**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or misappropriation of property were thoroughly investigated in order to prevent further potential abuse, neglect, exploitation or misappropriation while the investigation was in progress for one (Resident #1) of five residents reviewed for abuse and neglect, in that: The facility failed to investigate after Resident #1 was diagnosed with a Fentanyl overdose on 12/25/23. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/28/23 at 2:47 PM. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of a drug overdose, hospitalization, or death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including inhalant abuse (a broad range of household and industrial chemicals whose volatile vapors or pressurized gases can be concentrated and breathed in via the nose or mouth to produce intoxication), nicotine dependence, personal history of traumatic brain injury, major depressive disorder, and other psychoactive substance dependence. Review of Resident #1's admission MDS assessment, dated 09/15/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section G (Functional Status) reflected he was completely dependent with ADLs. Review of Resident #1's quarterly care plan, dated 09/28/23, reflected he presented with primary diagnosis of depression and bipolar with an intervention of ensuring all needs were met. Review of Resident #1's admission summary, dated [DATE], reflected the following: Lifestyle: Resident/family member report currently uses or HX of alcohol use. [Resident #1] has a history of smoking in past. Smoked, drank, abused drugs at an early age in life. Review of Resident #1's progress notes in his EMR, dated 12/25/23 at 11:36 PM and documented by RN C, reflected the following: Nurse called ER to get updated, [Resident #1] is being admitted d/t / opioid overdose, [Resident #1] tested positive for opioids and Fentanyl. [Resident #1] has current orders for opioids however does not have an order for Fentanyl. Review of Resident #1's hospital discharge paperwork, dated 12/25/23, reflected the following: Chief Complaint: [Resident #1] presets with Altered Mental Status HPI: .who presented to ED for evaluation of acute encephalopathy (a group of disorders that affect the brain and cause confusion, memory loss, or other mental changes) which began last night. Per chart review this afternoon nursing staff noticed [Resident #1] was not acting like himself and was more lethargic. Reportedly [nursing staff] are worried [Resident #1]'s family was giving him extra medications or narcotics . In ER [Resident #1] was medicated with multiple doses of Narcan (a drug used to treat known or possible opioid overdose), woke up had GCS 15 (The highest possible GCS score is 15, and the lowest is 3. A score of 15 means you were fully awake, responsive and have no problems with thinking ability or memory). Now requiring Narcan drip. Further workup revealing: UA consistent with infection, UDS + opiates and Fentanyl. Mental status: obtunded (dazed, desensitized), withdraws to pain. Principal Diagnosis: Opioid overdose Review of Resident #1's physician orders in his EMR, on 12/28/23, reflected no order for Fentanyl or any other opioids, besides Tylenol with Hydrocodeine. Review of Resident #1's EMR, on 12/28/23, reflected no admission paperwork, documents from his previous SNF , history and physical, or nurse practitioner notes. During an interview on 12/29/23 at 2:37 PM, Resident #1 stated he did not ask anyone for fentanyl or any illegal drugs, and no one, not facility staff or family member, gave him anything he did not recognize. He stated he started feeling off before his family arrived for a visit. He stated at lunch, his food was going everywhere but into his mouth. He stated after his family arrived, he felt the highest he had ever felt in his life. He stated when he went to the hospital back at the beginning of December, he did not feel high like he had this most recent incident. He stated no one brings him drugs and staff do not offer him drugs. During a telephone interview on 12/28/23 at 10:11 AM, Resident #1's FM A state he and two other family members came to pick up Resident #1 on 12/25/23 around 5:00 PM. He stated RN C showed them to his room where he immediately noticed something was off with Resident #1. He stated he seemed to be heavily medicated, had a blank stare, and was mumbling. He stated this was unlike him as he was normally very communicative. He stated he asked RN C, You all had not noticed he was like this? He stated RN C said no and left the room. He stated it was very unnerving no one had noticed Resident #1's change in condition as it was obvious something was wrong with him. He stated it looked like someone had given him drugs as he was acting high. He stated Resident #1 was sent to the hospital earlier in the month for similar symptoms and wondered if someone had drugged him then, too. During an interview on 12/28/23 at 10:59 AM, the ADM stated he was notified of Resident #1's Fentanyl overdose on the morning of 12/26/23. He stated he was told by RN C that family members came to visit him on 12/25/23 and spent some time in his room and then stated they were going to take him out for Christmas dinner. RN C told him the family pushed him down the hallway to leave and she (RN C) asked them to sign him out first. RN C told him that an aide noticed Resident #1 did not look right. RN C told him the aide got RN C and she determined he needed to be sent to the hospital. When asked if he believed this should have been self-reported to HHSC he stated he did not because Resident #1 had a history of drug use. He stated he got kicked out of his previous facility for smoking marijuana. He stated he did not believe drugs were pushed on him, rather that he asked for them. When asked if there was any kind of investigation conducted, he stated he was waiting until he could interview Resident #1 once he returned from the hospital because that would be the main source of his investigation. He stated he had seen Resident #1 a few times on 12/25/23 during the day and he was his normal self. He stated he was not sure if he had any other visitors that day but did regularly have friends that visited him in the facility. He stated he had noticed that not all visitors signed in the visitor log when they entered the facility. He stated he planned on banning the three family members that visited him that day. He stated there was nothing in his care plan regarding his history of drug use because they had not had any incidents with Resident #1 and drugs while he had been at the facility. A request was made at this time for any admitting documents or documentation from his previous facility. During an observation and interview on 12/28/23 at 11:41 AM, the Receptionist stated she worked Monday - Friday from 8:00 AM - 5:00 PM. She stated there was not a receptionist that worked on weekends and she did not work on Christmas Day. She stated visitors were to sign-in in their Visitor Logbook, and she pointed across the lobby to a binder. Record Review of the Visitor Logbook in the lobby, from 12/01/23 - 12/28/23, reflected no documented visitors for Resident #1. During an interview on 12/28/23 at 11:49 AM, LVN D stated she did not work on Christmas Day, but is almost always Resident #1's nurse on days she was working at the facility. She stated he often had visitors such as friends and family that would come by. She stated she had never heard of him