he would be relieved of secretions and congestion within five minutes of suctioning and no occurrence of infection. Record review of Resident #2's Order Summary Report dated 09/30/25 indicated: Change tracheotomy dressing with tracheotomy care every shift with a start date of 06/25/25. Record review of Resident #2's Infection Screening Evaluation dated 07/29/25 indicated recent chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's Infection Screening Evaluation dated 09/02/25 indicated recent chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's Infection Screening Evaluation dated 09/10/25 indicated recent chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's chest x-ray dated 09/10/2025 indicated pneumonia (infection of the lungs). Increased opacity is present at the left lung base representing either infiltrate or plural effusion. There has been no improvement with a prior chest x-ray performed on 09/02/25. Record review of SBAR communication Form written by RN B dated 09/29/25, indicated Resident #2 was experiencing a fever with low oxygen sat of 77%. O2 increased to 10 liters and O2 now 93%. Record review of progress note dated 09/29/25 at 2:29 PM written by RN B indicated the physician ordered an x-ray related to fever. Record review of progress note dated 09/30/35 at 12:48 PM written by RN B indicated, Resident #2 had worsening pneumonia on the left side. Also reported that he has developed a temp of 101.8 along with O2 having to be increased to 10 Liters to keep oxygen saturations over 90%. Resident is on day 8 of 14 of his Bactrim. Secretions have become very thick, green in color and has a very foul odor. New order received to send resident out to ER for assessment. [family member] informed and agrees with plan.During an observation on 09/29/25 at 4:17 PM, the Treatment Nurse prepared Resident #2's bedside table for tracheostomy care. The Treatment Nurse placed a piece of wax paper on the table, on the wax paper she placed the following: *two unopened bottles of sterile water, *a tracheostomy care kit, which was slightly opened, *unopened suction tubing, and *4 x 4 unsterile gauze pads from a multiuse package. RN B rearranged the items and positioned the bedside table for use. RN B washed her hands, then applied her sterile gloves, using sterile technique. RN B immediately picked up the unopened suction tubing package and opened it, which contaminated her sterile gloves. RN B then grabbed the unopened bottles of sterile water, opened it, and poured it into the sterile field. RN B then picked up the unsterile 4 x 4 gauze pads and placed them into sterile water. RN B did not reapply sterile gloves, after she contaminated her sterile gloves, and used the same gloves during the following care activities. RN B took the cotton-tipped applicators from the tracheostomy kit and then cleaned around the stoma (opening in the neck). RN B used the 4 x 4 gauze pads that were soaked in sterile water to clean around Resident #2's neck. RN B then cleaned inside the tracheostomy tubing with the 4 x 4 gauze pads. RN B removed her gloves and applied hand sanitizer. RN B replaced her gloves and replaced the tracheostomy neck ties. During an interview on 09/29/25 at 5:06 PM, RN B stated tracheostomy care was a sterile procedure. RN B stated the packaging should have been opened prior to applying her sterile gloves. RN B stated the outside packaging was not sterile. RN B stated everything completed after the sterile gloves were contaminated would not have been considered sterile. RN B stated she had not realized she broke sterile field during the procedure. RN B stated using sterile techniques during tracheostomy care was important to prevent the introduction of bacteria into the airway to prevent infections. RN B stated Resident #2 was currently being treated for pneumonia [TT15] (lung infection). During an interview on 09/30/25 at 11:44 AM, the Medical Director stated, nothing to do with tracheostomy care and suction was a sterile procedure The Medical Director stated the throat was not sterile and tracheostomy care and suctioning was a dirty procedure. The Medical Director stated nurses were required to be certified and competent to perform tracheostomy care and suctioning. The Medical Director stated staff should have received frequent in-service training from a certified respiratory therapist. The Medical Director stated there was a minimal risk for improperly performing tracheostomy care and suctioning. The Medical Director stated there was no risk of infection. The Medical Director stated having a tracheostomy placed residents at risk for bacterial infections from their own flora (bacteria) from their skin. During an interview on 09/30/25 at 12:46 PM, ADON K stated she was unable to locate the competency nurse check offs for sterile tracheotomy care and suctioning. ADON K stated the DON was responsible for completing competency checks for the nurses. ADON K stated the DON left a few weeks ago. During an interview on 09/30/25 at 1:53 PM, the Administrator stated tracheostomy care and suctioning was considered a sterile procedure and sterile technique was required. The Administrator stated she expected the nurses to ensure sterile technique was used during tracheostomy care and suctioning. The Administrator stated sterile supplies were always available. The Administrator stated it was important to ensure sterile technique was maintained during tracheostomy care and suctioning to protect the residents from infection. Record review of in service dated 08/12/25 with a subject of tracheotomy care and suctioning using sterile technique indicated twelve nursing staff signatures including LVN C, the Interim DON, RN B. Record review of the following staff competency nurse check offs for sterile tracheotomy care and suctioning included:Interim DON dated 02/25/2025RN B dated 07/16/2025. Record Review of the facility's undated policy titled Suctioning the Tracheostomy Tube, indicated, The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.b. Suctioning the lower airway is a sterile procedure. Record Review of the facility's undated policy titled Tracheostomy Care, indicated, The purpose of this procedure is to guide tracheostomy care.2. Gloves must be used on both hands during any or all manipulation . sterile gloves must be used during performing these procedures. Record review of the NCBI Bookshelf (A service of the National Library of Medicine and National Institutes of Health) in Chapter 22 Tracheostomy Care & Suctioning reflected .Tracheostomy suctioning uses a sterile catheter that is inserted through the surgical opening into the neck to the trachea to create an artificial airway. always review and follow agency policy regarding this specific skill.put on sterile gloves.the dominant hand will manipulate the catheter and must remain sterile.tracheostomy care provided with sterile technique. The Administrator was notified on 09/30/25 at 04:38 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator provided the Immediate Jeopardy template on 09/30/25 at 04:38 PM and a Plan of removal; (POR) was requested. The following plan of removal was submitted by the facility and accepted on 10/01/25 at 04:30 PM and included the following: Problem: Respiratory/Tracheostomy Care and SuctioningAlleged Issues: The facility failed to ensure LVN C assessed resident #1 when he exhibited abdominal retractions while breathing (a sign of respiratory distress), on 9/24/25The facility failed to ensure LVN A, LVN C, LVN D, and the Interim Don, use sterile technique while performing tracheotomy sectioning on resident number one.The facility failed to ensure RN B used sterile technique while performing tracheotomy care on resident #2 on 9/29/25.The facility failed to follow the tracheotomy care suctioning policy and procedureThe facility failed to provide competency check offs for LVN A, LVN C, LVN D on tracheotomy care and suctioning. Goal: Facility will be in compliance with federal health, safety, and/or quality regulations. Its employees or service providers are to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Approaches: RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. RN/DON A was in serviced by Facility Respiratory Therapist with documented competencies on file at the facility. The Administrator is not clinical but is aware of all in-services per the VP of Clinical Operations 1. Nursing staff will be in-serviced on the proper procedure tracheostomy care and suctioning. This in-service was initiated on 09/30/2025 by the RN/DON A. All nursing staff will be in-serviced prior to them arriving to the facility for their next shift. RN A, trained by the facility respiratory therapist RN A was trained July 16, 2025, and will deliver all following in service education to nurses one on one. Return demonstration by all nurses will be documented, and competency checklists will be kept in diners in the DON / Administrator's offices at the facility. All nurses will be trained before they accept residents for their next scheduled shift in Tracheostomy care and suctioning. 2. The regional nurse consultant will provide education regarding assessment of residents if changes in condition. This education will be provided to each nurse prior to the start of their next shift on the floor. This education will begin on 09/30/25 and continue until all staff are educated. An in-service on Respiratory assessments will be taught and any changes in condition will be documented and the physician will be notified of those changes. Changes in condition will include but not limited to shortness of breath; changes in respiratory status; using accessory muscles to breathe; drainage from trach; or decrease in 02 saturation. If provider orders transfer resident will be sent to the hospital via EMS transport as soon as possible. The facility respiratory therapist will be in the facility to provide further education with return demonstration, and competency checklists completed for facility nurses and interim DON on 10/1/2025. The Respiratory Therapist will visit monthly to ensure competency. 3. The facility medical Director was informed of the IJ on 09/30/25 in person, by the Facility Administrator. 4. Resident #1 is in the hospital 09/30/25. 5. Resident #2 is currently being treated with antibiotics for active infection. Resident #2 assessment was completed and resident sent to the hospital per physician orders. Resident #2 assessed on 9/29 /25 E interact change in condition form was completed and entered into the EMR. Resident was sent to the hospital on 9/30/25.Resident #3 assessment was completed on 10/1/2025; Resident #4 assessment was completed on 10/01/2025. 6. RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. All nursing staff will be in service prior to them arriving to the facility for their next shift. This will begin immediately, 09/30/2025. 7. Both the Administrator and DON will review new hire orientation packets to ensure these above in services are completed, and competency checklists are on file at the facility, prior to the first shift on the floor, including tracheostomy competencies including tracheostomy care per sterile technique and suctioning of the tracheostomy per sterile technique. RN/DON A who has been trained by the facility respiratory therapist and by the facility respiratory therapist provided this in-service to all facility nurses on staff at the time of the immediate jeopardy, nurses coming on shift at 10pm on 09/30/25 and all nurses coming on shift at 6am on 10/01/2025. The facility respiratory therapist will continue training on 10/01/2025 for any nurses who did not attend training, prior to their next scheduled shift on the floor. VP of Clinical will in-service the Administrator on this process ensuring all nurses will be trained on tracheostomy care and suctioning prior to their first shift on the floor caring for residents. DON and or RN trained by RT will complete the required tracheostomy training for nurses prior to their first shift on the floor, the administrator will ensure this training is completed. 8. All residents with enhanced barrier precautions were reviewed by the Don, ADON, and administrator, to ensure proper PPE was available outside the resident room. Monitoring:The DON, or designee will perform random in person audits with nursing staff to ensure they understand the tracheostomy suctioning/care via sterile technique procedure, at least 3 nursing staff weekly X1 month. This process will begin 10/03/2025. DON/ADON's will make rounds daily M-F, the weekend RN supervisor will round on all residents on the weekend, on all residents in facility to ensure nurses are properly performing trach care/suctioning per sterile technique. This process will be ongoing effective 09/30/2025. Assessment: All nurses on staff at the time of the immediate jeopardy were educated on tracheostomy suctioning and care of tracheostomy, with return demonstration by RN DON A is a DON from a sister facility assisting with training who has been trained by the facility respiratory therapist, with competency checklist on file at the facility on 09/30/25. QAPI Committee review: An interim QAPI committee meeting was completed on 09/30/25. IDT will review for compliance monthly in QAPI X3 months. On 10/02/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the immediate jeopardy (IJ) by: 1. Record review of DON GG ‘s competency, dated 07/16/25, reflected DON GG was competent with tracheostomy care and suctioning. DON GG was the DON from a sister facility who provided education to the facility nurses' on tracheostomy care and suctioning, including a competency check off and return skilled demonstration. 2. Record review of the in-service training report, dated 10/01/25, reflected the nurses were provided education on the proper procedure for tracheostomy care and suctioning. There were 11 nurse signatures. 3. Record review of the competency checkoffs dated between 09/30/25 and 10/01/25 reflected LVN A, LVN C, LVN D, LVN Y, LVN Z, LVN BB, RN B, RN X, RN AA, ADON K, ADON V, the Treatment Nurse, the MDS Coordinator, and the Interim DON were provided competency checks off with a return demonstration. The competencies reflected the nurses were competent with tracheostomy care and suctioning. 4. Record review of the in-service training report, dated 09/30/25, reflected nurses were provided education on how to perform a respiratory assessment, when it should be performed, notifying the physician, and implementing interventions. There were 5 nurse signatures. 5. During an interview on 10/02/25 at 4:01 PM, the Medical Director stated he was informed of the IJ from the Administrator at the facility. 6. Record review of Resident #1's hospital records, printed 09/29/25, reflected he was admitted on [DATE] with a diagnosis of bacteremia (blood infection). 8. Record review Resident #2's progress notes, dated 09/30/25, reflected Spoke with [Medical Director] after sending him the x-ray that resulted today showing worsening pneumonia on the left side. Also reported that he has developed a [temperature] of 101.8 along with [oxygen] having to be increased to 10 liters to keep oxygen saturations over 90%. Resident [2] is on day 8 of 14 of his [antibiotic]. Secretions have become very thick, green in color and has a very foul odor. New order received to send resident [#2] out to the [emergency room] for assessment. [Family member] informed and agrees with plan. 9. Record review of Resident #3's progress notes, dated 10/01/25 reflected [Resident #3] up to wheelchair with Foley catheter draining with amber color urine. No [complaints of] pain or discomfort at this time. No nausea or vomiting noted or reported. Resident continues on [antibiotics]. 10. Record review of Resident #4's progress notes, dated 10/01/25, reflected Skilled nurse assessed [Resident #4]. [Resident #4] bed at 45 degrees. [Respirations] 20, [Temperature] 98.0, [Blood Pressure] 132/87, saturation 95. Trach patent in place and air open. Secretions thin and clear. No odor at this time. No nasal flaring, no wheezing or grunting. No chest retractions. No coughing at this time. [Resident #4] rests at this time. 11.During an observation on 10/02/25 at 10:15 AM of PPE supplies outside the doors of all enhanced barrier precautions of the appropriate residents. Signage outside their door indicated the required PPE to be worn inside the room. There were isolation carts outside the rooms, which had face shields, isolation gowns, and gloves with hand sanitizer on top. The hand sanitizer dispensers were noted down the hallway. A staff member was dressed in an isolation gown and gloves and was preparing to enter Resident #4's resident room. 12.During an observation on 10/02/25 at 02:45 PM of proper sterile tracheostomy care and suction performed by RN B for Resident # 4. 13. During interviews on 10/02/25 conducted between 2:01 PM and 4:52 PM, LVN A, LVN C, LVN Y, LVN Z, LVN BB, RN B, RN X, RN AA, the Treatment Nurse, the MDS Coordinator, ADON K, ADON V, the Interim DON, and Administrator were able to verbalize sterile technique was required during tracheostomy care and suctioning. The nurses said tracheostomy care and suctioning should not have been performed without the proper supplies or equipment, which included sterile gloves and care kits. The nurses verified they were provided education and competency checkoffs on tracheostomy care and suctioning. The nursing managers were able to verbalize that monitoring will continue during rounds daily and checkoff competencies will be completed for new hires and nursing staff prior to working their next scheduled shift. 16. Record review of the Quality Assessment and Performance Improvement Plan, dated 09/30/25, reflected an impromptu meeting was conducted and 9 staff members were in attendance. The Administrator was informed the IJ was removed on 10/02/25 at 05:13 PM. The facility remained out of compliance at a scope of patterned and a severity level of no actual harm with a 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 that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 5 residents (Resident's #1, # 2, #3) reviewed for infection control practices. The facility failed to ensure LVN A, LVN C, LVN D, and the Interim DON used sterile technique while performing tracheotomy suctioning on Resident #1. The facility failed to ensure RN B used sterile technique while performing tracheotomy care on Resident #2 on 09/29/25. The facility failed to follow the tracheotomy care and suctioning policy and procedure. The facility failed to ensure LVN A, LVN C, LVN D, the interim ADON, LVN G and CNA H wore enhanced barrier precautions while performing care on Resident #1, who had a feeding tube, tracheostomy tube, wound, and Foley catheter. The facility failed to ensure CNA E and CNA F wore enhanced barrier precautions while providing care to Resident #3 who had a Foley Catheter. The facility failed to ensure the nursing staff knew how to access PPE and sterile supplies for enhanced barrier precautions. Immediate jeopardy (IJ) was identified on 09/30/25 at 04:00 PM. The IJ template was provided to the facility on [DATE] at 04:38 PM. While the IJ was removed on 10/02/25 at 05:13 PM, the facility remained out of compliance at a scope of a patterned and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been provided education on providing sterile tracheotomy care and suctioning and enhanced barrier precautions. These failures could place residents and staff at risk for cross contamination and serious injury, harm, impairment, and death from the spread of an infectious disease.Findings included: 1. Record review of a face sheet dated 09/29/25 indicated Resident #1 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included autistic disorder (difficulties in social communication and interaction, strong preference for routine, sensory processing differences, focused interest and repetitive behaviors), schizoaffective disorders (symptoms of delusional, hallucinations, depressed episodes followed by manic periods of high energy), anemias, and neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the control of urination), tracheostomy status, encounter for attention to gastrostomy (feeding tube). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #1 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #1 did not have BIMS score, which indicated Resident #1 was unable to complete the assessment. The MDS assessment indicated Resident #1 was dependent on staff for all ADLs. The MDS assessment indicated Resident #1 had a tracheotomy. Record review of Resident #1's care plan with a target date of 10/21/25 indicated he had a tracheotomy with a goal of he would be relieved of secretions and congestion within five minutes of suctioning and no occurrence of infection. Record review of Resident #1's Order Summary Report dated 09/29/25 indicated: Change tracheotomy dressing with tracheotomy care every day and PM with a start date of 06/27/25. Record review of Complaint/Grievance dated 08/12/25 indicated Resident #1's family member complained the staff was not providing tracheotomy care and suctioning using sterile technique. The grievance indicated the resolution was all nurses on North Hall were in serviced on tracheotomy care and suctioning using sterile technique. Record review of the admission hospital records dated 09/25/25 indicated Resident #1 was admitted with chronic respiratory failure with tracheostomy in place. Laboratory results indicated Resident #1 had bacteremia (bacteria is present in the bloodstream), staph hominis (gram positive bacteria in the bloodstream), and pseudomonas (gram positive bacteria found in lungs, skin, ears) 2. Record review of a face sheet dated 09/30/25 indicated Resident #2 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included anoxic (lack of oxygen) brain damage, flaccid neuropathic bladder (central nervous system or nerves involved in the control of urination) , anemia, epilepsy (seizures), mild protein-calorie malnutrition, cerebral infarction due to embolism (stroke), acute respiratory failure, tracheostomy (surgical procedure that creates an opening in the front of the neck (trachea) and inserts a tube to help a person breath). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #2 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #4 did not have BIMS score, which indicated Resident #4 was unable to complete the assessment. The MDS assessment indicated Resident #4 was dependent on staff for all ADLs. The MDS assessment indicated Resident #4 had a tracheotomy. Record review of Resident #2's care plan with a target date of 10/14/25 indicated he had a tracheotomy with a goal of he would be relieved of secretions and congestion within five minutes of suctioning and no occurrence of infection. Record review of Resident #2's Order Summary Report dated 09/30/25 indicated: Change tracheotomy dressing with tracheotomy care every shift with a start date of 06/25/25. Record review of Resident #2's Infection Screening Evaluation dated 07/29/25 indicated current active infection related to chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's Infection Screening Evaluation dated 09/02/25 indicated a current active infection related to chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's Infection Screening Evaluation dated 09/10/25 indicated current active infection related to chest x-ray showing new infiltrates consistent with pneumonia. Record review of Resident #2's chest x-ray dated 09/10/2025 indicated pneumonia (infection of the lungs). Increased opacity is present at the left lung base representing either infiltrate or plural effusion. There has been no improvement with a prior chest x-ray performed on 09/02/25. Record review of SBAR communication Form dated 09/29/25, indicated Resident #2 was experiencing a fever with low oxygen sat of 77%. O2 increased to 10 liters and O2 now 93%. Record review of Resident #2 progress note dated 09/29/25 at 14:29 PM, indicated the physician ordered an x-ray related to a fever. Record review of progress note dated 09/30/35 at 12:48 PM indicated, Resident #2 had worsening pneumonia on the left side. Also reported that he has developed a temp of 101.8 along with O2 having to be increased to 10 Liters to keep oxygen saturations over 90%. Resident is on day 8 of 14 of his Bactrim. Secretions have become very thick, green in color and has a very foul odor. New order received to send resident out to ER for assessment. Wife informed and agrees with plan. Record review of in service dated 08/12/25 with a subject of tracheotomy care and suctioning using sterile technique indicated twelve nursing staff signatures including LVN C, the Interim DON, RN B. Record review of the following staff competency nurse check offs for sterile tracheotomy care and suctioning included:Interim DON dated 02/25/2025RN B dated 07/16/2025 During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/15/25 at 09:20 PM, CNA H and LVN G entered Resident #1's room wearing a mask, CNA H and LVN G donned gloves and repositioned Resident #1, provided incontinent care and adjusted the bed covers. CNA H and LVN G did not wear a gown for enhanced barrier precautions. During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/16/25 at 05:09 AM, LVN A entered Resident #1's room wearing gloves and carrying a pitcher of water. LVN A flushed Resident #1's PEG tube (a feeding tube inserted into the abdomen into the stomach) and then provided incontinent care. LVN A did not change gloves or perform hand hygiene. LVN A proceeded to grab the suction catheter from the bedside table and suctioned Resident #1. LVN A did not change her gloves or use sterile technique during the suctioning procedure. LVN A repositioned Resident #1 in the bed, took off her gloves and exited the room. LVN A did not wear a gown for enhanced barrier precautions. During an observation on 09/29/25 at 2:19 PM of a video, date stamped 09/23/25 at 11:09 AM, LVN C entered into Resident #1's room and put on non-sterile gloves. LVN C repositioned Resident #1's bedcovers. LVN C did not change her gloves or perform hand hygiene. Then LVN C grabbed the suction catheter from the bedside table drawer and unraveled Resident #1's TV control cord from the suction tubing. LVN C proceeded to suction Resident #1. LVN C took off her gloves and exited Resident #1's room. LVN C did not apply sterile gloves or use sterile technique for the suctioning procedure. LVN C did not wear a gown for enhanced barrier precautions. During an observation on 09/29/25 at 02:19 PM of a video, date stamped 09/23/25 at 09:30 PM, LVN D was in Resident #1's room and had a sterile field set up on the bedside table. LVN D appeared to be wearing sterile gloves. LVN D touched the suctioning machine with her dominant hand and proceed to suction Resident #1. After LVN D touched the suction machine contaminating her dominant hand. LVN D failed to follow sterile technique for the suctioning procedure. LVN D removed her gloves, discarded the used supplies and exited the room. LVN D did not wear a gown for enhanced barrier protection. During an observation on 09/29/25 at 02:19 PM of a video, date stamped 09/24/25 at 09:54 AM, the Interim DON and Resident #1's family member entered Resident #1's room. The Interim DON performed an assessment by taking Resident #1's temperature, checked his oxygen levels with the pulse oximetry (device use the measure the amount of oxygen in the blood), and listened to his lungs. The Interim DON removed the suction catheter from the bedside table drawer and suctioned Resident #1. Resident #1's family member asked the Interim DON why she was not using sterile gloves. The Interim DON said, the facility did not have the correct size to fit her hands in stock. The Interim DON did not apply sterile gloves or use sterile technique for the suctioning procedure. The Interim DON did no wear a gown for enhanced barrier protection. During an observation on 09/29/25 at 4:17 PM, the Treatment Nurse prepared Resident #2's bedside table for tracheostomy care. The Treatment Nurse placed a piece of wax paper on the table, then placed the following on the wax paper: two unopened bottles of sterile water, a tracheostomy care kit, which was slightly opened, unopened suction tubing, and 4 x 4 unsterile gauze pads from a multiuse package. RN B rearranged the items and positioned the bedside table for use. RN B washed her hands, then applied her sterile gloves, using sterile technique. RN B immediately picked up the unopened suction tubing package and opened it, which contaminated her sterile gloves. RN B then grabbed the unopened bottles of sterile water, opened it, and poured it into the sterile field. RN B then picked up the unsterile 4 x 4 gauze pads and placed them into sterile water. RN B did not reapply sterile gloves, after she contaminated her sterile gloves, and used the same gloves during the following care activities. RN B took the cotton-tipped applicators from the tracheostomy kit and then cleaned around the stoma (opening in the neck). RN B used the 4 x 4 gauze pads that were soaked in sterile water to clean around Resident #2's neck. RN B then cleaned inside the tracheostomy tubing with the 4 x 4 gauze pads. RN B removed her gloves and applied hand sanitizer. RN B replaced her gloves and replaced the tracheostomy neck ties. During an interview on 09/29/25 at 5:06 PM, RN B stated tracheostomy care was a sterile procedure. RN B stated the packaging should have been opened prior to applying her sterile gloves. RN B stated the outside packaging was not sterile. RN B stated everything completed after the sterile gloves were contaminated would not have been considered sterile. RN B stated she had not realized she broke sterile field during the procedure. RN B stated using sterile techniques during tracheostomy care was important to prevent the introduction of bacteria into the airway to prevent infections. RN B stated Resident #2 was currently being treated for pneumonia (lung infection).During an interview on 09/30/25 at 11:44 AM, the Medical Director stated nothing to do with tracheostomy care and suction was a sterile procedure. The Medical Director stated the throat was not sterile and tracheostomy care and suctioning was actually a dirty procedure. The Medical Director stated nurses were required to be certified and competent to perform tracheostomy care and suctioning. The Medical Director stated staff should have received frequent in-service training from a certified respiratory therapist. The Medical Director stated there was minimal risk for improperly performing tracheostomy care and suctioning. The Medical Director stated there was no risk of infection. The Medical Director stated having a tracheostomy placed residents at risk for bacterial infections from their own flora (bacteria) from their skin. During an interview on 09/30/25 at 12:46 PM, ADON K stated she was unable to locate the competency nurse check offs for infection control. ADON K stated the DON was responsible for completing competency checks for the nurses. ADON K stated the DON left a few weeks ago. During an interview on 09/30/25 at 1:13 PM, LVN A stated enhanced barrier precautions should have been used on any resident with a gastrostomy tube, Foley catheter, wounds, or a tracheostomy tube. LVN A stated enhanced barrier precautions was PPE, that included: an isolation gown, gloves, and shoe covers. LVN A stated hand hygiene should have been performed between patient care, or when visibly soiled. LVN A stated gloves should have been changed and hand hygiene performed between different procedures. LVN A stated tracheostomy care and suctions was considered a sterile procedure. LVN A stated the tracheostomy was direct airway into the lungs. LVN A stated the night of 09/15/25 into the morning of 09/16/25 was her last days as full time at the facility. LVN A stated she was unable to remember the care she provided to Resident #1. LVN A stated the PPE required for enhanced barrier precautions were not always available for use by the staff. LVN A stated she was unable to recall if it was available for use on the morning of 09/16/25. LVN A stated if the PPE was not available, she was probably in a hurry to get everything completed. LVN A stated it was important to ensure enhanced barrier precautions were used and sterile technique was maintained during tracheostomy care and suctioning to protect the staff and residents from infection. During an interview on 09/30/25 at 1:53 PM, the Administrator stated she expected direct care staff to ensure enhanced barrier precautions were worn into residents' room as required. The Administrator stated tracheostomy care and suctioning was considered a sterile procedure and sterile technique was required. The Administrator stated she expected the nurses to ensure sterile technique was used during tracheostomy care and suctioning. The Administrator stated sterile supplies and PPE supplies were always available. The Administrator stated it was important to ensure enhanced barrier precautions were used and sterile technique was maintained during tracheostomy care and suctioning to protect the residents from infection. During an interview on 09/20/25 at 2:08 PM, the Interim DON stated enhanced barrier precautions were utilized for residents with a tracheostomy, Foley catheter, or infection. The Interim DON stated the PPE required for enhanced barrier precautions included: face shield, mask, gown, gloves, and sometimes goggles. The Interim DON stated she expected PPE to be utilized, when it is available. The Interim DON stated she had issues with PPE supplies being unavailable. The Interim DON stated when PPE supplies was unavailable, she attempted to find it or borrow it from the nursing facility next door. The Interim DON stated it was reported to the person who reorders supplies. The Interim DON stated tracheostomy care and suctioning was considered a sterile procedure. The Interim DON stated sterile technique was required. The Interim DON stated it was important to maintain sterile technique during tracheostomy care and suctioning to decrease the risk of infection. The Interim DON stated not having the appropriate equipment and PPE supplies could have contributed to Resident #1, Resident #2, and Resident #4's infections. The Interim DON stated on 09/24/25 she performed unsterile tracheostomy suctioning because the facility did not have any sterile gloves that fit her. The Interim DON stated Resident #1 needed to be assessed and had obvious signs of respiratory distress. The Interim DON stated Resident #1's family had reported that LVN C refused to assess Resident #1, which was why she was in the room. The Interim DON stated she expected the nursing staff to perform a focused assessment for any change of condition. The Interim DON stated she expected the nurses to utilize the nursing judgment and prioritize care. The Interim DON stated airway and breathing were the two top priorities. The Interim DON stated an assessment was performed to ensure patient safety and maintain well-being. During an interview on 09/30/25 at 2:26 PM, LVN C stated she normally worked 6 AM - 2 PM shift on Monday through Friday. LVN C stated enhanced barrier precautions were utilized for resident's who had wounds or infections, a tracheostomy tube, a Foley catheter, or a feeding tube. LVN C stated a gown, gloves, mask, and goggles as needed should have been worn when providing care. LVN C stated tracheostomy care and suctioning was a sterile procedure and sterile technique was required. LVN C stated she did not always have access to the PPE supplies or sterile tracheostomy care kits. LVN C stated sometimes she had to perform tracheostomy care without PPE or sterile supplies. LVN C stated supplies were unavailable on a regular basis. LVN C stated it was important to ensure sterile technique was used to prevent infection. 3. Record review of a face sheet dated 10/01/25 indicated Resident #3 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included paraplegia (medical condition characterized by the partial or complete loss of motor and sensory function in the lower half of the body including both legs), chronic cystitis without hematuria (bladder infections), infection and inflammatory reaction due to indwelling urethral catheter, anemias, and neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system, or nerves involved in the control of urination), traumatic amputation at level between left hip and knee, colostomy status (surgical procedure creates opening in the abdominal wall through which the large intestine is brought to the surface of the body). Record review of the Comprehensive MDS assessment dated [DATE] indicated, Resident #3 was able to make himself understood and was able to understand others. The MDS assessment indicated Resident #3 had a BIMS score of 14, which indicated Resident #3 was cognitively intact. The MDS assessment indicated Resident #3 was dependent on staff for transfers, showers, toileting and dressing and required assistance for eating and personal hygiene. The MDS assessment indicated Resident #3 had a Foley catheter colostomy and wounds Record review of Resident #3's care plan with a target date of 09/28/2025 indicated he had indwelling Foley catheter with a goal of resident #3 would remain free from any catheter related trauma. Record review of Resident #3's Order Summary Report dated 10/01/2025 indicated: EBP: Staff must use gowns and gloves during high contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds or indwelling medical devices). every shift for EBP Precautions with a start date of 04/16/2025. Record review of Resident #3's Infection Screening Evaluation dated 09/13/25 indicated a current active diagnosis of infection related to new or increasing purulent drainage. Record review of Resident #3's nursing progress note dated 09/13/2025 indicated during wound care, noted resident wound to the sacrum increasing slough and drainage. Physician notified and new orders received. During an observation on 09/27/25 at 03:33 PM, CNA E and CNA F entered Resident #3's room. CNA E and CNA F donned gloves. CNA E and CNA F transfer Resident #3 from wheelchair to bed. CNA E and CNA F reposition Resident #3 once he was placed into the bed. CNA E and CNA F adjust bed covers. CNA E and CNA F exit Resident #3's room. During an interview on 09/27/25 at 04:15 PM, CNA E stated she should have put on a gown due to enhanced barrier precautions because Resident #3 has a wound and has a Foley catheter. CNA E said it was important to use enhanced barrier precautions to protect the residents from risk of infections. During an interview on 09/27/25 at 04:35 PM, CNA F stated she had forgotten to grab a gown when she transferred Resident #3. CNA F stated the importance of wearing the gown for enhanced barrier precautions was to prevent the spread of bacteria between residents during close contact. Record review of the facility's Infection Surveillance Monthly Report as of September 30. 