requesting illegal substances of any kind. During a telephone interview on 12/28/23 at 1:31 PM, Resident #1's FM B stated that the current hospitalization was the second mysterious incident that has happened to Resident #1 at this facility. He stated on 12/08/23 he was sent to the hospital with the same symptoms, but a drug test was not performed. He stated the family members that visited him on 12/25/23 were family members from the other side of the family. He stated an incident like these two had not happened before at any other facility and Resident #1 had been residing in nursing facilities for over 20 years. He stated at most nursing facilities, you had to sign in when you entered, and this facility did not do that. He stated there is a book but no one enforced the rule. He stated he had never signed in and no one had ever asked who he was. He stated Resident #1 did have a history of drug abuse which is what led to him needing nursing facility care. He stated he asked Resident #1 at the hospital if he requested drugs and he responded, Why would I request something that could kill me? During a telephone interview on 12/28/23 at 2:11 PM, RN C stated she was working on 12/25/23 when Resident #1 had to be sent to the hospital. She stated during the day he was acting normal and there was nothing out of the usual. She stated in the evening, three family members that she had never seen before came to see him and stated they were going to take him home for Christmas. As they made their way down the hall, she yelled for someone to sign him out first. She stated an aide, who she could not remember who it was, told her that Resident #1 did not look right. She stated she went and assessed him and he was slumped in his wheelchair, was ashy white, eyes were dilated, and he could not talk - which was out of the norm for him. She stated his oxygen level was 81% and she told the family she was calling 911. She stated since the symptoms were very similar to the symptoms he experienced in early December, she requested that a drug test be conducted in the ER. During an interview on 12/28/23 at 2:24 PM, the ADM stated he could not find any admission documents or documents from Resident #1's previous facility. He stated he was an Interim ADM and was not working at the facility when Resident #1 was admitted . He stated the Admissions Coordinator that worked at the facility at that time no longer worked there. Review of the facility's Illegal Drug Use Policy, dated 09/01/23, reflected the following: This facility is an illegal drug-free facility. Illegal drugs are defined for the purpose of this policy as the use, possession, or distribution of any substances which is unlawful under the Controlled Substances Act. The facility reserves the right to inspect staff only areas, conduct staff alcohol and drug testing, and terminate staff employment for violation of this policy. 1. No one is allowed to possess, be under the influence of, or use any of said illegal drugs on the premises of this facility. The ADM was notified on 12/28/23 at 2:47 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 12/29/23 at 11:31 AM: F 689 - The facility failed to ensure resident environment remains as free of accident hazards as possible On 12/28/2023 an abbreviated survey was initiated at (facility). On 12/28/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: Per the ADM, Resident #1 has a history of drug use and was kicked out of his old facility for smoking marijuana. He stated they did not investigate the incident because it was his belief that the family brought in the drugs, due to the resident being fine during the day until the family arrived. During an interview with Resident #1's FM revealed that there is no way of knowing who gave the resident his drugs. However, there is no way for the resident to get the drugs himself, regardless of if he asks for them or not. He stated they have no visitation process, and no one has ever asked him to sign in and anyone could just walk into the facility whenever. Interviews with staff revealed Resident #1 has family and friends visiting him often. Review of the Visitor Log at the entrance of the facility reflected no visitors had signed in for this resident for the month of December. There is nothing in Resident #1's CP regarding a history of drug use/addiction, so no interventions were in place. Immediate Action: 1. Action: Resident returned from the hospital and assessed by licensed nurse and care plan updated by MDS Nurse. Current interventions include scheduling a care conference with resident and responsible party to discuss current interventions put into place to prevent reoccurrence. Resident is receiving (psychiatry care services). Referral for face-to-face visit requested. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 5:35 p.m. Responsible: MDS Nurse and Charge Nurse 2. Action: Incident report completed by Interim DON of alleged incident occurring on 12/25/2023 Start Date: 12/28/2023 Completion Date: 12/28/2023 @ 4:42 p.m. Responsible: Interim DON 3. Action: Ad Hoc QAPI Notified Medical Director of IJ template and action items to lower the immediacy. Start Date: 12/28/2023 Completion Date: 12/28/2023 @ 6:34 p.m. Responsible: Administrator, Medical Director, [NAME] President of Clinical Operations Identification of Resident(s) Affected or Likely to be Affected: 1. Action: Review of all residents ICD-10 codes completed by MDS nurse for identification of other residents with illicit drug history to ensure care plans are in place. No other residents identified. Start Date: 12/28/2023 Completion Date: 12/29/2023 at 5:00 p.m. Responsible: MDS Nurse Actions to Prevent Occurrence/Recurrence: 1. Action: Education provided to Administrator and Interim DON on investigating allegations of residents under the facility's care being on illegal drugs and contacting the proper authorities. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 5:35 p.m. Responsible: [NAME] President of Clinical Operations 2. Action: Signage posted at all facility entrances on no illicit drugs are to be brought in by visitors and/or staff. All facility staff educated on signage posted at all entrances indicating no illicit drugs are to be brought in by visitors and/or staff prior to working their next shift. All new hires will be educated prior to working their first shift. Administrator will designate Department Managers and/or designee to visualize signage remains in place every 8 hours x 7 days a week x 4 weeks. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 6:30 p.m. Responsible: Administrator, Department Managers, [NAME] President of Clinical Operations, and/or designee 3. Action: Visitor log placed at nursing station for facility staff to write name of who is visiting and which resident they are visiting. All facility staff educated on new visitor log and how to complete prior to working their next shift. All new hires will be educated prior to working their first shift. Start Date: 12/28/2023 Completion Date: 12/28/2023 7 p.m. Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, and/or designee 4. Action: All facility staff educated on Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately. Start date: 12/29/2023 Completion: 12/29/2023 Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, and/or designee Action Item: Monitoring for compliance Vice President of Clinical Operations will review all Incident and Accident reports 5 days a week (Monday to encompass Friday-Sunday) x 4 weeks to ensure thorough investigations were completed and interventions care planned. MDS nurse to complete weekly audits of residents ICD-10 codes for current illicit drug use and/or history and such is care planned. Interim DON to audit visitor list at nurses station 5 days a week (Monday to encompass Friday-Sunday) x 4 weeks to ensure visitors are appropriately logged and log indicates which resident they were visiting. Interim DON and/or ADON to validate all staff education completed weekly x 4 weeks. Administrator to validate completion of the above weekly x 4 weeks. Vice President of Clinical Operations to validate completion of the above weekly x 4 weeks. Start Date: 12/28/2023 Completion Date: 2/1/2023 Responsible: [NAME] President of Clinical Operations, MDS nurse, Interim DON, Administrator and/or designee The Surveyor monitored the POR on 12/29/23 as followed: Observation on 12/29/23 at 2:24 PM revealed a sign on the entrance door that read ATTENTION ALL STAFF AND VISITORS: ILLICIT DRUGS ARE NOT PERMITTED TO BE BROUGHT INTO THE FACILITY OR GIVEN TO ANYONE AT THE FACILITY. During interviews on 12/29/23 from 2:58 PM - 5:55 PM with one HSKA, three LVNs, one MA, and two CNAs revealed they were all in-serviced before their shifts on illegal drugs not be allowed in the facility, on the facility's Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately, the signage posted on all entrance/exit doors regarding no illegal drugs were to be brought in, and the new visitor sign-in process. Observation on 12/29/23 at 3:32 PM revealed a visitor logbook at the nurses' station that was highly visible. There was a large sign that read ALL VISITORS MUST SIGN IN AT THE NURSES STATION. Review of an in-service entitled Illegal Drug Signage conducted by the MDSC, dated 12/28/23, reflected staff were educated on the following: There is a sign posted at the entrance for all staff and visitors that illicit drugs are not permitted to be brought into the facility or given to anyone in the facility. Review of an in-service conducted by the VPCO , dated 12/28/23, reflected staff were educated on the following: Anytime we receive information from outside entities or facility staff and/or visitors regarding illegal drug use the investigation must be started immediately and reported to the Police Department and HHSC if warranted. Review of the facility's Ad Hoc QAPI meeting, dated 12/28/23, reflected the following were in attendance: ADM, VPCO, RDO, and MD. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plans, in that: The facility failed to care plan Resident #1's history of illegal drug abuse. On 12/25/23, Resident #1 went unresponsive and was diagnosed with a Fentanyl overdose in the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/28/23 at 2:47 PM. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of a drug overdose, hospitalization, or death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including inhalant abuse (a broad range of household and industrial chemicals whose volatile vapors or pressurized gases can be concentrated and breathed in via the nose or mouth to produce intoxication), nicotine dependence, personal history of traumatic brain injury, major depressive disorder, and other psychoactive substance dependence. Review of Resident #1's admission MDS assessment, dated 09/15/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section G (Functional Status) reflected he was completely dependent for ADLs. Review of Resident #1's quarterly care plan, dated 09/28/23, reflected he presented with primary diagnosis of depression and bipolar with an intervention of ensuring all needs were met. There was nothing in the care plan reflected he had a history of drug abuse. Review of Resident #1's admission summary, dated [DATE], reflected the following: Lifestyle: Resident/family member report currently uses or HX of alcohol use. [Resident #1] has a history of smoking in past. Smoked, drank, abused drugs at an early age in life. Review of Resident #1's progress notes in his EMR, dated 12/25/23 at 11:36 PM and documented by RN C, reflected the following: Nurse called ER to get updated, [Resident #1] is being admitted d/t / opioid overdose, [Resident #1] tested positive for opioids and Fentanyl. [Resident #1] has current orders for opioids however does not have an order for Fentanyl. Review of Resident #1's hospital discharge paperwork, dated 12/25/23, reflected the following: Chief Complaint: [Resident #1] presets with Altered Mental Status HPI: .who presented to ED for evaluation of acute encephalopathy (a group of disorders that affect the brain and cause confusion, memory loss, or other mental changes) which began last night. Per chart review this afternoon nursing staff noticed [Resident #1] was not acting like himself and was more lethargic. Reportedly [nursing staff] are worried [Resident #1]'s family was giving him extra medications or narcotics . In ER [Resident #1] was medicated with multiple doses of Narcan (a drug used to treat known or possible opioid overdose), woke up had GCS 15 . Now requiring Narcan drip. Further workup revealing: UA consistent with infection, UDS + opiates and Fentanyl. Mental status: obtunded (dazed, desensitized), withdraws to pain. Principal Diagnosis: Opioid overdose Review of Resident #1's EMR, on 12/28/23, reflected no admission paperwork, documents from his previous SNF , history and physical, or nurse practitioner notes. During an interview on 12/29/23 at 2:37 PM, Resident #1 stated he did not ask anyone for fentanyl or any illegal drugs, and no one, not facility staff or family member, gave him anything he did not recognize. He stated he started feeling off before his family arrived for a visit. He stated at lunch, his food was going everywhere but into his mouth. He stated after his family arrived, he felt the highest he had ever felt in his life. He stated when he went to the hospital back at the beginning of December, he did not feel high like he had this most recent incident. He stated no one brings him drugs and staff do not offer him drugs. During a telephone interview on 12/28/23 at 10:11 AM, Resident #1's FM A state he and two other family members came to pick up Resident #1 on 12/25/23 around 5:00 PM. He stated RN C showed them to his room where he immediately noticed something was off with Resident #1. He stated he seemed to be heavily medicated, had a blank stare, and was mumbling. He stated this was unlike him as he was normally very communicative. He stated he asked RN C, You all had not noticed he was like this? He stated RN C said no and left the room. He stated it was very unnerving no one had noticed Resident #1's change in condition as it was obvious something was wrong with him. He stated it looked like someone had given him drugs as he was acting high. He stated Resident #1 was sent to the hospital earlier in the month for similar symptoms and wondered if someone had drugged him then, too. During an interview on 12/28/23 at 10:59 AM, the ADM stated he was notified of Resident #1's Fentanyl overdose on the morning of 12/26/23. He stated he was told by RN C that family members came to visit him on 12/25/23 and spent some time in his room and then stated they were going to take him out for Christmas dinner. RN C told him the family pushed him down the hallway to leave and she (RN C) asked them to sign him out first. RN C told him that an aide noticed Resident #1 did not look right. RN C told him the aide got