2025 indicated 13 total infections and 5 confirmed infections. 4. Record review of a face sheet dated 09/29/25 indicated Resident #4 was a [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included acute kidney failure, chronic respiratory failure, diffuse traumatic brain injury with loss of consciousness, disturbances of salivary secretions, neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the control of urination), tracheostomy status, encounter for attention to gastrostomy (feeding tube). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #4 was rarely able to make himself understood and was rarely understood by others. The MDS assessment indicated Resident #4 did not have BIMS score, which indicated Resident #4 was unable to complete the assessment. The MDS assessment indicated Resident #4 was dependent on staff for all ADLs. The MDS assessment indicated Resident #4 had an indwelling catheter. Record review of Resident #4's care plan did not indicate he had an indwelling catheter Resident #1's care plan did not address securing his Foley catheter. Record review of Resident #4's Order Summary Report dated 09/29/25 indicated: Foley catheters care every shift and as needed and may use leg strap to secure Foley tubing with a start date of 07/26/25. EBP: Staff must use gowns and gloves during high contact resident care activities that could possibly result in the transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds or indwelling medical devices). every shift for EBP Precautions with a start date of 07/25/25. Record review of Resident #4's hospital admission record dated 07/08/25 indicated a diagnoses of septic shock bronchopneumonia due to Escherichia coli. Record review of Resident #4's hospital admission record dated 08/12/25 indicated a diagnosis of catheter associated urinary tract infection. Record review of Resident #4's nursing progress note dated 09/26/25 indicated Resident #4 has developed a fever with increased respiratory effort. A new order was received for a chest x-ray. 5. Record review of a face sheet dated 10/0/25 indicated Resident #5 was a [AGE] year-old female initially admitted to the facility on 05/2020 and a readmission date of 09/27/25 with diagnoses which included type 2 diabetes , neuromuscular dysfunction of the bladder (problem due to disease or injury of the central nervous system or nerves involved in the control of urination), dehydration, abnormal weight loss, anxiety disorder (excessive worry), insomnia, encounter for attention to gastrostomy (feeding tube), colostomy status Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #5 was able to make herself understood and was able to understand others. The MDS assessment indicated Resident #5 had a BIMS score of 9, which indicated Resident #5 was moderately cognitively impaired. The MDS assessment indicated Resident #5 was dependent on staff for transfers, toileting, showering, with set up assistance needed for eating and personal hygiene. The MDS assessment indicated Resident #5 had a colostomy and indwelling catheter Record review of Resident #5's care plan did not indicate he had an indwelling catheter Resident #1's care plan did not address securing his Foley catheter. Record review of Resident #4's Order Summary Report dated 09/29/25 indicated: Foley catheter care every shift and as needed and may use leg strap to secure Foley tubing with a start date of 06/03/25. Colostomy care every shift and as needed with a start date of 02/03/25. EBP: Staff must use gowns and gloves during high contact resident care activities that could possibly result in transfer of MDROs to hands and clothing of staff. Enhanced Barrier Precautions are recommended for residents known to be colonized or infected with a MDRO as well as those who are not confirmed to have an MDRO (e.g., residents with wounds or indwelling medical devices). every shift for EBP Precautions with a start date of 02/03/2025 Record review of Resident #5's hospital Discharge summary dated 09/2725 indicated a diagnosis of E Coli bacteremia, urinary tract infection secondary to ESBL producing E Coli upon admission.[TT3] Record Review of the facility's undated policy titled Suctioning the Tracheostomy Tube, indicated, The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract.b. Suctioning the lower airway is a sterile procedure. Record Review of the facility's undated policy titled Tracheostomy Care, indicated, The purpose of this procedure is to guide tracheostomy care.2. Gloves must be used on both hands during any or all manipulation . sterile gloves must be used during performing these procedures. Record review of the NCBI Bookshelf (A service of the National Library of Medicine and National Institutes of Health) in Chapter 22 Tracheostomy Care & Suctioning reflected .Tracheostomy suctioning uses a sterile catheter that is inserted through the surgical opening into the neck to the trachea to create an artificial airway. always review and follow agency policy regarding this specific skill.put on sterile gloves.the dominant hand will manipulate the catheter and must remain sterile.tracheostomy care provided with sterile technique. Record Review of the facility's undated policy titled. Enhanced Barrier Precautions, indicated, Enhanced Barrier Precautions refers to an infection control intervention designed to reduce the transmission of multidrug-resistant organism that employs targeted gown and glove used during high contact resident care activities.Enhanced Barrier Precautions are indicated for residents with wounds and/or indwelling medical devices. The Administrator was notified on 09/30/25 at 04:38 PM that an Immediate Jeopardy situation was identified due to the above failure. The Administrator provided the Immediate Jeopardy template on 09/30/25 at 04:38 PM and a POR was requested. The following plan of removal was submitted by the facility and accepted on 10/01/25 a 04:30 PM and included the following: Problem: Infection ControlAlleged Issues: The facility failed to Implement the infection control policy and procedure for tracheostomy care/suctioning and enhanced barrier precautions.The facility failed to ensure LVN A, LVN C, LVN D, and the interim [NAME] used sterile technique while performing tracheostomy suctioning on resident number one.The facility failed to ensure RN B used sterile technique while performing tracheostomy care on resident #2 on 9/29/25.The facility failed to ensure LVN A, LVN C, LVN D, the interim Don, LVN G and C NA H wore enhanced barrier precautions while performing care on resident #1, who had a feeding tube, tracheostomy tube, wound, and Foley catheter.The facility failed to ensure LVN E LVN F wore enhanced barrier precautions while providing care to resident #3 who had a Foley catheter and wound.The facility failed to ensure the nursing staff knew how to access PPE and sterile supplies for enhanced barrier precautions and tracheostomy care/suctioning. Goal: Facility will be in compliance with federal health, safety, and/or quality regulations. Its employees or service providers are to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Approaches: RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. RN/DON A was serviced by Facility Respiratory Therapist with documented competencies on file at the facility and kept in binders in the DON's office and Administrator's office. The Administrator is not clinical but is aware of all in-services per the VP of Clinical Operations.Nursing staff will be in-serviced on the proper procedure for enhanced barrier precautions and the policy and procedure for enhanced barrier precautions. This in-service was initiated on 09/30/2025 by the RN/DON A. All nursing staff will be in-serviced prior to them arriving to the facility for their next shift. The Director of Nursing, Regional nurse consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. All facility staff will receive training on enhanced barrier precautions on 09/30/2025. Any staff who did not receive training on enhanced barrier precautions on 09/30/2025 will receive this education prior to their next scheduled shift on the floor caring for residents. The facility medical Director was informed of the IJ on 09/30/25 by the VP of Clinical Operations.1. Resident #1 is in the hospital 09/30/25. 2. Residents #2 was assessed on 9/29/2025; resident #3 was assessed on 8/21/25 & 9/13/25, resident #4 was assessed on 9/26/25; resident #5was assessed on 9/18/25. All are currently being treated with antibiotics for active infections. The Interim DON performed new assessments on 10/01/25 for residents 3, 4, and 5 on 10/01/2025. No further complications identified. Resident #1 is currently in the hospital. 3. All nurses will be trained in suctioning and care of tracheostomy per sterile technique and suctioning of tracheostomy by RN/DON A who has been trained by the facility respiratory therapist and by the facility respiratory therapist, on 09/30/2025. All nurses will be trained before they accept residents for their next scheduled shift. 4. RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one. All nursing staff will be in-serviced prior to them arriving at the facility for their next shift. This will begin immediately, 09/30/2025. All facility staff will receive training on enhanced barrier precautions on 09/30/2025. Any staff who did not receive training on enhanced barrier precautions on 09/30/2025 will receive this education prior to their next scheduled shift on the floor cari

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 7 (Resident #1) residents reviewed for quality of care. 1.The facility failed to provide wound care to Resident #1's right lower extremity stump (the remaining part of the right leg after amputation) as ordered resulting in infection and surgical debridement (the removal of damaged tissues from a wound) to rule out osteomyelitis (inflammation of the bone caused by infection). 2.The facility failed to report redness to Resident #1's abdomen to the Nurse Practitioner or Wound Care Physician resulting in hospitalization related to cellulitis (bacterial skin infection) and panniculitis (inflammation of the subcutaneous fat) requiring intravenous (IV) antibiotics. 3.The facility failed to document wound care assessments per facility policy. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 2:35 p.m. on 4/2/24. While the IJ was removed on 4/3/24, the facility remained out of compliance with a scope identified as patterned and a severity of no actual harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could result in residents with venous stasis ulcer of not having their treatments performed as ordered, wounds becoming infected wounds, and decreased wound healing. Findings Included: 1. Record review of the face sheet dated 4/3/24 indicated Resident #1 was a [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including panniculitis, morbid obesity, diabetes, acquired absence of right leg below the knee, localized edema (swelling), and congestive heart failure (chronic condition in which the heart does not pump blood as well as it should). Record review of the physician orders dated 4/3/24 indicated Resident #1 had an order to cleanse right below the knee amputation with normal saline, pat dry, apply calcium alginate (highly absorptive, non-occlusive dressing made of soft, non-woven calcium alginate fibers), collagen (wound dressing derived from collagen used to absorb exudate (fluids excreted by a wound), and cover with a dry dressing daily and as needed starting on 2/5/24. The physician orders indicated Resident #1 had an order for lymphedema (swelling caused by a lymphatic system blockage) wound of left abdomen skin prep daily starting 4/2/24. Record review of the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #1 had a surgical wound and moisture associated skin damage. Record review of the care plan revised 4/3/24 indicated Resident #1 had actual impairment to skin integrity: unstageable [wound] to the right leg with interventions including cleanse wound, apply medications and dressings as ordered. The care plan indicated Resident #1 had an infection of the wound. The care plan indicated Resident #1 had panniculitis . The care plan indicated had potential impairment to skin integrity of the lower abdomen and skin folds related to morbid obesity/incontinence. Resident had wound to right leg with treatment continued. Record review of the TAR dated 2/1/24 through 2/29/24 indicated Resident #1's treatment to cleanse right below the knee amputation with normal saline, pat dry, apply calcium alginate, collagen and cover with a dry dressing daily and as needed was only performed on 2/7/24, 2/8/24, 2/10/24, 2/12/24, 2/13/24, 2/15/24, 2/16/24, 2/17/24, 2/22/24, 2/26/24, 2/27/24, 2/28/24, and 2/29/24. Record review of the TAR dated 3/1/24 through 3/31/24 indicated Resident #1's treatment to cleanse right below the knee amputation with normal saline, pat dry, apply calcium alginate, collagen and cover with a dry dressing daily and as needed was only performed on 3/1/24, 3/3/24, 3/10/24, 3/11/24, 3/30/24, and 3/31/24. Record review of the skin assessment dated [DATE] indicated Resident #1 had a right lower leg wound infection measuring 1.5cm x 0.3cm x 0.2cm. The skin assessment indicated Resident #1 had a wound to the right leg with treatment in place. Record review of the skin assessment dated [DATE] indicated Resident #1 had a right lower leg wound infection measuring 1.5cm x 0.3cm x 0.2cm. The skin assessment indicated Resident #1 had a wound to the right leg with treatment in place. The skin assessment indicated Resident #1 had redness to left lateral side of abdomen with barrier cream (a product applied to the skin to help maintain the skins physical barrier, providing protection from irritants and preventing the skin from drying out) applied and Resident #1 was instructed to change positions every 2 hours. Record review of the skin assessment dated [DATE] indicated Resident #1 had a wound to the right leg with treatment in place. The skin assessment indicated Resident #1 had redness to left lateral side of abdomen with barrier cream applied and Resident #1 was instructed to change positions every 2 hours. Record review of the skin assessment dated [DATE] indicated Resident #1 had a wound to the right leg with treatment in place. The skin assessment indicated Resident #1 had redness to left lateral side of abdomen with barrier cream applied and Resident #1 was instructed to change positions every 2 hours. Record review of wound assessments indicated Resident #1 did not have a wound assessment performed by the facility from 2/1/24 through 3/13/24 when Resident #1 was transferred to the hospital. Record review of the Wound Care Physician's note dated 2/12/24 indicated Resident #1 had a right leg wound measuring 1cm x 0.3cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was healing as evidenced by 0% decrease in surface area within the wound bed. Record review of the Wound Care Physician's note dated 2/19/24 indicated Resident #1 had a right leg wound measuring 1cm x 0.3cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was at goal. Record review of the Wound Care Physician's note dated 2/26/24 indicated Resident #1 had a right leg wound measuring 2cm x 1.4cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound had exacerbated due to more edema in the leg. Record review of the Wound Care Physician's note dated 3/4/24 indicated Resident #1 had a right leg wound measuring 2cm x 1.4cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was at goal. Record review of the Wound Care Physician's note dated 3/11/24 indicated Resident #1 had a right leg wound measuring 2cm x 1.4cm x 0.2cm. The Wound Care Physician's note indicated the right leg wound was at goal. Record review of the nursing progress note dated 3/11/24 indicated Resident #1 received an order for Doxycycline (antibiotic) 100mg twice a day for 7 days related to right stump wound. Record review of the nursing progress note dated 3/13/24 indicated Resident #1 noted with change in condition including not feeling well, body aches, chills, fever, and right leg pain and swelling. The nursing progress note indicated a new order was received to send Resident #1 to the emergency department for evaluation and treatment. Record review of the nursing progress note dated 3/27/24 indicated Resident #1 returned to the facility. Record review of the hospital paperwork for hospital admission dated 3/13/24 through 3/27/24 indicated Resident #1 was admitted to the hospital with a primary diagnosis of acute panniculitis. The hospital paperwork indicated Resident #1 had discharge diagnoses including acute panniculitis, bacteremia (viable bacteria in the blood), and osteomyelitis of right tibia. The hospital paperwork indicated Resident #1 was admitted to the hospital with fever, chills and brought to emergency room for he was found to have an elevated white cell count of 17,200 (normal range 4,500 to 11,000) and large left-sided cellulitis involving his entire left abdominal wall pannus (excess skin and fat that hangs down from the abdomen). The hospital paperwork indicated Resident #1 was started on broad-spectrum IV antibiotics and based cellulitis spread from left flank to across his left midline. The hospital paperwork indicated Resident #1 had some evidence of wounds in his left abdominal wall. The hospital paperwork indicated Resident #1 had a right below-knee amputation stump ulcer with x-ray revealing