RN C and she determined he needed to be sent to the hospital. He stated he got kicked out of his previous facility for smoking marijuana. He stated he did not believe drugs were pushed on him, rather that he asked for them. When asked if there was any kind of investigation conducted, he stated he was waiting until he could interview Resident #1 once he returned from the hospital because that would be the main source of his investigation. He stated he had seen Resident #1 a few times on 12/25/23 during the day and he was his normal self. He stated he was not sure if he had any other visitors that day but did regularly have friends that visited him in the facility. He stated he had noticed that not all visitors signed in the visitor log when they entered the facility. He stated he planned on banning the three family members that visited him that day. The ADM stated the MDSC was primarily responsible for ensuring the accuracy of care plans. He stated it was important to individualize the care plans to each resident to ensure the highest quality of care to avoid any potential minor or major harm. He stated he would assume Resident #1's drug history was not in his care plan due to it not having happened while he had been residing at the facility. During an observation and interview on 12/28/23 at 11:41 AM, the Receptionist stated she worked Monday - Friday from 8:00 AM - 5:00 PM. She stated there was not a receptionist that worked on weekends and she did not work on Christmas Day. She stated visitors were to sign-in in their Visitor Logbook, and she pointed across the lobby to a binder. Record Review of the Visitor Logbook in the lobby, from 12/01/23 - 12/28/23, reflected no documented visitors for Resident #1. During an interview on 12/28/23 at 11:49 AM, LVN D stated she did not work on Christmas Day, but is almost always Resident #1's nurse on days she was working at the facility. She stated he often had visitors such as friends and family that would come by. She stated she had never heard of him requesting illegal substances of any kind. During a telephone interview on 12/28/23 at 1:31 PM, Resident #1's FM B stated that the current hospitalization was the second mysterious incident that has happened to Resident #1 at this facility. He stated on 12/08/23 he was sent to the hospital with the same symptoms, but a drug test was not performed. He stated the family members that visited him on 12/25/23 were family members from the other side of the family. He stated an incident like these two had not happened before at any other facility and Resident #1 had been residing in nursing facilities for over 20 years. He stated at most nursing facilities, you had to sign in when you entered, and this facility did not do that. He stated there is a book but no one enforced the rule. He stated he had never signed in and no one had ever asked who he was. He stated Resident #1 did have a history of drug abuse which is what led to him needing nursing facility care. He stated he asked Resident #1 at the hospital if he requested drugs and he responded, Why would I request something that could kill me? During a telephone interview on 12/28/23 at 2:11 PM, RN C stated she was working on 12/25/23 when Resident #1 had to be sent to the hospital. She stated during the day he was acting normal and there was nothing out of the usual. She stated in the evening, three family members that she had never seen before came to see him and stated they were going to take him home for Christmas. As they made their way down the hall, she yelled for someone to sign him out first. She stated an aide, who she could not remember who it was, told her that Resident #1 did not look right. She stated she went and assessed him and he was slumped in his wheelchair, was ashy white, eyes were dilated, and he could not talk - which was out of the norm for him. She stated his oxygen level was 81% and she told the family she was calling 911. She stated since the symptoms were very similar to the symptoms he experienced in early December , she requested that a drug test be conducted in the ER. During an interview on 12/28/23 at 2:24 PM, the ADM stated he could not find any admission documents or documents from Resident #1's previous facility. He stated he was an Interim ADM and was not working at the facility when Resident #1 was admitted . He stated the Admissions Coordinator that worked at the facility at that time no longer worked there. During an interview on 12/29/23 at 4:25 PM, the MDSC stated she was responsible for all resident care plans. She stated she looked at what was triggering from the MDS, medications that needed monitoring, diagnoses, and behaviors. She stated not having any interventions for Resident #1 regarding his history of drug abuse was an over-sight and was missed. Review of the facility's Comprehensive Care Plans Policy, dated 01/01/23, reflected the following: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The ADM was notified on 12/28/23 at 2:47 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 12/29/23 at 11:31 AM: F656 - The facility must develop and implement a comprehensive person-centered care plan for each resident. On 12/28/2023 an abbreviated survey was initiated at (facility). On 12/29/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: Resident #1 is a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including TBI, cocaine dependence (in remission), and bipolar disorder. Interview with the ADM revealed that on 12/25/23 around 5:00 PM, three of Resident #1's family members came to visit. Approximately 20 minutes later the family was pushing him down the hallway towards the exit to take him to dinner when a CNA noticed that he did not look like himself. The CNA went and got the nurse who observed him to be sedated, have low O2 sats, and was unresponsive. Resident #1 was immediately sent to the hospital. Due to him having a similar episode earlier in the month, the nurse requested that a drug test be conducted at the ER. The results showed fentanyl and THC in the resident's system. Per the ADM, Resident #1 has a history of drug use and was kicked out of his old facility for smoking marijuana. He stated they did not investigate the incident because it was his belief that the family brought in the drugs, due to the resident being fine during the day until the family arrived. Interviews with staff revealed Resident #1 has family and friends visiting him often. Review of the Visitor Log at the entrance of the facility reflected no visitors had signed in for this resident for the month of December. There is nothing in Resident #1's CP regarding a history of drug use/addiction, so no interventions were in place. Review of the facility's ANE Policy reflects that the facility will implement policies and procedures to prevent neglect. Facility Response: Immediate Action 1. Action: Resident returned from the hospital and assessed by licensed nurse and care plan updated by MDS Nurse. Current interventions include scheduling a care conference, scheduled for 12/29/2023 at 3:00 pm with resident and responsible party to discuss current interventions put into place to prevent reoccurrence (1) Observe resident(s) for signs and symptoms of drug use, change in level of consciousness, excessive sedation, speech impairment. Any findings to be reported to administrator/designee, medical director, and responsible party and (2) Educate resident(s) on the adverse effects that illegal drugs could have on their overall health condition. Resident is receiving Psychiatry Services. Referral for face-to-face visit requested by MDS nurse. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 5:35 p.m. Responsible: MDS Nurse and Charge Nurse Identification of Resident(s) Affected or Likely to be Affected: Action: Review of all residents ICD-10 codes completed by MDS nurse for identification of other residents with illicit drug history to ensure care plans are in place. 1 other resident identified and care plan updated by MDS nurse. Start Date: 12/28/2023 Completion Date: 12/29/2023 at 12:00 p.m. Responsible: MDS Nurse Action to Prevent Occurrence/Recurrence: Action 1: Interim Director of Nursing and MDS Nurse educated to ensure care plans are in place and interventions are present for all current residents with a history of drug addiction (through audit only 2 residents identified with a history of drug addiction) and all future admissions with a history/current drug abuse will have a history of drug abuse care plan initiated, with interventions, per regulation. New admissions with a history of drug abuse will be identified through their referral paperwork or upon admission assessment. State Date: 12/29/2023 Completion: 12/29/2023 at 2 p.m. Responsible: [NAME] President of Clinical Operations Action 2: All facility staff educated on Illegal Drug Use Policy and immediately reporting any illegal drugs found in a resident's room or on the facility grounds to the administrator/designee immediately. The administrator/designee will call the proper authorities, initiate an investigation, report to HHSC if warranted, and will notify the DON/MDS to ensure a care plan is initiated/updated and interventions are in place. The Administrator, Interim DON, VP of Clinical Operations, and the MDS nurse will educated all facility staff prior to working their next scheduled shift. The Administrator, Interim DON, and/or the MDS nurse will educate all new staff prior to working their first shift. Start date: 12/29/2023 Completion: 12/29/2023 by 12 p.m. Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, MDS nurse and/or designee Action for Monitoring for Compliance: Action: MDS nurse to complete weekly audits of residents ICD-10 codes for current illicit drug use and/or history and ensure it is care planned weekly x 4 weeks. Administrator/designee will document on the morning stand up form, any residents with a new diagnosis of illicit drug use 5 days a week x 4 weeks (Monday to encompass Friday - Sunday). The VP of clinical operations will validate daily stand-up forms weekly x 4 weeks. All new admissions identified as having a history of drug addiction, the MDS Coordinator will initiate a care plan and ensure interventions are in place. VP of Clinical Operations will audit weekly all new admission for illegal drug use and validate care plan includes drug use history. At a minimum the QAPI committee will review all education and all audits surrounding deficient practice. Start Date: 12/28/2023 Completion: 12/29/2023 by 12 p.m. Responsible: Administrator, Interim DON, MDS nurse, and or/designee Action: Ad Hoc QAPI Notified Medical Director of IJ template and action items to lower the immediacy. Start Date: 12/29/2023 Completion Date: 12/29/2023 @ 12 p.m. Responsible: Administrator, Medical Director, [NAME] President of Clinical Operations The Surveyor monitored the POR on 12/29/23 as followed: Observation on 12/29/23 at 2:24 PM revealed a sign on the entrance door that read ATTENTION ALL STAFF AND VISITORS: ILLICIT DRUGS ARE NOT PERMITTED TO BE BROUGHT INTO THE FACILITY OR GIVEN TO ANYONE AT THE FACILITY. During interviews on 12/29/23 from 2:58 PM - 5:55 PM with one HSKA, three LVNs, one MA, and two CNAs revealed they were all in-serviced before their shifts on illegal drugs not be allowed in the facility, on the facility's Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately, the signage posted on all entrance/exit doors regarding no illegal drugs were to be brought in, and the new visitor sign-in process. Observation on 12/29/23 at 3:32 PM revealed a visitor logbook at the nurses' station that was highly visible. There was a large sign that read ALL VISITORS MUST SIGN IN AT THE NURSES STATION. Review of an in-service entitled Illegal Drug Signage conducted by the MDSC, dated 12/28/23, reflected staff were educated on the following: There is a sign posted at the entrance for all staff and visitors that illicit drugs are not permitted to be brought into the facility or given to anyone in the facility. Review of an in-service conducted by the VPCO , dated 12/28/23, reflected staff were educated on the following: Anytime we receive information from outside entities or facility staff and/or visitors regarding illegal drug use the investigation must be started immediately and reported to the Police Department and HHSC if warranted. Review of the facility's Ad Hoc QAPI meeting, dated 12/28/23, reflected the following were in attendance: ADM, VPCO, RDO, and MD. Review of an in-service conducted by the VPCO, dated 12/29/23, reflected the MDSC was educated on the following: All residents diagnoses are part of the care plan and should be included with interventions. In morning meeting review of all new diagnosis of illicit drug use are to be care planned immediately. You must let the ADM know in morning meeting of any residents with a new diagnosis of illicit drug use. Review of Resident #1's updated care plan, dated 12/29/23, reflected he had a history of illicit drug use with interventions of notifying the NP if there is a change in condition and to set up appointment with psychiatric services. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident recived adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for accidents and hazards, in that: The facility failed to supervise or prevent access to illegal drugs for Resident #1, knowing he had a history of drug use. On 12/25/23, Resident #1 went unresponsive and was diagnosed with a Fentanyl overdose in the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/28/23 at 2:47 PM. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of a drug overdose, hospitalization, or death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including inhalant abuse (a broad range of household and industrial chemicals whose volatile vapors or pressurized gases can be concentrated and breathed in via the nose or mouth to produce intoxication), nicotine dependence, personal history of traumatic brain injury, major depressive disorder, and other psychoactive substance dependence. Review of Resident #1's admission MDS assessment, dated 09/15/23, reflected a BIMS of 12, indicating a moderate cognitive impairment. Section G (Functional Status) reflected he was completely dependent with ADLs. Review of Resident #1's quarterly care plan, dated 09/28/23, reflected he presented with primary diagnosis of depression and bipolar with an intervention of ensuring all needs were met. Review of Resident #1's admission summary, dated [DATE], reflected the following: Lifestyle: Resident/family member report currently uses or HX of alcohol use. [Resident #1] has a history of smoking in past. Smoked, drank, abused drugs at an early age in life. Review of Resident #1's progress notes in his EMR, dated 12/25/23 at 11:36 PM and documented by RN C, reflected the following: Nurse called ER to get updated, [Resident #1] is being admitted d/t / opioid overdose, [Resident #1] tested positive for opioids and Fentanyl. [Resident #1] has current orders for opioids however does not have an order for Fentanyl. Review of Resident #1's hospital discharge paperwork, dated 12/25/23, reflected the following: Chief Complaint: [Resident #1] presets with Altered Mental Status HPI: .who presented to ED for evaluation of acute encephalopathy (a group of disorders that affect the brain and cause confusion, memory loss, or other mental changes) which began last night. Per chart review this afternoon nursing staff noticed [Resident #1] was not acting like himself and was more lethargic. Reportedly [nursing staff] are worried [Resident #1]'s family was giving him extra medications or narcotics . In ER [Resident #1] was medicated with multiple doses of Narcan (a drug used to treat known or possible opioid overdose), woke up had GCS 15 (The highest possible GCS score is 15, and the lowest is 3. A score of 15 means you were fully awake, responsive and have no problems with thinking ability or memory). Now requiring Narcan drip. Further workup revealing: UA consistent with infection, UDS + opiates and Fentanyl. Mental status: obtunded (dazed, desensitized), withdraws to pain. Principal Diagnosis: Opioid overdose Review of Resident #1's physician orders in his EMR, on 12/28/23, reflected no order for Fentanyl or any other opioids, besides Tylenol with Hydrocodeine. Review of Resident #1's EMR, on 12/28/23, reflected no admission paperwork, documents from his previous SNF , history and physical, or nurse practitioner notes. During an interview on 12/29/23 at 2:37 PM, Resident #1 stated he did not ask anyone for fentanyl or any illegal drugs, and no one, not facility staff or family member, gave him anything he did not recognize. He stated he started feeling off before his family arrived for a visit. He stated at lunch, his food was going everywhere but into his mouth. He stated after his family arrived, he felt the highest he had ever felt in his life. He stated when he went to the hospital back at the beginning of December, he did not feel high like he had this most recent incident. He stated no one brings him drugs and staff do not offer him drugs. During a telephone interview on 12/28/23 at 10:11 AM, Resident #1's FM A state he and two other family members came to pick up Resident #1 on 12/25/23 around 5:00 PM. He stated RN C showed them to his room where he immediately noticed something was off with Resident #1. He stated he seemed to be heavily medicated, had a blank stare, and was mumbling. He stated this was unlike him as he was normally very communicative. He stated he asked RN C, You all had not noticed he was like this? He stated RN C said no and left the room. He stated it was very unnerving no one had noticed Resident #1's change in condition as it was obvious something was wrong with him. He stated it looked like someone had given him drugs as he was acting high. He stated Resident #1 was sent to the hospital earlier in the month for similar symptoms and wondered if someone had drugged him then, too. During an interview on 12/28/23 at 10:59 AM, the ADM stated he was notified of Resident #1's Fentanyl overdose on the morning of 12/26/23. He stated he was told by RN C that family members came to visit him on 12/25/23 and spent some time in his room and then stated they were going to take him out for Christmas dinner. RN C told him the family pushed him down the hallway to leave and she (RN C) asked them to sign him out first. RN C told him that an aide noticed Resident #1 did not look right. RN C told him the aide got RN C and she determined he needed to be sent to the hospital. When asked if he believed this should have been self-reported to HHSC he stated he did not because Resident #1 had a history of drug use. He stated he got kicked out of his previous facility for smoking marijuana. He stated he did not believe drugs were pushed on him, rather that he asked for them. When asked if there was any kind of investigation conducted, he stated he was waiting until he could interview Resident #1 once he returned from the hospital because that would be the main source of his investigation. He stated he had seen Resident #1 a few times on 12/25/23 during the day and he was his normal self. He stated he was not sure if he had any other visitors that day but did regularly have friends that visited him in the facility. He stated he had noticed that not all visitors signed in the visitor log when they entered the facility. He stated he planned on banning the three family members that visited him that day. He stated there was nothing in his care plan regarding his history of drug use because they had not had any incidents with Resident #1 and drugs while he had been at the facility. A request was made at this time for any admitting documents or documentation from his previous facility. During an observation and interview on 12/28/23 at 11:41 AM, the Receptionist stated she worked Monday - Friday from 8:00 AM - 5:00 PM. She stated there was not a receptionist that worked on weekends and she did not work on Christmas Day. She stated visitors were to sign-in in their Visitor Logbook, and she pointed across the lobby to a binder. Record Review of the Visitor Logbook in the lobby, from 12/01/23 - 12/28/23, reflected no documented visitors for Resident #1. During an interview on 12/28/23 at 11:49 AM, LVN D stated she did not work on Christmas Day, but is almost always Resident #1's nurse on days she was working at the facility. She stated he often had visitors such as friends and family that would come by. She stated she had never heard of him requesting illegal substances of any kind. During a telephone interview on 12/28/23 at 1:31 PM, Resident #1's FM B stated that the current hospitalization was the second mysterious incident that has happened to Resident #1 at this facility. He stated on 12/08/23 he was sent to the hospital with the same symptoms, but a drug test was not performed. He stated the family members that visited him on 12/25/23 were family members from the other side of the family. He stated an incident like these two had not happened before at any other facility and Resident #1 had been residing in nursing facilities for over 20 years. He stated at most nursing facilities, you had to sign in when you entered, and this facility did not do that. He stated there is a book but no one enforced the rule. He stated he had never signed in and no one had ever asked who he was. He stated Resident #1 did have a history of drug abuse which is what led to him needing nursing facility care. He stated he asked Resident #1 at the hospital if he requested drugs and he responded, Why would I request something that could kill me? During a telephone interview on 12/28/23 at 2:11 PM, RN C stated she was working on 12/25/23 when Resident #1 had to be sent to the hospital. She stated during the day he was acting normal and there was nothing out of the usual. She stated in the evening, three family members that she had never seen before came to see him and stated they were going to take him home for Christmas. As they made their way down the hall, she yelled for someone to sign him out first. She stated an aide, who she could not remember who it was, told her that Resident #1 did not look right. She stated she went and assessed him and he was slumped in his wheelchair, was ashy white, eyes were dilated, and he could not talk - which was out of the norm for him. She stated his oxygen level was 81% and she told the family she was calling 911. She stated since the symptoms were very similar to the symptoms he experienced in early December, she requested that a drug test be conducted in the ER. During an interview on 12/28/23 at 2:24 PM, the ADM stated he could not find any admission documents or documents from Resident #1's previous facility. He stated he was an Interim ADM and was not working at the facility when Resident #1 was admitted . He stated the Admissions Coordinator that worked at the facility at that time no longer worked there. Review of the facility's Illegal Drug Use Policy, dated 09/01/23, reflected the following: This facility is an illegal drug-free facility. Illegal drugs are defined for the purpose of this policy as the use, possession, or distribution of any substances which is unlawful under the Controlled Substances Act. The facility reserves the right to inspect staff only areas, conduct staff alcohol and drug testing, and terminate staff employment for violation of this policy. 