osteomyelitis. The hospital paperwork indicated after right below the knee stump debridement on 03/21/2024 there was not any evidence of bone involvement. During an interview on 3/28/24 at 1:26 p.m. Resident #1 said there had been staffing issues with treatment nurses. Resident #1 said his wound care had not been done as scheduled. Resident #1 said he had just returned from the hospital due to infection to wound and cellulitis to abdomen. Resident #1 said he had surgery on his below the knee amputation while in the hospital to determine in the infection was in the bone. Resident #1 said the infection had not made it to the bone and was only in the soft tissue. Resident #1 said he had not been receiving proper wound care prior to being hospitalized . During an interview on 4/2/24 at 9:59 a.m. LVN A said she was familiar with Resident #1. LVN A said Resident #1's wound care was performed daily. LVN A said LVN F or LVN E were responsible for performing Resident #1's wound care. LVN A said the nurses were responsible for completing skin assessments. LVN A said she did not know if the increased redness to Resident #1's abdomen had been reported. LVN A said all wound treatments from the wound care physician were recommendations. LVN A said she would have to find out if the wound care physician recommendations were implemented or needed to be approved by the resident's primary care physician. LVN A said Resident #1 had a skin assessment dated [DATE] which indicated redness to left lateral abdomen. During an interview on 4/2/24 at 10:14 a.m. the Wound Care Physician said he was familiar with Resident #1. The Wound Care Physician said Resident #1 had lots of lymphedema (swelling, most often in an arm or leg, caused by lymphatic system blockage) in his right stump. The Wound Care Physician said the facility had not had a treatment nurse in months. The Wound Care Physician said it was not ideal for dressing changes that were ordered daily not to be performed. The Wound Care Physician said it was not out of the realm for a dressing change ordered daily and not being performed daily to lead to infection. The Wound Care Physician said he was not informed of redness or increased redness to Resident #1's abdomen but the facility may have informed his primary care physician. The Wound Care Physician said wound treatments in his notes were recommendations. The Wound Care Physician said he saw residents at the facility weekly. The Wound Care Physician said he could not say if lymphedema treatment recommendation not being performed would lead to worsening lymphedema or infection. During an interview on 4/2/24 at 10:21 a.m. the Nurse Practitioner said she was familiar with Resident #1. The Nurse Practitioner said she had not had any reports from the facility regarding Resident #1 having redness or increased redness to his abdomen. The Nurse Practitioner said most facilities notify them of changes in skin conditions or treatment orders, but this facility did not. The Nurse Practitioner said communication from this facility was lacking. The Nurse Practitioner said wound care treatments not performed as ordered could possibly lead to infection, but the surveyor would need to refer to the Wound Care Doctor. During an interview on 4/2/24 at 12:23 p.m. LVN B said charge nurses were responsible for wound care and skin assessments at this time. LVN B said the last training she had received at the facility regarding skin assessments, wound documentation, or wound care policies was a couple of months ago. LVN B said the TAR indicated whether wound care had been performed. LVN B said if it was not charted in the TAR wound care was performed you could look at the date on the dressing. LVN B said if it was further back than one day and was not charted in the TAR wound care was performed it could not be proved it was performed. LVN B said skin assessment should be completed weekly. Record review of the facility's Documentation of Wound Treatments policy dated 7/2022 indicated, The facility completes accurate documentation of the wound assessments and treatments, including response to treatments, change in condition, and changes in treatment. Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates .Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift. Additional documentation shall include but is not limited to .e. Notification to physician and/or responsible party regarding wound or treatment changes. The Administrator was notified on 4/2/24 at 2:48 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 4/2/24 at 2:56 p.m. The facility's Plan of Removal was accepted on 4/3/24 at 9:40 a.m. and included: Plan of Removal 1. Immediate actions The Medical Director and Resident #1's Primary Care Physician were notified by the Assistant Director of Nursing on 04/02/2024. A full skin sweep was completed on all residents on 03/27-28/2024 by the Assistant Director of Nursing and the Director of Nursing. All residents admitted or readmitted from 03/27/2024 forward were reviewed to ensure for head-to-toe skin and wound assessments were completed appropriately. Any admitted or readmitted residents from 03/27/2024 forward that were identified to not have skin assessments were assessed immediately on 04/02/2024. An omissions report was pulled from 03/27/2024 forward and all omissions were addressed by the Director of Nursing. This was completed on 04/02/2024 and all staff were trained on how to pull the omissions report and directed to check it daily prior to the end of their shift to ensure no treatments are missed going forward. The omissions report identified staff who had not completed their treatments as ordered. Resident #1 was immediately provided a head-to-toe skin assessment by the Director of Nursing and treatment was provided according to the Physician's orders for all areas on 04/02/2024. 2. Education (provided by DON, ADON or Designee) The Regional Director of Clinical Services in-serviced the Director of Nursing and Assistant Director of Nursing on all of the below in-services on 04/02/2024. All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on appropriately completing skin assessments and notifying the Physician of all newly identified skin issues in a timely manner on 04/02/2024. Each nurse will be in-serviced prior to returning to shift. This will be completed by 04/03/2024 and nurses will not return to shift without the in-service. The Director of Nursing and Assistant Director of Nursing are responsible for ensuring each nurse completes their skin assessments. All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on Policy and Procedure for Pressure Injury Prevention and Skin and Wound Care Management on 04/02/2024. This in-service will be completed by 04/03/2024 and nurses will not return to shift without the in-service. This in-service includes appropriately completing skin assessments, information on pressure and injury prevention, treatment for non-pressure injuries, the importance of wound care management and following the treatment orders. All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on pulling an omission's report prior to the end of each shift and correcting any absence of documentation on 04/02/2024. The Omission report would show any order on the TAR that was not completed during the scheduled shift. This in-service will be completed by 04/03/2024 and nurses will not return to shift without the in-service. All nurses were in-serviced by the Director of Nursing/Assistant Director of Nursing on pulling and signing all MARs and TARs prior to the end of their shift on 04/02/2024. This in-service will be completed by 04/03/2024 and nurses will not return to shift without the in-service. If a nurse is unable to complete an assessment or wound care during their shift, they will notify the Director of Nurses and Assistant Director of nurses prior to leaving their shift. The oncoming shift will be notified during report that an assessment or treatment was not completed. 3. Medical Director - The Medical Director has been notified of the Immediate Jeopardy. 4. QAPI Committee Review - An interim QAPI committee meeting was completed on 04/02/2024. 5. Plan of removal date: 04/02/2024 On 4/3/24 it was onfirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review on 4/3/24 of 3 of 3 new admissions or re-admission from 3/27/24 through 4/3/24 indicated all admissions had skin assessments performed and wound assessments performed if applicable. Record review of a random sample of 16 of 66 residents on 4/3/24 indicated all sampled residents had skin assessments performed between 3/27/24 and 4/2/24. Record review of the QAPI sign-in sheet indicated the facility had an ad-hoc QAPI meeting on 4/2/24 regarding wound treatments, skin and wound assessments, physician notification, and omission report. The QAPI sign-in sheet indicated all appropriate members of the IDT team were present for the QAPI meeting. During interviews with staff (LVN C, LVN D, LVN E, LVN B, and the ADON) on 4/3/24 between 11:00 a.m. and 12:19 p.m. staff were able to explain importance of ensuring TARs and MARs were signed off, how to pull an omission audit to check to make sure all TARs and MARs had been signed off and treatments had been completed, how often skin and wound assessments should be performed, the importance of reporting changes in skin conditions to the PCP or wound care doctor, and interventions to prevent pressure ulcers including offloading, turning and repositioning every 2 hours, pressure relieving cushions in a resident's wheelchair, and bathing to aide in circulation. On 4/3/24 at 12:21 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance the facility remained out of compliance with a scope identified as patterned and a severity of no actual harm with a potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 2 of 7 (Resident #1 and Resident #2) residents reviewed for abuse. The facility failed to protect Resident #1 and Resident #2 from verbal and physical abuse by CNA B. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 8/11/23 at 4:15 p.m. While the IJ was removed on 8/13/23, the facility remained out of compliance at no actual harm that is not immediate with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings Included: 1. Record review of the face sheet orders dated 8/08/23 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, abnormalities of gait and mobility, amputation of right and left leg below the knee, muscle weakness, lack of coordination, and anxiety. Record review of the MDS dated [DATE] indicated Resident # 1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility. The MDS did not indicate Resident #1 used limb prosthesis (artificial device that replaces a missing body part) for mobility. Record review of the care plan last updated 7/14/23 indicated Resident #1 had an ADL self-care deficit with interventions including resident requires 1 staff member to assist with transfers and resident requires 1-2 staff members to assist with bed mobility. Record review of CNA B's time sheets from 8/05/23 through 8/08/23 indicated she worked the following shifts/hours: 8/05/23-5:56 a.m. to 2:12 p.m. 8/06/23-6:01 a.m. to 2:05 p.m. 8/07/23-6:02 a.m. to 1:16 p.m. 8/08/23-5:50 a.m. to 12:36 p.m. During an interview on 8/08/23 at 11:17 a.m. RN A said she started at the facility in 2023. RN A said the weekend of August 4-6th she had witnessed abuse to Resident #1. RN A said CNA B had asked her to help get Resident #1 up about 7:00 a.m. RN A said Resident #1 was a double amputee and needed assistance with his prosthetics. RN A said Resident #1 could not hold his legs up at the same time as he was a large man. RN A said she got one prosthetic on and CNA B was trying to put on the other prosthetic and Resident #1 could not lift his leg. RN A said CNA B slapped the Resident #1's leg, cursed at him, and referred to him as an idiot. RN A said she asked CNA B to leave the room and she finished putting the other prosthetic on for Resident #1. RN A said she reported the incident to the DON and was informed to call the Administrator. RN A said she called the Administrator and left a message regarding the alleged abuse and had to leave him a message. RN A said she called the Administrator back on Monday and left another message. During an interview on 8/08/23 at 11:24 a.m. Resident #1 said there might have been an issue over assisting him with putting his prosthetic legs on over the weekend. Resident #1 said if someone had cussed him he would not have heard it because he chooses not to hear those words and said he does not know those type of words. Resident #1 said the surveyor would have to ask the staff about what happened and he was not saying anything. During an interview on 8/08/23 at 12:53 p.m. the DON said CNA B had been suspended on 8/08/23 pending investigation of abuse allegation. The DON said the abuse allegation was involving Resident #1 and happened over the weekend of August 4-6, 2023. The DON said she had been notified by RN A on 8/05/23 of the alleged abuse by CNA B to Resident #1. The DON said she advised RN A to contact the Administrator who was the Abuse Coordinator. During an interview on 8/08/23 at 12:54 p.m. the Administrator said CNA B had been suspended on 8/08/23 pending investigation of alleged abuse of Resident #1. The Administrator said he had spoken to RN A on 8/08/23 regarding the allegation of abuse. 2. Record review of the face sheet dated 8/11/23 indicated Resident #2 was a [AGE] year-old woman admitted to the facility on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), muscle weakness, lack of coordination, and glaucoma (an eye condition where the nerve connecting the eye to the brain is damaged, usually due to high eye pressure, and can cause blindness). Record review of the MDS dated [DATE] indicated Resident #2 usually understood others and was usually understood by others. The MDS indicated Resident #2 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Record review of the care plan dated 6/12/23 indicated Resident #2 had a potential for an activities of daily living self-care performance deficit. Record review of a grievance dated 7/13/23 indicated the Social Worker from Resident #2's dialysis center reported to the facility that Resident #2 informed the dialysis center that CNA B had cursed her and pulled her leg causing pain. The grievance indicated the facility's resolutions were to have Resident #2 be a two-person transfer, not have CNA B provide care to Resident #2, and refer to psych67 services to ensure she is psychosocially and emotionally stable. During an interview on 8/11/23 at 3:06 p.m. the DON said CNA B did not get immediately suspended following the allegation of abuse against Resident #1. The DON said she instructed RN A to get CNA B out of Resident #1's room and CNA B was not to provide care for Resident #1. The DON said CNA B worked the rest of her shift on 8/05/23 and her scheduled shifts 8/06/23, 8/07/23, and 8/08/23 until suspension on 8/08/23. The DON said she worked the floor on 8/06/23 and CNA B did not interact with Resident #1. The DON said she did not follow up with the Administrator regarding the allegation of abuse because RN A said she had left a message for the Administrator and since she never heard back from RN A she assumed RN A had spoken with the Administrator. The DON said she was aware of the allegation of abuse made by the dialysis center's Social Work against CNA B. The DON said CNA B was working the date of 7/13/23 and completed her entire shift. The DON said since Resident #2 was at dialysis CNA B was not a threat to her pending investigation. The DON said CNA B's shift had ended and she was not at the facility when Resident #2 returned from dialysis. The DON said CNA B was permitted to return to work the next day (7/14/23) as it was determined no abuse occurred during the investigation. During an interview on 8/11/23 at 3:17 p.m. Resident #2 said the incident on 7/13/23 had been taken care of by the facility. Resident #2 said CNA B no longer provided care for her. Resident #2 said she needed assistance with sitting up and transferring. Resident #2 said CNA B would drop her legs and let them fall to the floor via gravity and not provide her support for sitting upright when transferring her. Resident #2 said CNA B called her a heifer. During an interview on 8/11/23 at 3:26 p.m. the Administrator said he did not return RN A's phone call on 8/05/23 because he was out of town. The Administrator said he did not see the message from RN A until Monday, 8/07/23. The Administrator said he returned RN A's phone call on Tuesday, 8/08/23. The Administrator said he would have expected the DON to suspend CNA B pending investigation after the allegation of abuse on 8/05/23. The Administrator said the grievance filed on 7/13/23 regarding CNA B and Resident #2 would be considered an allegation of abuse. The Administrator said Resident #2 was interviewed upon her return to the facility from dialysis and Resident #2 relayed a different story than what the Dialysis Social Worker reported. The Administrator said CNA B was not suspended following the allegation of abuse on 7/13/23 and the allegation was not reported to the state agency. Record review of the facility's Abuse, Neglect, and Exploitation policy dated 2023 indicated, It is the policy of this facility to provide protection for the health, welfare, and right of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish, which can include staff to resident and certain resident to resident altercations .The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of resident and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations .The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written . The Administrator was notified on 8/11/23 at 5:10 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 8/11/23 at 5:13 p.m. The facility's Plan of Removal was accepted on 8/13/23 at 1:35 p.m. and included: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. RDCO in-serviced Administrator, Director of Nurses, and ADON on Abuse Policy and Implementation of Abuse Policy, as well as addendum related to reporting in the absence of the abuse coordinator. Emphasized the fact, when an allegation of abuse has been made, the alleged perpetrator is to be immediately suspended and must leave the facility until the investigation has been completed by the abuse coordinator. (Completion Date: 08/11/23) 2. Safe Surveys were completed on residents to identify any evidence of abuse or neglect. Concerns were not identified. Resident #1 and Resident #2 were interviewed by the DON, safe survey completed to ensure no psychological harm was done. No psychological harm was done, per resident #1 and resident #2 (completed 8/12/23). RN A assessed resident #1 on 08/12/23. Wound Care Nurse assessed resident #2 head to toe to ensure no physical harm was done. 08/11/23. 3. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 08/11/23) Disciplinary action was taken with staff member accused of abuse (staff member was terminated following investigation 08/08/23). (Statement received from witness RN who was in the room with C NA B Same alleged perpetrator for incident on 08/08/23 and abuse allegation from resident #2 on 07/13/23.C NA B was terminated by the administrator on 8/8/23). Alleged abuse was reported to DHHS on 08/08/2023. Administrator reported alleged abuse of resident #2 to HHSC on 08/12/23. Residents were interviewed/assessed by Administrator, DON, ADON to identify if they felt safe and if they had experienced abuse while living at the facility. Concerns were not identified. (08/11/23). Abuse policies were reviewed and additional in service was added for Administrator, Social Worker, ADON, to include: if abuse coordinator is not available, the DON will notify the RDCO for reporting allegations of abuse to HHSC. RDCO completed this in-service (08/11/23). Admin, DON, and designees educated all staff on facility abuse policies. Education included the facility abuse policy with emphasis on staff to stay with resident until alleged perpetrator is removed from facility pending investigation. Staff are not to wait for abuse coordinator to direct them to remove the alleged perpetrator, the staff member is to ask the alleged perpetrator to leave facility immediately. Completed 08/12/23. DON and designees educated all staff on abuse prevention and reporting. Education included the facility abuse policy with emphasis on staff to stay with resident until alleged perpetrator is removed from facility pending investigation. Staff are not to wait for abuse coordinator to direct them to remove the alleged perpetrator, the staff member is to ask the alleged perpetrator to leave facility immediately. Completed 08/12/23. Staff members were not permitted to work a shift until education had been completed. The regional/corporate consultant team members will visit the facility (at least weekly) to provide oversight, audits, and additional training as needed (08/11/2023). The DON will review 5 random residents monthly X3 months to ensure no further allegations of abuse. The Administrator or designee will continue to interview residents on a monthly basis to ensure they have not experienced abuse. The findings of these interviews will be presented to the QAA Committee. In-service given to DON, social worker and Administrator, to all review all grievances in am meeting to ensure no alleged abuse was reported. In-service conducted by RDCO on 08/12/23. On 8/13/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews with staff on 8/13/23 between 5:21 p.m. and 7:22 p.m. (CNA C, RN D, CNA E, Dietary Aide F, [NAME] G, Hospitality Aide H, Housekeeper J, RN A, LVN K, CNA L, Housekeeping Supervisor M, DON ,CNA O, Social Worker, and the Administrator) were performed. During the interviews staff were able to identify policies and procedures of the facility's Abuse and Neglect policy including reporting to the Abuse Coordinator, protecting the residents, and having alleged perpetrators leave the facility pending investigation. The Administrator, DON, and Social Worker were able to identify proper time frames in reporting allegations of abuse to the state agency and investigation protocols for allegations of abuse. Record review of skin assessment for Resident #1 and Resident #2 completed with no skin issue documented. Interview with Resident #1 and Resident #2 on 8/13/23 between 7:08 p.m. and 7:12 p.m. were performed. Resident #1 and Resident #2 both said they had no complaints or issues at this time. On 8/13/23 at 7:35 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm that is not immediate with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement written policies to prevent abuse, neglect, and exploitation for 2 of 7 (Resident #1 and Resident #2) residents reviewed for abuse. The facility did not follow facility policy by suspending or removing the CNA B from the premises after allegations of abuse were made. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 8/11/23 at 4:15 p.m. While the IJ was removed on 8/13/23, the facility remained out of compliance at no actual harm that is not immediate with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the resident at risk for unreported allegations of abuse, neglect, and injuries of unknown origin, and further abuse by the alleged perpetrator. Findings included: 1. Record review of the facility's Abuse Investigation and Reporting policy dated 7/2022 indicated, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation .D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. E. Protection from retaliation .Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies within specific time frames: a. Immediately, but no later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or result in seriously bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in seriously bodily injury. Record review of the face sheet orders dated 8/08/23 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, abnormalities of gait and mobility, amputation of right and left leg below the knee, muscle weakness, lack of coordination, and anxiety. Record review of the MDS assessment dated [DATE] indicated Resident # 1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility. The MDS did not indicate Resident #1 used limb prosthesis (artificial device that replaces a missing body part) for mobility. Record review of the care plan last updated 7/14/23 indicated Resident #1 had an ADL self-care deficit with interventions including resident requires 1 staff member to assist with transfers and resident requires 1-2 staff members to assist with bed mobility. Record review of CNA B's time sheets from 8/05/23 through 8/08/23 indicated she worked the following shifts/hours: 8/05/23-5:56 a.m. to 2:12 p.m. 8/06/23-6:01 a.m. to 2:05 p.m. 8/07/23-6:02 a.m. to 1:16 p.m. 8/08/23-5:50 a.m. to 12:36 p.m. Record review in TULIP on 8/08/23 indicated there was not a facility report regarding abuse for Resident #1. During an interview on 8/08/23 at 11:17 a.m. RN A said she started at the facility in 2023. RN A said the weekend of August 4-6th she had witnessed abuse to Resident #1. RN A said CNA B had asked her to help get Resident #1 up about 7:00 a.m. RN A said Resident #1 was a double amputee and needed assistance with his prosthetics. RN A said Resident #1 could not hold his legs up at the same time as he was a large man. RN A said she got one prosthetic on and CNA B was trying to put on the other prosthetic and Resident #1 could not lift his leg. RN A said CNA B slapped the Resident #1's leg, cursed at him, and referred to him as an idiot. RN A said she asked CNA B to leave the room and she finished putting the other prosthetic on for Resident #1. RN A said she reported the incident to the DON and was informed to call the Administrator. RN A said she called the Administrator and left a message regarding the alleged abuse and had to leave him a message. RN A said she called the Administrator back on Monday and left another message. During an interview on 8/08/23 at 11:24 a.m. Resident #1 said there might have been an issue over assisting him with putting his prosthetic legs on over the weekend. Resident #1 said if someone had cussed him he would not have heard it because he chooses not to hear those words and said he does not know those type of words. Resident #1 said the surveyor would have to ask the staff about what happened and he was not saying anything. During an interview on 8/08/23 at 12:53 p.m. the DON said CNA B had been suspended on 8/08/23 pending investigation of abuse allegation. The DON said the abuse allegation was involving Resident #1 and happened over the weekend of August 4-6, 2023. The DON said she had been notified by RN A on 8/05/23 of the alleged abuse by CNA B to Resident #1. The DON said she advised RN A to contact the Administrator who was the Abuse Coordinator. The DON said she never told the Administrator of the alleged abuse because she was under the impression RN A had reported to him. During an interview on 8/08/23 at 12:54 p.m. the Administrator said CNA B had been suspended on 8/08/23 pending investigation of alleged abuse of Resident #1. The Administrator said he had spoken to RN A on 8/08/23 regarding the allegation of abuse. The Administrator said RN A had called and left him messages stating she need to speak with him. The Administrator said he was not aware she needed to speak with him regarding an abuse allegation. During an interview on 8/11/23 at 1:18 p.m. RN A said when the incident occurred on 8/05/23 with Resident #1 and CNA B she asked CNA B to leave the room but did not ask CNA B to leave the premises. RN A said she contacted the DON, reported what had happened, and asked if she needed to document anything or do anything else. RN A said the DON told her not to do anything else or document anything but to call the Administrator who was the Abuse Coordinator to report the incident. RN A said CNA B worked the rest of her shift on 8/05/23. Record review on 8/11/23 in TULIP indicated the allegation of abuse of Resident #1 by CNA B had not been reported to the state agency by the facility. 2. Record review of the face sheet dated 8/11/23 indicated Resident #2 was a [AGE] year-old woman admitted to the facility on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), muscle weakness, lack of coordination, and glaucoma (an eye condition where the nerve connecting the eye to the brain is damaged, usually due to high eye pressure, and can cause blindness) Record review of the MDS dated [DATE] indicated Resident #2 usually understood others and was usually understood by others. The MDS indicated Resident #2 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Record review of the care plan dated 6/12/23 indicated Resident #2 had a potential for an activities of daily living self-care performance deficit. Record review of a grievance dated 7/13/23 indicated the Social Worker from Resident #2's dialysis center reported to the facility that Resident #2 informed the dialysis center that CNA B had cursed her and pulled her leg causing pain. The grievance indicated the facility's resolutions were to have Resident #2 be a two-person transfer, not have CNA B provide care to Resident #2, and refer to psych services to ensure she is psychosocially and emotionally stable. During an interview on 8/11/23 at 3:06 p.m. the DON said CNA B did not get immediately suspended following the allegation of abuse against Resident #1. The DON said she instructed RN A to get CNA B out of Resident #1's room and CNA B was not to provide care for Resident #1. The DON said CNA B worked the rest of her shift on 8/05/23 and her scheduled shifts 8/06/23, 8/07/23, and 8/08/23 until suspension on 8/08/23. The DON said she worked the floor on 8/06/23 and CNA B did not interact with Resident #1. The DON said she did not follow up with the Administrator regarding the allegation of abuse because RN A said she had left a message for the Administrator and since she never heard back from RN A she assumed RN A had spoken with the Administrator. The DON said she was aware of the allegation of abuse made by the dialysis center's Social Work against CNA B. The DON said CNA B was working the date of 7/13/23 and completed her entire shift. The DON said since Resident #2 was at dialysis CNA B was not a threat to her pending investigation. The DON said CNA B's shift had ended and she was not at the facility when Resident #2 returned from dialysis. The DON said CNA B was permitted to return to work the next day (7/14/23) as it was determined no abuse occurred during the investigation. During an interview on 8/11/23 at 3:17 p.m. Resident #2 said the incident on 7/13/23 had been taken care of by the facility. Resident #2 said CNA B no longer provided care for her. Resident #2 said she needed assistance with sitting up and transferring. Resident #2 said CNA B would drop her legs and let them fall to the floor via gravity and not provide her support for sitting upright when transferring her. Resident #2 said CNA B called her a heifer. During an interview on 8/11/23 at 3:26 p.m. the Administrator said he did not return RN A's phone call on 8/05/23 because he was out of town. The Administrator said he did not see the message from RN A until Monday, 8/07/23. The Administrator said he returned RN A's phone call on Tuesday, 8/08/23. The Administrator said he would have expected the DON to suspend CNA B pending investigation after the allegation of abuse on 8/05/23. The Administrator said the grievance filed on 7/13/23 regarding CNA B and Resident #2 would be considered an allegation of abuse. The Administrator said Resident #2 was interviewed upon her return to the facility from dialysis and Resident #2 relayed a different story than what the Dialysis Social Worker reported. The Administrator said CNA B was not suspended following the allegation of abuse on 7/13/23 and the allegation was not reported to the state agency. The Administrator was notified on 8/11/23 at 5:10 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 8/11/23 at 5:13 p.m. The facility's Plan of Removal was accepted on 8/13/23 at 1:35 p.m. and included: 1. Immediate action(s) taken for the resident(s) found to have been affected include: A thorough investigation was conducted by the facility Administrator regarding the allegations made by resident #1 and Resident #2. CNA B was terminated upon investigation on 08/08/23. Staffing patterns were adjusted to assure the protection of the resident. The director of nursing assessed resident #1 and resident #2 2. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: An in-service education program was conducted by the RDCO, for Director of Nursing Services and the Administrator with all direct care and ancillary staff addressing the facility policies and procedures regarding alleged violations (8/12/23). The RDCO in-serviced the Administrator, DON, ADON, and social worker (8/11/23). This included the facility abuse policy, the timeframe for reporting abuse is within 2 hours of the time the abuse coordinator was made aware of the abuse allegation. The abuse coordinator, or RDCO in the absence of the abuse coordinator will begin the investigation immediately. This includes, Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation The results of the investigation must be reported within 5 days of alleged abuse allegation to DHHS. This was completed 08/12/23. The abuse policy was not revised, a separate in-service for the Administrator and Social Worker included the importance of reporting timely, and notification of RDCO if abuse coordinator was going to be unavailable, (8/11/23). No staff will be allowed to work until their training is completed. The abuse policy states that the alleged perpetrator should be immediately removed from the facility pending investigation, by a staff member. This was emphasized during the in-service (8/11/23). 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any alleged violations are identified, properly investigated and reported according to facility policy and procedures. Findings of this audit will be discussed weekly with the abuse coordinator. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. Corrective action completion date: 08/11/2023. On 8/13/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews with staff on 8/13/23 between 5:21 p.m. and 7:22 p.m. (CNA C, RN D, CNA E, Dietary Aide F, [NAME] G, Hospitality Aide H, Housekeeper J, RN A, LVN K, CNA L, Housekeeping Supervisor M, DON ,CNA O, Social Worker, and the Administrator) were performed. During the interviews staff were able to identify policies and procedures of the facility's Abuse and Neglect policy including reporting to the Abuse Coordinator, protecting the residents, and having alleged perpetrators leave the facility pending investigation. The Administrator, DON, and Social Worker were able to identify proper time frames in reporting allegations of abuse to the state agency and investigation protocols for allegations of abuse. On 8/13/23 at 7:35 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm that is not immediate with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to investigate allegations of abuse and prevent further potential abuse for 2 of 7 (Resident #1 and Resident #2) reviewed for abuse investigations. The facility failed to investigate allegation of physical and verbal abuse to Resident #1 and Resident #2 from CNA B. The facility failed to remove the alleged perpetrator (CNA B) from the facility to protect the residents from abuse. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 8/11/23 at 4:15 p.m. While the IJ was removed on 8/13/23, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could result in residents experience serious harm, impairment, or death due to facility failure of thoroughly investigating abuse allegations and protecting residents from alleged perpetrators. Findings Included: 1. Record review of the face sheet orders dated 8/08/23 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including dementia, abnormalities of gait and mobility, amputation of right and left leg below the knee, muscle weakness, lack of coordination, and anxiety. Record review of the MDS dated [DATE] indicated Resident # 1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 12 and was moderately cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility. The MDS did not indicate Resident #1 used limb prosthesis (artificial device that replaces a missing body part) for mobility. Record review of the care plan last updated 7/14/23 indicated Resident #1 had an ADL self-care deficit with interventions including resident requires 1 staff member to assist with transfers and resident requires 1-2 staff members to assist with bed mobility. Record review of CNA B's time sheets from 8/05/23 through 8/08/23 indicated she worked the following shifts/hours: 8/05/23-5:56 a.m. to 2:12 p.m. 8/06/23-6:01 a.m. to 2:05 p.m. 8/07/23-6:02 a.m. to 1:16 p.m. 8/08/23-5:50 a.m. to 12:36 p.m. During an interview on 8/08/23 at 11:17 a.m. RN A said she started at the facility in 2023. RN A said the weekend of August 4-6th she had witnessed abuse to Resident #1. RN A said CNA B had asked her to help get Resident #1 up about 7:00 a.m. RN A said Resident #1 was a double amputee and needed assistance with his prosthetics. RN A said Resident #1 could not hold his legs up at the same time as he was a large man. RN A said she got one prosthetic on and CNA B was trying to put on the other prosthetic and Resident #1 could not lift his leg. RN A said CNA B slapped the Resident #1's leg, cursed at him, and referred to him as an idiot. RN A said she asked CNA B to leave the room and she finished putting the other prosthetic on for Resident #1. RN A said she reported the incident to the DON and was informed to call the Administrator. RN A said she called the Administrator and left a message regarding the alleged abuse and had to leave him a message. RN A said she called the Administrator back on Monday and left another message. During an interview on 8/08/23 at 11:24 a.m. Resident #1 said there might have been an issue over assisting him with putting his prosthetic legs on over the weekend. Resident #1 said if someone had cussed him he would not have heard it because he chooses not to hear those words and said he does not know those type of words. Resident #1 said the surveyor would have to ask the staff about what happened and he was not saying anything. During an interview on 8/08/23 at 12:53 p.m. the DON said CNA B had been suspended on 8/08/23 pending investigation of abuse allegation. The DON said the abuse allegation was involving Resident #1 and happened over the weekend of August 4-6, 2023. The DON said she had been notified by RN A on 8/05/23 of the alleged abuse by CNA B to Resident #1. DON said she advised RN A to contact the Administrator who was the Abuse Coordinator. The DON said she never told the Administrator of the alleged abuse because she was under the impression RN A had reported to him. During an interview on 8/08/23 at 12:54 p.m. the Administrator said CNA B had been suspended on 8/08/23 pending investigation of alleged abuse of Resident #1. The Administrator said he had spoken to RN A on 8/08/23 regarding the allegation of abuse. The Administrator said RN A had called and left him messages stating she need to speak with him. The Administrator said he was not aware she needed to speak with him regarding an abuse allegation. During an interview on 8/11/23 at 1:18 p.m. RN A said when the incident occurred on 8/05/23 with Resident #1 and CNA B she asked CNA B to leave the room but did not ask CNA B to leave the premises. RN A said she contacted the DON, reported what had happened, and asked if she needed to document anything or do anything else. RN A said the DON told her not to do anything else or document anything but to call the Administrator who was the Abuse Coordinator to report the incident. RN A said CNA B worked the rest of her shift on 8/05/23. 2. Record review of the face sheet dated 8/11/23 indicated Resident #2 was a [AGE] year-old woman admitted to the facility on [DATE] with diagnoses including end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis), muscle weakness, lack of coordination, and glaucoma (an eye condition where the nerve connecting the eye to the brain is damaged, usually due to high eye pressure, and can cause blindness) Record review of the MDS dated [DATE] indicated Resident #2 usually understood others and was usually understood by others. The MDS indicated Resident #2 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #2 required extensive assistance with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. Record review of the care plan dated 6/12/23 indicated Resident #2 had a potential for an activities of daily living self-care performance deficit. Record review of a grievance dated 7/13/23 indicated the Social Worker from Resident #2's dialysis center reported to the facility that Resident #2 informed the dialysis center that CNA B had cursed her and pulled her leg causing pain. The grievance indicated the facility's resolutions were to have Resident #2 be a two-person transfer, not have CNA B provide care to Resident #2, and refer to psychiatric services to ensure she is psychosocially and emotionally stable. During an interview on 8/11/23 at 3:06 p.m. the DON said CNA B did not get immediately suspended following the allegation of abuse against Resident #1. The DON said she instructed RN A to get CNA B out of Resident #1's room and CNA B was not to provide care for Resident #1. The DON said CNA B worked the rest of her shift on 8/05/23 and her scheduled shifts 8/06/23, 8/07/23, and 8/08/23 until suspension on 8/08/23. The DON said she worked the floor on 8/06/23 and CNA B did not interact with Resident #1. The DON said she did not follow up with the Administrator regarding the allegation of abuse because RN A said she had left a message for the Administrator and since she never heard back from RN A she assumed RN A had spoken with the Administrator. The DON said she was aware of the allegation of abuse made by the dialysis center's Social Work against CNA B. The DON said CNA B was working the date of 7/13/23 and completed her entire shift. The DON said since Resident #2 was at dialysis CNA B was not a threat to her pending investigation. The DON said CNA B's shift had ended and she was not at the facility when Resident #2 returned from dialysis. The DON said CNA B was permitted to return to work the next day (7/14/23) as it was determined no abuse occurred during the investigation. The DON said the investigation of Resident #2's allegation of abuse consisted of an interview with Resident #2 upon her return from dialysis. During an interview on 8/11/23 at 3:17 p.m. Resident #2 said the incident on 7/13/23 had been taken care of by the facility. Resident #2 said CNA B no longer provided care for her. Resident #2 said she needed assistance with sitting up and transferring. Resident #2 said CNA B would drop her legs and let them fall to the floor via gravity and not provide her support for sitting upright when transferring her. Resident #2 said CNA B called her a heifer. During an interview on 8/11/23 at 3:26 p.m. the Administrator said he did not return RN A's phone call on 8/05/23 because he was out of town. The Administrator said he did not see the message from RN A until Monday, 8/07/23. The Administrator said he returned RN A's phone call on Tuesday, 8/08/23. The Administrator said he would have expected the DON to suspend CNA B pending investigation after the allegation of abuse on 8/05/23. The Administrator said the grievance filed on 7/13/23 regarding CNA B and Resident #2 would be considered an allegation of abuse. The Administrator said Resident #2 was interviewed upon her return to the facility from dialysis and Resident #2 relayed a different story than what the Dialysis Social Worker reported. The Administrator said CNA B was not suspended following the allegation of abuse on 7/13/23. Record review of the facility's Abuse Investigation and Reporting policy dated 7/2022 indicated, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation .D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. E. Protection from retaliation .Reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies within specific time frames: a. Immediately, but no later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or result in seriously bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in seriously bodily injury. The Administrator was notified on 8/11/23 at 5:10 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 8/11/23 at 5:13 p.m. The facility's Plan of Removal was accepted on 8/13/23 at 1:35 p.m. and included: 5. Immediate action(s) taken for the resident(s) found to have been affected include: Resident #1 and resident #2 physician and the resident's responsible party were notified promptly upon completion of the assessment by the Director of Nursing/Facility Administrator 08/08/23. A thorough investigation was initiated by the facility Administrator on 08/08/23. Safe surveys for residents were completed to ensure that no other allegations of abuse were voiced by residents on 8/11/23. The facility administrator and director of nursing interviewed resident #1 and resident #2. Interview statements were documented (08/08/23). The director of nursing completed the safe survey assessments on resident #1 and resident #2. (08/11/23) Identification of other residents having the potential to be affected was accomplished by the facility administrator/abuse coordinator (8/12/23). The facility has determined that all residents have the potential to be affected. 6. Actions taken/systems put into place to reduce the risk of future occurrence include: An in-service education program was conducted by the Regional Director of Clinical Operations with the Administrator addressing circumstances that require reporting for timely investigations, and his responsibilities related to investigations. (08/11/23). The administrator was in-serviced regarding reporting any allegation of abuse within 2 hours of learning of the allegation. The entire abuse policy, emphasizing that the alleged perpetrator should be removed from the facility immediately pending investigation. The facility administrator was educated by the RDCO regarding procedures for investigating potential abuse including, identifying the alleged perpetrator based on resident and staff interviews. Obtaining written statements from all staff witnesses and within immediate vicinity of alleged victim, the alleged perpetrator, as well as the victim statement. Facility administrator was also educated on investigating differed types of alleged violations, focusing on the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause and providing thorough documentation of the investigation, per facility abuse policy on (8/11/23). When an allegation of abuse has been identified, a staff member will stay with the resident until the alleged perpetrator is escorted from the facility by another staff member, pending investigation. Staff were in-serviced on the facility abuse policy, emphasizing this procedure, by the RDCO, Administrator, DON, and ADON on 8/11/23. The facility social worker will be in-serviced by the Administrator/RDCO prior to returning to work, regarding his responsibility regarding reporting any allegations of abuse to the abuse coordinator immediately. The social worker receives grievances from outside the facility. The social worker was in-serviced by the RDCO on immediately reporting any allegation of abuse to the abuse coordinator immediately so it can be investigated by the Abuse Coordinator/Facility Administrator. Education completed by RDCO/Facility Administrator 08/12/23 7. How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing Services, or designee, will conduct a random audit of five (5) residents weekly for four (4) consecutive weeks. These residents will be assessed and interviewed to ensure that any injuries are identified, properly investigated, and reported to the appropriate people. Findings of this audit will be discussed with the IDT team. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. Corrective action completion date: 08/11/23. On 8/13/23 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Interviews with staff on 8/13/23 between 5:21 p.m. and 7:22 p.m. (CNA C, RN D, CNA E, Dietary Aide F, [NAME] G, Hospitality Aide H, Housekeeper J, RN A, LVN K, CNA L, Housekeeping Supervisor M, DON ,CNA O, Social Worker, and the Administrator) were performed. During the interviews staff were able to identify policies and procedures of the facility's Abuse and Neglect policy including reporting to the Abuse Coordinator, protecting the residents, and having alleged perpetrators leave the facility pending investigation. The Administrator, DON, and Social Worker were able to identify proper times frame in reporting allegations of abuse to the state agency and investigation protocols for allegations of abuse. Interview with Resident #1 and Resident #2 on 8/13/23 between 7:08 p.m. and 7:12 p.m. were performed. Resident #1 and Resident #2 both said they had no complaints or issues at this time. On 8/13/23 at 7:35 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 6 (Resident #1) residents reviewed for quality of care. 1. The facility failed to intervene when Resident #1, who was on anticoagulants, fell on [DATE] and hit her head resulting in a raised area to her head. Resident #1 experienced a change in condition which included vomiting and loss of consciousness. Resident #1 was not sent to the hospital until 34 hours after the fall when the change of condition occurred. Resident #1 was pronounced deceased on [DATE] at 10:43 p.m. 2. The facility failed to document Resident #1's neuro checks per facility policy timely and accurately. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 1:44 p.m While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm or death related to not receiving proper care or death following a fall with head injury while taking anticoagulation medication (blood thinners) or medications with similar traits. Findings Include: 1. Record review of Resident #1's face sheet, dated [DATE], indicated she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses including encephalopathy (temporary or permanent condition that affects the brain's structure or function causing an altered mental state and confusion), cerebral infarction (lack oxygen to the brain causing damage to brain tissue), and heart failure (heart muscle is unable to pump enough blood through the heart to meet the body's needs for blood and oxygen). Record review on [DATE] revealed there was no documentation of a MDS for Resident #1 in her file at this time. Record review on [DATE] revealed there was no documentation of a baseline or comprehensive care plan for Resident #1 in her file at this time. Record review of Resident #1's physician's orders dated [DATE] indicated Resident #1 had an order for Aspirin 81mg daily starting [DATE] for heart health and an order for Clopidogrel Bisulfate 75mg once a day starting [DATE] for stroke (lack oxygen to the brain causing damage to brain tissue) prevention. Record review of Resident #1's medication administration record for [DATE], indicated she was administered Aspirin 81mg and Clopidogrel Bisulfate 75mg on [DATE]. Record review of Resident #1's admission assessment dated [DATE], indicated she was admitted for a stroke and had short and long-term memory problems. She was alert and talkative. She was totally dependent and required two-person assistance with transfers and bed mobility. She had a fall in the past 30 days and was admitted to the hospital after being found on the floor. She had normal respirations with clear right and left lung sounds to both upper and lower lobes. Her skin was cool, dry, warm and had no skin lesions. There were no documented skin concerns. Record review of Resident #1's nursing progress notes dated [DATE] at 11:00 a.m. by the ADON, indicated she was admitted to the facility, alert, oriented to herself, and unable to walk. Record review of Resident #1's nursing progress notes dated [DATE] at 11:45 p.m. by LVN B, indicated she screamed and hollered out most of the 2:00 p.m.-10:00 p.m She took her clothes off and tried to get out of bed continuously. Fall mats were placed and her bed was put in the lowest position. She fell and climbed out of bed multiple times during the shift on to the floor/floor mats and rolled around on the floor. She fell out of bed at approximately 9:00 p.m. and hit her head. She had a large hematoma approximately 6cm x 5cm x 1.5cm to the left side of her head that was purple and red in color. Neuro checks were started. The physician was notified and ordered Ativan and to monitor her hematoma and neuro status. Record review of an Incident Report dated [DATE] at 11:55 p.m. by LVN B, indicated Resident #1 fell out of bed at approximately 9:00 p.m. and hit her head. She had a large hematoma approximately 6cm x 5cm x 1.5cm to the left side of her head that was purple and red in color. Neuro checks were started. The physician was notified and ordered Ativan and to monitor her hematoma and neuro status. The incident report indicated Resident #1 was oriented to person and her predisposing physiological factors included a gait imbalance, impaired memory and confused. There were no witnesses. Record review of Resident #1's Neurological Assessment Flow sheet dated [DATE] indicated neuro checks were initiated at 9:00 p.m. and she was scheduled to have neuro checks conducted every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 1 hour for 4 hours, every 4 hours for 24 hours, then every 8 hours for 32 hours until [DATE] at 4:00 p.m Documented neuro checks on 06/21 at 9:00 p.m., 9:15 p.m., 9:30 p.m., 9:45 p.m., 10:00 p.m., 10:30 p.m.,11:00 p.m., 11:30 p.m. and on 06/22 at 12:00 a.m., 1:00 a.m., 2:00 a.m., 3:00 a.m. indicated she was very drowsy, responded to touch stimuli and rambled when speaking. Documented neuro checks on 06/22 at 7:00 a.m. and 8:00 a.m. indicated she was awake, aware, oriented and her speech was clear. Resident #1's neuro check on 06/22 at 12:00 p.m. indicated there was no documented neuro check on her Neurological Assessment Flow sheet. Resident #1's neuro checks on 06/22 at 4:00 p.m. and 8:00 p.m. were documented on a sheet of paper, labeled Licensed Nurses Progress Notes, not on her Neurological Assessment Flow sheet and indicated she was lethargic, responded slowly to verbal stimuli and rambled when speaking. Documented neuro checks on 06/23 at 12:00 a.m. and 4:00 a.m. indicated she was awake, aware, oriented and rambled when speaking. Documented neuro checks on 06/23 at 8:00 a.m. and 4:00 p.m. indicated she was at the hospital. Record Review of an admission History and Physical dated [DATE] by Resident #1's Physician, indicated she was screaming without complaints and had denied having shortness of breath or pain. She was a poor historian and unable to give a history of personal information. She had a history of a stroke, methamphetamine abuse, chronic screaming and agitation. The physical exam indicated she had a left anterior temporal bruise with no protuberance. The assessment/plan indicated she had a history of a stroke and was taking Aspirin and Clopidogrel Bisulfate. Continue neurochecks and if worse then send to the emergency department. Record review of Resident #1's nursing progress notes dated [DATE] at 10:21 p.m. by LVN B, indicated she screamed, cried out and tried to get out of bed during the 2:00 p.m.-10:00 p.m. shift. Resident #1's physician was in the facility and assessed her. Her physician indicated the resident acted the same way in the hospital screaming and crying all day. Record review of Resident #1's nursing progress notes dated [DATE] at 7:00 a.m. by LVN C, indicated she was notified by a CNA the resident had brown secretion coming from her nose and mouth. During her assessment, the resident had inspiratory (breathing air in) and expiratory (breathing air out) crackles (popping sounds in the lungs produced by fluid, mucus, or pus) and was using her accessory muscles (muscles not typically used for breathing) to breath. She notified EMS and put oxygen on the resident. The resident had a blood pressure of 149/85 (Normal range is less than 120/80), heart rate of 145 (Normal range is 60 to 100 beats per minute), respirations of 26 (Normal range is 12-20 breaths per minute), and an oxygen level of 73% (Normal level is 95%-100%). EMS transferred the resident by stretcher. Record review of Resident #1's Hospital Records dated [DATE], indicated she was found unresponsive at the nursing on [DATE] and was transferred to the hospital. A CT scan revealed evidence she had a large left-sided subdural hemorrhage (blood accumulating under the skull) with intraventricular hemorrhage (bleeding inside or around the spaces in the brain that contain the cerebral spinal fluid). She was intubated (tube inserted into a patient's windpipe to help them breathe) emergency department and had fixed dilated pupils and no neurological (nervous system function) response. She was emergently taken by neurosurgery to the operating room for a left craniotomy (brain surgery that involves cutting a piece of the skull to access the brain) and evacuation of the subdural hematoma (blood accumulating under the skull). She was admitted to the intensive care unit (unit with specialized staff, equipment, and standards that handles severe, potentially life-threatening cases) after surgery. Resident #1's family was informed of her poor prognosis on [DATE], they expressed comfort care (care focused on the quality of the last days of life). Resident #1 was extubated (breathing tube taken out a patient's windpipe) on [DATE], after her family was informed of her poor prognosis and they expressed comfort care measures (care focused on the quality of the last days of life). Resident #1 was pronounced deceased on [DATE] at 10:43 p.m. During an observation on [DATE] at 6:05 p.m., Resident #1 was in a room on the ICU at the hospital. Resident #1 was lying in bed with her eyes closed unresponsive and had a white bandage wrapped around the top of her head. Resident #1 was connected to a ventilator (machine that helps you breathe). During an interview on [DATE] at 6:09 p.m., RN A said she was Resident #1's nurse in the ICU. RN A said Resident #1 was admitted to the hospital because she had bleeding in her brain. RN A said Resident #1 had brain surgery to stop the bleeding and to reduce the swelling to her brain caused by the blood collected around it. RN A said the doctor told Resident #1's family that she would not show any improvement because she had too much trauma to her brain. RN A said Resident #1's family had decided to take her off the ventilator tomorrow. During an interview on [DATE] at 2:14 p.m., LVN B said she worked the 2:00 p.m.-10:00 p.m. shift and was the charge nurse for Resident #1 when she fell on [DATE]. LVN B said a CNA notified her Resident #1 was on the floor. LVN B said she went to Resident #1's room immediately and found her lying on the floor next to her bed. LVN B said Resident #1's head was at the end of the bed with her feet facing toward the head of the bed. LVN B said Resident #1 had a dark purple and blue hematoma to the left side of her forehead near her temple and she initiated neuro checks on her. LVN B said neuro checks are scheduled checks over 72 hours consisting of checking a residents level of consciousness, blood pressure, arm and leg movements, and pupil size and reaction. LVN B said all scheduled neuro checks should be completed and documented on neuro check flow sheet in order to monitor the checks for any changes with the resident and notify the physician when there is a change. LVN B said Resident #1's initial neuro check was normal. LVN B said she notified Resident #1's physician immediately when she left her room and informed him of her fall, hematoma and neuro check findings. LVN B said Resident #1's physician ordered anxiety medication and told her to continue neuro checks and monitor her for any changes. LVN B said the fall protocol was to assess the resident, initiate neuro checks, notify the physician, initiate physician orders, and use good nursing judgement sending a resident to the hospital. LVN B said on [DATE] she worked the 2:00 p.m.-10:00 p.m., Resident #1's physician assessed her. LVN B said Resident #1's Physician said he was not concerned because she had no change in her level of consciousness and her hematoma was smaller. LVN B said she worked the 6:00 a.m.-2:00 p.m. shift on [DATE] when Resident #1 had a change in her level of consciousness and was sent to the hospital. LVN B said the facility implemented a new Head Injury policy a day or two after Resident #1 was sent to the hospital. LVN B said she was in-serviced on witnessed or unwitnessed resident falls with head injuries and sending them to the hospital for a CT scan including residents who were on anticoagulants/antiplatelets. LVN B said they did not have a policy on falls with head injuries before Resident #1 fell. During an interview with on [DATE] at 8:49 a.m., Resident #1's Physician said LVN B notified him on [DATE] that Resident #1 fell and that she had a hematoma about the size of a goose egg. The Physician said he ordered Resident #1 anxiety medication and told LVN B to continue neuro checks and monitor her for any changes. The Physician said he did not give an order to send Resident #1 to the hospital for a CT scan because he knew her medical and behavioral history prior to being admitted to the facility and there were no level of consciousness changes reported by LVN B or when he assessed her the day after the fall. The Physician said Resident #1 was on Aspirin and Clopidogrel Bisulfate which are antiplatelet medications with a lower risk for bleeding. The Physician said if Resident #1 was on an anticoagulant medication with a higher risk for bleeding, such as coumadin (blood thinner medication) or Eliquis (blood thinner medication), he would have sent her to the hospital immediately. The Physician said a resident who has a fall with a head injury and is on an anticoagulant medication is at risk of injury or death from a brain bleed. During an interview on [DATE] at 9:23 a.m., the DON said LVN B worked the 2:00 p.m.-10:00 p.m. shift on [DATE] when Resident #1 had an unwitnessed fall. The DON said LVN B assessed Resident #1, initiated neuro checks and notified the physician. The DON said if a resident has an unwitnessed fall the charge nurse was responsible to assess the resident, initiate neuro checks, and notify the physician of the fall and any injuries as a result of the fall. The DON said on [DATE] Resident #1 had a change in her conditions and she was sent to the hospital. The DON said neuro checks are scheduled checks over 72 hours consisting of checking a residents level of consciousness, blood pressure, arm and leg movements, and pupil size and reaction. The DON said on [DATE] Resident #1 had a change in her conditions and she was sent to the hospital. The DON said the facility implemented a new fall policy on [DATE]. The DON said the Head Injury policy addressed witnessed or unwitnessed falls with head injuries that included residents taking anticoagulant/antiplatelet medications. The DON said if a resident has a fall and was taking an anticoagulant/antiplatelet medication the resident was sent to the hospital for a CT scan. The DON said the fall policy did not address falls with head injuries until after Resident #1 was sent to the hospital. The DON said a resident who has a fall with a head injury and is on an anticoagulant/antiplatelet medication is at risk of injury or death from a brain bleed. The DON said on [DATE] at 12:00 p.m. there was no documented neuro check for Resident #1. The DON said all scheduled neuro checks should be completed and documented on the resident's neuro check flow sheet in order to monitor the checks for any changes in the resident and any changes in the resident should be reported to the physician. Record review of the facility's Falls-Evaluation and Prevention policy dated 04/2022 indicated, Following a fall, the following steps should be taken .If there was a loss of conscious or the fall was unwitnessed, neuro signs should be initiated and checked for at least 72 hours .Notify the physician and responsible party. Document the physician orders and/or response from the physician and responsible party. The policy did not address falls with head injuries when a resident is on anticoagulant (blood thinner) or antiplatelet (prevents blood cells from sticking together and form a blood clot) medications. Record review of the facility's Head Injury policy implemented [DATE] indicated, It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury .2. Call 911/EMS and attempt to stabilize the resident's condition if respiratory distress or a hemorrhaging wound occurs .4. Notify physician and follow orders for care .c. Report any recent medication changes or use of antiplatelet/anticoagulant medications. Record review on [DATE] of https://premierneurologycenter.com/blog/blood-thinners-head-injuries-what-you-need-to-know/ indicated, .If you are taking an older blood thinner such as warfarin, clopidogrel, or you are taking aspirin in addition to a blood thinners, it is especially important to seek medical attention right away if you experience a head injury since the risk of delayed hemorrhage is higher in patients taking these medications. A CT scan will be performed to assess the extent of the injury . If you are taking a blood thinner, it is important to be aware of the risk associated with head injuries. If you experience a bump, blow, or jolt to the head, it is important to seek medical attention right away. Even if you do not feel any symptoms after the injury, it is still important to be evaluated by a doctor. If you are taking an older blood thinner such as .aspirin in addition to a blood thinner, it is especially important to seek medical attention right away if you experience a head injury since the risk of delayed hemorrhage is higher in patients taking these medications. The Administrator was notified on [DATE] at 1:38 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on [DATE] at 1:44 p.m. The facility's Plan of Removal was accepted on [DATE] at 5:20 p.m. and included: Approaches: The RDCO and DON will deliver in service education to nurses one on one. 1. All nurses will be educated on fall policy. All nurses on staff at this time besides one that is out of state on vacation, see #7. This policy includes head injuries, but not specific to head injuries with anticoagulants/antiplatelets, this was the point when we included the head injury policy. See #2. Completed [DATE] 2. Nurses will be in serviced on head injury policy. This policy is to be an addition to the fall policy. This policy includes instructions on sending residents who are on anticoagulant medications, and have a fall with head injury or unwitnessed fall, to the ER for CT. All nurses have completed this in service, with the exception of the one that is on vacation, when she returns, before she goes on the floor, she will be in serviced. We did speak with her and let her know. Completed [DATE] 3. Facility medical director will be informed of IJ being called. The RDCO notified the medical director. Completed [DATE]. 4. Nurses will be in serviced on properly completing neuro checks on approved form when a fall with head injury, or unwitnessed fall occurs. Documented on correct form, in completion, prior to the end of the nurse shift. The neuro check sheet is to be completed as the neuros are due. There should not be any blank areas. To be verified by the end of their shift. The RDCO/DON in serviced the nurses. Completed [DATE]. 5. Blank neuro check form to be distributed to nurse's stations with instructions on how to complete. The RDCO printed neuro sheets and provided to nurse's stations. Completed [DATE] 6. Any fall with head injury or unwitnessed fall that occurs with a resident who receives anticoagulant medications will be sent to the ER for CT scan. Education completed [DATE]. Nurses were in serviced that if neuros are abnormal for any reason, they are to call the provider for orders to send to ER. The RDCO/DON provided the in service. All nurses have completed this in service, with the exception of the one that is on vacation, when she returns, before she goes on the floor, she will be in serviced. We did speak with her and let her know. All residents who have had a fall with head injury or unwitnessed falls will be sent to ER immediately for CT if the resident is on an anticoagulant/antiplatelet medication. This will be added to the DON/ADON in service. Completed by RDCO [DATE]. 7. The nurse that is out of town on vacation will receive the in service one on one prior to beginning her shift. She has been called on the phone and informed of this. She verbalized understanding. We did all of these in services one on one. Monitoring: Upon hire, annually and as needed. Will review for compliance monthly in QAPI X3 months. The DON/designee will monitor falls daily in the am clinical meeting. Nurses call the DON with every fall. The DON has been in serviced to ask the question, is the resident on anticoagulant/antiplatelet medications, and if so, the DON will instruct the nurse to send the resident out to ER for CT if anticoagulant/antiplatelet medications are in use. The DON or designee will review falls in a.m. clinical meeting. Neuros following a fall will be reviewed daily as well for the entire 72 hours post fall, also daily in the clinical meeting, by the DON/Designee to validate completion. All falls from the last 30 days were reviewed by the RDCO to ensure neuro checks were completed and no delay of treatment occurred. The policy for head injuries states any change in neuro checks will warrant a call to the provider for further orders, including but not limited to, transfer to ER for CT. Placed note on EMR Dashboard on nurse's home screen, Nurses: You MUST notify the DON of all falls. If a fall is unwitnessed, or a resident has a head injury related to a fall, YOU MUST START NEUROS!! If the resident is on an anticoagulant/antiplatelet medication, you MUST SEND THEM TO THE ER FOR A CT SCAN. Notify provider that this is our policy. Any abnormality in neuros, SEND THEM TO THE ER On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verifying the Medical Director had been informed of the Immediate Jeopardy from a printed copy of a text message communication between the RDCO and the Medical Director. Interviews with 10 Licensed Nurses (on all shifts 6 a.m.- 2 p.m., 2 p.m.-10 p.m., 10 p.m.- 6 a.m. and Weekend Double) were performed on [DATE]. All licensed nurses were able to correctly identify falls, witnessed or unwitnessed falls with head injuries including residents who were on anticoagulants/antiplatelets and sending them to the hospital for a CT scan, properly completing neuro checks during and end of their shift to verify all checks were documented, calling the physician of abnormal neuro checks and for orders to send to the hospital. During an interview on [DATE] at 5:31 p.m., the DON said she in-serviced the nursing staff on the Head Injury policy. The DON said she the charges nurse are to call her with every fall and ask them if the resident is on anticoagulant/antiplatelet medications, and if they are, I will instruct nurse to send the resident out to ER for CT. The DON said she will review any falls in a.m. clinical meeting and review the neuro checks daily for the entire 72 hours post fall checks to ensure all neuro checks are documented and completed. Record review on [DATE] of resident falls within the last 30 days requiring neuro checks indicated with documented neuro checks were completed. Record review of the facility's Falls and Head Injury policies on [DATE] confirmed the updated language to call EMS if a resident with a head injury was on antiplatelet/anticoagulant medications. On [DATE] at 7:19 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for smoking. The facility failed to ensure Resident #1 was provided supervision when he smoked. Resident #1 had a history of attempting to smoke while wearing his oxygen tank (secured to the back of his motorized wheelchair). On 03/26/2023, a lit cigarette was discarded on the ground and ignited his oxygen tubing and catheter bag that was laying at the bottom of his motorized wheelchair. An Immediate Jeopardy (IJ) was identified on 04/01/2023 at 3:20 PM. While the IJ was removed on 04/03/2023 at 7:12 PM, the facility remained out of compliance at no actual harm because the facility needed to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of harm, severe injury, and possible death to residents who wear oxygen and were inadequately assessed for smoking safely unsupervised. The findings included: Record review of Resident #1's face sheet, dated 04/02/2023, revealed Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (occurs when disease of the heart or lungs leads to failure to maintain adequate blood oxygen levels), cognitive communication deficit (difficulty with thinking and how someone uses language), and paraplegia (impairment in motor (movement) or sensory (feeling) function of the lower extremities). Record review of the order summary report, dated 04/01/2023, revealed Resident #1 had an order, which started on 03/18/2023, for Oxygen continuously via nasal cannula . Record review of Resident #1's comprehensive MDS assessment, dated 03/24/2023, revealed it had not been completed. Record review of the comprehensive care plan, initiated on 03/20/2023, revealed Resident #1 had altered respiratory status and difficulty breathing. The interventions included oxygen at 2 LPM via NC every shift. The comprehensive care plan further revealed a smoking care plan was initiated on 03/26/2023 after Resident #1 ignited his oxygen tubing on the smoking patio. The intervention included Resident is deemed unsafe smoker, he smoked with oxygen tank in place after being educated to leave oxygen concentrator at nurses' station when going out to smoke. Record review of the occupational therapy treatment encounter note, dated 03/22/2023, revealed Resident #1 was educated on the safety concerns including the oxygen tank attached to his motorized wheelchair and not being allowed in the smoking courtyard. Record review of the nursing progress note, dated 03/22/2023 at 2:35 PM, revealed Resident #1 was repeatedly going outside in the common smoking area to smoke while oxygen was connected. The progress notes further revealed the charge nurse, ADON, and DON provided education and Resident #1 agreed not to smoke while using oxygen. Record review of the smoking assessment, effective date 03/22/2023, revealed Resident #1 had a history of smoking-related problems that would be hazardous to self or others. The smoking assessment revealed Resident went to smoking area in power chair with his oxygen tank. The tank was removed, and resident educated. The smoking assessment revealed Resident #1 was able to keep his lighter and cigarettes and was safe to smoke unsupervised. The assessment was signed by the DON on 03/27/2023. Record review of the nursing progress note, dated 03/25/2023 at 11:47 PM, revealed Resident #1 was provided additional education regarding removing his oxygen tank prior to going outside to smoke. Record review of the nursing progress note, dated 03/26/2023 at 3:45 PM, revealed Resident #1 had been off the hall for about an hour visiting another resident. Resident #1 went out to smoking area, and per resident witnesses' Resident #1 removed his nasal cannula and laid it on his foley catheter bag and proceeded to take out a cigarette and light it. While smoking, Resident #1 dropped his cigarette on top of oxygen tubing that was on ground. The oxygen tubing and foley catheter caught fire. A resident in the area grabbed the fire extinguisher and quickly put out the fire. There were no visible injuries, 911 was called, the doctor was notified, and a message with call back number was left for family. Record review of the incident report, dated 03/26/2023 at 3:30 PM, revealed Resident #1 was outside smoking with oxygen tank on, per witnesses' he took the nasal cannula off and placed it on the ground on his foley tubing prior to lighting the cigarette. He dropped his cigarette and the oxygen tubing ignited burning the oxygen tubing and foley tubing. Another resident immediately got the fire extinguisher and put out fire, and someone else hollered for nurse. Charge nurse went into smoking area and noted white substance all over resident. Nurse observed resident sitting in his power chair, holding the power cord to chair, and burnt oxygen tubing. The incident report further revealed immediate action taken was 911 was called, fire extinguisher was used, resident transported to ER to rule out any injury. Oxygen tank was turned off and removed from chair. Resident returned to nurses' station for eval. Record review of the Smoking Policy In-service, initiated on 03/26/2023, revealed staff were in-serviced on the smoking policy that was implemented in 06/2022 which indicated oxygen was prohibited in the smoking area. The in-service further revealed 7. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether supervision is required for smoking, or if resident is safe to smoke at all. 8. Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas (weather permitting), at designated times, and in accordance with his/her care plan. The in-service further revealed 13. Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. Record review of the Supervised Smoking Schedule, undated, revealed instructions that included: Do not throw cigarettes on the ground, use the ashtrays. No cigarettes, cigars, lighters or matches (any lighting instrument) in a resident's room or on your person at any time. The schedule further revealed the smoking times as follows: 6:00 AM - 6:15 AM supervised by the staff on duty 9:00 AM - 9:15 AM supervised by the staff on duty 12:45 PM - 1:00 PM supervised by the staff on duty 4:00 PM - 4:15 PM supervised by the staff on duty 7:00 PM - 7:15 PM supervised by the staff on duty 10:00 PM - 10:15 PM supervised by the staff on duty During an interview on 04/01/2023 at 9:07 AM, LVN D stated the residents were able to take themselves out to the smoking area and smoke if they were able to smoke unsupervised. LVN D stated there were currently no designated smoking times in place and residents could go out whenever. LVN D stated the residents were able to keep their cigarettes and lighters. During an observation on 04/01/2023 at 9:05 AM, four residents (Resident's #2, #5, #6, and #7) were outside in the smoking courtyard. Residents #2, #5, #6, and #7 had their own cigarettes and lighters. During an interview 04/01/2023 at 9:10 AM, Resident #2 stated she was the person who used the fire extinguisher to put the fire out on 03/26/2023. Resident #2 stated it was windy the day of the incident and Resident #1 was sitting in his motorized wheelchair against the wall. Resident #2 stated Resident #1 had taken his nasal cannula out of his nose and placed it on top of his catheter bag. Resident #2 stated Resident #1 was not right in the head and had come out several times with his oxygen tank on the back of his motorized wheelchair. Resident #2 stated the nurses would have normally turned the oxygen tank off, but it was on the day of the incident. Resident #2 stated another resident had dropped his cigarette on the ground and the wind blew it toward the nasal cannula and the tubing ignited causing a fire. Resident #2 stated she immediately grabbed the fire extinguisher and put out the fire. Resident #2 stated she did not believe there were any injuries to Resident #1. During an interview on 04/01/2023 at 9:16 AM, Resident #5 stated the facility staff told them during the past week that the residents were not allowed to smoke without supervision anymore. Resident #5 stated the staff members had not supervised them this morning, but she was under the impression it was to have started. Resident #5 stated the facility told the residents who smoked they would also have to give up their cigarettes and lighters and could only smoke during the designated smoking times for only 15 minutes. Resident #5 stated the staff had not taken her cigarettes or lighter and had not provided supervision at this time. During an interview on 04/01/2023 at 9:47 AM, LVN C stated on the morning of the incident on 03/26/2023 and the day prior on 03/25/2023 she had talked to Resident #1 several times about going outside with his oxygen on. LVN C stated Resident #1 had gone to another hall to visit another resident. LVN C stated Resident #1 entered the smoking area after leaving the other resident's room. LVN C stated a CNA had come to tell her he was outside with oxygen on. LVN C stated RN F had beat her to the smoking area and the fire was already extinguished. LVN C stated paramedics had been called so Resident #1 could have been checked out. LVN C stated he had some redness to his bilateral lower extremities, but they looked like that prior to the incident. LVN C stated to her knowledge, he took his nasal cannula off and placed it at the bottom of his motorized wheelchair where it caught fire. LVN C stated he had no injuries. LVN C stated some residents required supervision and some did not dependent on their smoking assessment. LVN C stated the facility had no set times for residents who were able to smoke unsupervised. LVN C stated the facility did an in-service stating residents had to be supervised while smoking and should have designated times but was usure when it started. LVN C stated it should have been implemented by today. During an observation on 04/01/2023 at 9:54 AM, four residents were outside smoking with no staff supervision. During an interview on 04/01/2023 at 9:58 AM, Resident #3 stated she did not smoke but liked to sit outside. Resident #3 stated she witnessed the incident that happened on 03/26/2023 with Resident #1. Resident #3 stated Resident #1 was confused and would often become naked by taking his gown off. Resident #3 stated Resident #1 had taken his oxygen off and placed it on his catheter bag. Resident #3 stated Resident #1 threw his lit cigarette on the ground, and he started yelling he was on fire. Resident #3 stated the flames were going and another resident grabbed the fire extinguisher and put out the fire. Resident #3 stated a different resident hollered for a nurse. Resident #3 stated the fire department arrived at the facility and told her Everyone could have been blown to pieces. During an interview on 04/01/2023 at 10:18 PM, the DON stated on 03/26/2023 Resident #1 had taken his oxygen tank attached to his motorized wheelchair out into the smoking area. The DON stated it was discovered during the investigation that Resident #1 was not actually smoking but another resident was smoking beside him and dropped his cigarette on the ground. The DON said the cigarette rolled toward Resident #1's motorized wheelchair where his oxygen tubing was laying on his catheter bag and ignited. The DON stated another resident put out the fire using the fire extinguisher and Resident #1 was sent to the emergency room as a precaution. The DON stated when Resident #1 returned to the facility he was re-assessed as an unsafe smoker and his smoking materials were taken. The DON stated Resident #1 had one prior incident on 03/22/2023 where he was found outside with his oxygen tank on. The DON stated herself, the ADON, the nurse, and therapy provided Resident #1 with education regarding taking his oxygen tank into the smoking area. The DON stated he was deemed a safe smoker at that time because he was able to verbalize understanding of the smoking policy. The DON stated the corporate office had changed the smoking policy and she had in-serviced the residents and the staff. The DON stated the supervised smoking at designated times was supposed to have been implemented on Monday, 04/03/2023. During an observation and interview on 04/01/2023 at 12:35 PM, Resident #1 was sitting up in his hospital bed. Resident #1 looked frail and unkempt as evidenced by the hospital gown falling off his bony shoulders and his hair was disheveled and falling into his face. Resident #1 was wearing a nasal cannula and was struggling to breath during the interview. Resident #1 stated he remembered the incident that occurred on 03/26/2023. Resident #1 stated he was not smoking but another resident was sitting beside him and was smoking. Resident #1 stated the other resident dropped his cigarette and about 5 minutes later his nasal cannula and foley catheter tubing caught on fire. Resident #1 stated it was a small flame and he was not injured. Resident #1 stated the facility made him go to the hospital and he believed they made a mountain out of a molehill. Resident #1 stated he knew all about safety and for significant damage to have been done, it would have needed to happen in an enclosed space. Resident #1 stated he normally went into the smoking area with his oxygen tank, but the staff would turn off the oxygen or he would himself. During an interview on 04/01/2023 at 1:22 PM, CNA B stated she worked the hall were Resident #1 resided and had taken care of him. CNA B stated Resident #1 wanted to do what he wanted to when he wanted to do it. CNA B stated Resident #1 had behaviors, but it seemed like they were getting better. CNA B stated she observed Resident #1 outside in the smoking area on multiple occasions with his oxygen tank on the back of his motorized wheelchair. CNA B stated Resident #1 was an unsupervised smoker, and she believed the nurses were turning the oxygen off. CNA B stated all the nurses were aware Resident #1 was going outside with his oxygen tank on. CNA B stated she was provided an in-service on the new smoking policy and stated all residents were going to be supervised while smoking and only allowed to smoke at designated times. During an interview on 04/01/2023 at 1:41 PM, MA E stated she worked on the hall were Resident #1 resided. MA E stated Resident #1 was told things and he would forget them. During an interview on 04/01/2023 at 2:29 PM, COTA R stated 03/22/2023 was the first day Resident #1 was out of the bed. COTA R stated she was performing a safe motorized wheelchair assessment on Resident #1 when he mentioned he wanted to go outside for a cigarette. COTA R stated she provided education on safety to Resident #1 and instructed him it was not appropriate to go outside with his oxygen tank hooked on the back of his motorized wheelchair. COTA R stated she informed the nurse he was asking for a cigarette. COTA R stated Resident #1 was later found outside with his oxygen tank on his motorized wheelchair. Record review of the Resident Smoking policy, updated in 03/2023, revealed 7. Residents who smoke will be assessed, using the Resident Safe Smoking Assessment, to determine the level of supervision the resident requires. 8. All residents who smoke will be allowed to smoke in designated smoking areas (weather permitting), at designated times with supervision, and in accordance with his/her care plan. The policy further revealed 13. Smoking materials of residents who smoke will be maintained by nursing staff. The Administrator was notified on 04/01/2023 at 3:52 PM that an immediate jeopardy situation was identified due to the above failures. The Administrator and the DON was provided the immediate jeopardy template on 04/01/2023 at 3:59 PM. During an interview on 04/02/2023 at 10:55 AM, the DON stated before the incident on 03/26/2023, the facility assessed residents for safe smoking, the need for supervision, and whether residents were able to keep their smoking materials by performing a smoking assessment. The DON stated it had been the policy from the time she started at the facility. The DON stated there was no set person to complete the smoking assessment. The DON stated often the MDS nurse, the charge nurse, or herself would have completed the smoking assessments. The DON stated this was monitored during daily clinical meetings and if the assessment was not completed, she would do it. The DON stated Resident #1 had a BIMS score of 14, which indicated no cognitive impairment and was able to verbalize understanding of the smoking policy. The facility's plan of removal was accepted on 04/03/2023 at 2:56 PM and included the following: The facility failed to provide supervision to Resident #1 who required oxygen and smoked. All Smoking assessments and Care plans were reviewed for residents who smoke, and changes were made as necessary on 3/26/2023 by the director of nurses. Residents who smoke were reviewed for care plan and if a care plan was not noted, a care plan was completed. On 3/31/2023 residents who smoked and used oxygen were asked to attend a care plan meeting so that the care plan could be updated to reflect that they used oxygen and understood that they could not go outside to smoke with oxygen. Every resident who smokes verified they understood that they were not allowed go outside to smoke with oxygen. Resident #1 was assessed and transferred to ER 3/26/2023 at approximately 3:45 PM to evaluate and treat as necessary. The Resident returned 3/26/2023 at approximately 9:00 PM with no new orders and with no injuries reported by the ER. The facility smoking policy was updated on 3/31/2023 and at that time DON/ADON began in-servicing facility staff on the policy changes. Facility policy was updated by corporate office to provide scheduled supervised smoking times for all residents who smoke on 3/31/2023. Assigned smoking times are supervised as follows: 6:00am to 6:15am - Charge Nurse on North Wing will assign staff member to take residents smoking paraphernalia out to smoke area and allow residents to smoke while being supervised. 9:00am - 915am - Activity Director or her designee will supervise M-F, Housekeeping staff member on duty will supervise during this time on Sat - Sun. 12:45pm - 1:00pm - Social Services will supervise during this time frame and housekeeping staff member will supervise on Sat - Sun. 4:00pm - 4:15pm - North Wing Charge Nurse will assign Aide/C.N.A. 7:00pm- 715: pm - South Wing Charge Nurse will assign Aide/C.N.A. 10:00 pm - 10:15pm - East Wing Charge nurse will assign Aide/C.N.A. DON, ADON, and the wound care nurse in-serviced all staff regarding the new smoking policy and the supervised smoking requirements. This will be monitored by the Administrator, DON and ADON. Smoking policy will be covered during orientation for new hires. All staff currently on duty were in-serviced at 11:00 AM on 4/3/2023. Any staff members not available for in-service will be in-serviced prior to returning to shift. All resident smokers were invited to a meeting on 3/31/2023 conducted by Social Worker and Administrator. Each resident in attendance was provided a copy of the changes. The Smoking policy is part of the admission agreement, and the revised policy will be placed in admission packet immediately. Not all residents who smoke showed up for the meeting. For those who did not attend, the ADON went to each resident on 4/2/2023 at 2:00PM to educate them on the new smoking policy to ensure they understood. Also, the residents were reminded that they must turn in all cigarettes and lighters to the nurse. The new smoking policy was updated on 3/31/2023 to reflect that oxygen tanks are not allowed in the smoking area. The person assigned to supervise smoking will ensure there are no oxygen tanks in the smoking area. Policy related to supervision during smoking times has been implemented and is in place. The new smoking policy implementation explanation started 3/31/23 with all residents who smoke. The new smoking policy implementation was completed on 4/2/2023 for all residents who smoke. All residents who smoke were asked again on 4/3/2023 at 11:00 AM to turn in cigarettes and lighters to the charge nurse for storage. Staff in-serviced again regarding the new smoking policy to ensure everyone understood on 4/03/2023 at 12:00PM. On 04/03/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation on 04/03/2023 at 4:25 PM, 13 residents were outside smoking supervised by CNA B. During resident interviews on 04/03/2023 between 4:33 PM - 5:09 PM, Resident's #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 were able to verbalize understanding of the new smoking policy, which included supervised smoking and designated smoking times, verbalize understanding of not going into the smoking area with oxygen, and verified all cigarettes and lighters were turned into the facility staff. Record review of the comprehensive care plan for Resident's #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, and #27 revealed they had been reviewed and revised as necessary. Record review of the smoking assessments for Resident's #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #16, #17, #18, #19, #20, #22, #23, #24, #25, #26, and #27 revealed they had been reviewed and revised as necessary. Record review of the new smoking policy in-service provided to staff, dated 03/31/2023, 04/01/2023, and 04/02/2023, revealed 42 staff members had signed and dated the read and understood the new smoking policy, which included oxygen was not allowed in the smoking area, residents were required to keep their cigarettes and lighters at the nurse's station, and designated smoking times and supervision. During interview on 04/03/2023 between 4:25 PM and 6:28 PM, the following staff members, LVN K, MA L, LVN M, CNA N, CNA O, CNA P, CNA B, LVN D, CNA Q, and the ADON were interviewed and verbalized understanding that no oxygen was allowed in the smoking area, residents were required to keep their cigarettes and lighters at the nurse's station, and the new digitated smoking times and supervision. On 04/03/2023 at 7:12 PM, the Administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.