1. No one is allowed to possess, be under the influence of, or use any of said illegal drugs on the premises of this facility. The ADM was notified on 12/28/23 at 2:47 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 12/29/23 at 11:31 AM: F 689 - The facility failed to ensure resident environment remains as free of accident hazards as possible On 12/28/2023 an abbreviated survey was initiated at (facility). On 12/28/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to resident health and safety. The notification of Immediate Jeopardy states as follows: Per the ADM, Resident #1 has a history of drug use and was kicked out of his old facility for smoking marijuana. He stated they did not investigate the incident because it was his belief that the family brought in the drugs, due to the resident being fine during the day until the family arrived. During an interview with Resident #1's FM revealed that there is no way of knowing who gave the resident his drugs. However, there is no way for the resident to get the drugs himself, regardless of if he asks for them or not. He stated they have no visitation process, and no one has ever asked him to sign in and anyone could just walk into the facility whenever. Interviews with staff revealed Resident #1 has family and friends visiting him often. Review of the Visitor Log at the entrance of the facility reflected no visitors had signed in for this resident for the month of December. There is nothing in Resident #1's CP regarding a history of drug use/addiction, so no interventions were in place. Immediate Action: 1. Action: Resident returned from the hospital and assessed by licensed nurse and care plan updated by MDS Nurse. Current interventions include scheduling a care conference with resident and responsible party to discuss current interventions put into place to prevent reoccurrence. Resident is receiving (psychiatry care services). Referral for face-to-face visit requested. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 5:35 p.m. Responsible: MDS Nurse and Charge Nurse 2. Action: Incident report completed by Interim DON of alleged incident occurring on 12/25/2023 Start Date: 12/28/2023 Completion Date: 12/28/2023 @ 4:42 p.m. Responsible: Interim DON 3. Action: Ad Hoc QAPI Notified Medical Director of IJ template and action items to lower the immediacy. Start Date: 12/28/2023 Completion Date: 12/28/2023 @ 6:34 p.m. Responsible: Administrator, Medical Director, [NAME] President of Clinical Operations Identification of Resident(s) Affected or Likely to be Affected: 1. Action: Review of all residents ICD-10 codes completed by MDS nurse for identification of other residents with illicit drug history to ensure care plans are in place. No other residents identified. Start Date: 12/28/2023 Completion Date: 12/29/2023 at 5:00 p.m. Responsible: MDS Nurse Actions to Prevent Occurrence/Recurrence: 1. Action: Education provided to Administrator and Interim DON on investigating allegations of residents under the facility's care being on illegal drugs and contacting the proper authorities. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 5:35 p.m. Responsible: [NAME] President of Clinical Operations 2. Action: Signage posted at all facility entrances on no illicit drugs are to be brought in by visitors and/or staff. All facility staff educated on signage posted at all entrances indicating no illicit drugs are to be brought in by visitors and/or staff prior to working their next shift. All new hires will be educated prior to working their first shift. Administrator will designate Department Managers and/or designee to visualize signage remains in place every 8 hours x 7 days a week x 4 weeks. Start Date: 12/28/2023 Completion Date: 12/28/2023 at 6:30 p.m. Responsible: Administrator, Department Managers, [NAME] President of Clinical Operations, and/or designee 3. Action: Visitor log placed at nursing station for facility staff to write name of who is visiting and which resident they are visiting. All facility staff educated on new visitor log and how to complete prior to working their next shift. All new hires will be educated prior to working their first shift. Start Date: 12/28/2023 Completion Date: 12/28/2023 7 p.m. Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, and/or designee 4. Action: All facility staff educated on Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately. Start date: 12/29/2023 Completion: 12/29/2023 Responsible: Administrator, Interim DON, [NAME] President of Clinical Operations, and/or designee Action Item: Monitoring for compliance Vice President of Clinical Operations will review all Incident and Accident reports 5 days a week (Monday to encompass Friday-Sunday) x 4 weeks to ensure thorough investigations were completed and interventions care planned. MDS nurse to complete weekly audits of residents ICD-10 codes for current illicit drug use and/or history and such is care planned. Interim DON to audit visitor list at nurses station 5 days a week (Monday to encompass Friday-Sunday) x 4 weeks to ensure visitors are appropriately logged and log indicates which resident they were visiting. Interim DON and/or ADON to validate all staff education completed weekly x 4 weeks. Administrator to validate completion of the above weekly x 4 weeks. Vice President of Clinical Operations to validate completion of the above weekly x 4 weeks. Start Date: 12/28/2023 Completion Date: 2/1/2023 Responsible: [NAME] President of Clinical Operations, MDS nurse, Interim DON, Administrator and/or designee The Surveyor monitored the POR on 12/29/23 as followed: Observation on 12/29/23 at 2:24 PM revealed a sign on the entrance door that read ATTENTION ALL STAFF AND VISITORS: ILLICIT DRUGS ARE NOT PERMITTED TO BE BROUGHT INTO THE FACILITY OR GIVEN TO ANYONE AT THE FACILITY. During interviews on 12/29/23 from 2:58 PM - 5:55 PM with one HSKA, three LVNs, one MA, and two CNAs revealed they were all in-serviced before their shifts on illegal drugs not be allowed in the facility, on the facility's Illegal Drug Use Policy and immediately reporting any illegal drugs found in a residents room or on the facility grounds to the Administrator immediately, the signage posted on all entrance/exit doors regarding no illegal drugs were to be brought in, and the new visitor sign-in process. Observation on 12/29/23 at 3:32 PM revealed a visitor logbook at the nurses' station that was highly visible. There was a large sign that read ALL VISITORS MUST SIGN IN AT THE NURSES STATION. Review of an in-service entitled Illegal Drug Signage conducted by the MDSC, dated 12/28/23, reflected staff were educated on the following: There is a sign posted at the entrance for all staff and visitors that illicit drugs are not permitted to be brought into the facility or given to anyone in the facility. Review of an in-service conducted by the VPCO , dated 12/28/23, reflected staff were educated on the following: Anytime we receive information from outside entities or facility staff and/or visitors regarding illegal drug use the investigation must be started immediately and reported to the Police Department and HHSC if warranted. Review of the facility's Ad Hoc QAPI meeting, dated 12/28/23, reflected the following were in attendance: ADM, VPCO, RDO, and MD. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for 1 of 8 (Resident # 1 residents reviewed for abuse. The facility failed to ensure Resident # 1 was not assaulted by Resident # 4 on [DATE]. Resident #1 was hospitalized on [DATE] and died from the injuries sustained on [DATE]. Resident # 1 had a history or wandering in residents rooms and Resident # 4 had a history of aggressive behaviors towards other residents and staff. An IJ was identified on [DATE]. The IJ began on [DATE] and removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm that was not immediate Jeopardy and a severity level of isolated because (e.g.) all staff had not been trained on abuse/neglect, supervision, wandering/ elopement signs. This failure placed all residents at risk of being Abused. Findings included: Record review of Resident # 1 and Resident #4 records are closed records. Resident # 1 discahrged from facility to hopsital on [DATE] and died on [DATE]. Resident # 4 transferred to another facility not to return to this facility on [DATE]. Record review of Resident #1's face sheet reflected she was a [AGE] year-old woman admitted to the facility on [DATE]. Resident # 1 was admitted with diagnoses of Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Alzheimer's (a type of Dementia that affects memory, thinking and behavior), Cirrhosis of the Liver (severe scaring of the liver). Record review of Quarterly MDS dated [DATE], reflected Resident #1 had a BIMS score of 99 which indicated unable to complete assessment. Resident # 1 had a history of wander ing and exit seeking behaviors. Review of a Care Plan dated [DATE] reflected Resident # 1 had exit seeking behaviors and had the following interventions: Check for proper functioning of the wander guard system every shift Monitor resident for tail gaiting when visitor and staff exiting facility Reassess elopement risk at least quarterly Refer to social services as needed Use diversion activities when exit seeking behavior occurs Use verbal and if necessary physical cues for redirection to persuade exit-Convey acceptance during periods of inappropriate behavior Talk to resident during entire procedure of care seeking behaviors. Use wander guard system to alert staff of exit seeking behavior Record Review of hospital records dated [DATE]for Resident #1 reflected, Resident #1 was admitted to the hospital on [DATE]. The records reflected Resident # 1 was diagnosed with a Subdural Hematoma (a type of bleeding in which a collection of blood usually associated with a traumatic brain injury). The records reflected that Resident # 1 clinically decompensated and a repeat CT showed a worsening (SDH) Subdural Hematoma (a type of bleeding in which a collection of blood usually associated with a traumatic brain injury) and a (SAH) Seperatical Subarachroid Hemorrhage bleeding that is spreading to other parts of the body). The medical records further reflected that on [DATE] Resident # 1 had a decompressive craniotomy (used to treat intercranial pressure that is unresponsive to conventional treatment for SDH/SAH). Review of Resident #4 face sheet reflected he was a [AGE] year-old man admitted to the facility on [DATE]. Resident # 4 was admitted with a diagnosis of Generalized Epilepsy ( a form of epilepsy characterized by general seizures with no apparent cause), Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), Congenital deformity of spine (the vertebrae don't form properly very early in fetal development), Contracture right elbow(an injury that causes pain and limits bending of the elbow), Unspecified Dementia(a Mental disorder in which a person loses the ability to think, remember, learn, and make decisions), Unspecified Psychosis (when there is inadequate information to make the diagnosis of a specific psychotic disorder), Moderate intellectual disabilities (intellectual and adaptive functioning that are approximately three to four standard deviations below the mean), and Schizoaffective Disorder(a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder). Record review of Resident # 4 MDS dated [DATE] reflected a BIMS score of 00 (which indicated the resident does not have the cognitive ability for the assessment to be completed). The MDS reflected Resident # 4 is ambulatory no assistance walking or with transfers. Resident #4 has a contracted arm, so he only has the use of one arm. Requires assistance dressing, some ADL's. Record review of Resident #4 care plan dated [DATE], reflected a behavior to be physically aggressive. The plan reflected that Resident # 4 is very protective of his belongings and has become aggressive with staff and recently with another resident. Interventions included: Administer medications as ordered, analyze time of day, places, circumstances, triggers, and what de-escalates behavior and document. Monitor Q shift (every shift) and document observed behavior and attempted interventions Monitor/document any signs /symptoms that resident is posing a danger to self or others Staff to provide Q 15minute (every shift) or Q 1-hour (every shift) checks as directed Staff will encourage resident to keep distance from other residents that provoke agitation Record review of facility progress notes dated [DATE] - [DATE] of Resident # 4 aggressive behaviors towards others, the incidents are as follows: Incident [DATE], Resident # 4 assaulted Resident # 1 causing death. Incident [DATE], Resident # 4 assaulted another resident. Incident [DATE], Resident # 4 assaulted another resident Incident [DATE], Resident # 4 assaulted staff member LVN D Observation of facility video dated [DATE], reflected Resident #1 going into Resident # 4's room earlier that day with several staff on the hall never redirected. The video showed there were two staff observed in the hall prior to Resident # 1 entering Resident # 4's room. The video showed LVN B on the hall, and another unknown staff no redirection was provided. Resident #1 sustained were a busted lip that was bleeding, busted nose, one tooth was knocked out, and swelling to the left side on her forehead. Resident # 1 died from the injuries she sustained. Observation on [DATE] at 12:30pm, revealed an unidentified resident wandering on the East end of the hall near the Pharmacy supply room, which was observed to be open at the time. No staff observed in the area to resident this resident. Observation on [DATE] at 4:00, revealed unidentified resident on far East end of the building, near back exit door. Resident came in conference where surveyor was working asking to be changed, no staff observed on hall, resident not redirected. During a phone interview on [DATE] at 5:21pm with LVN A, revealed she was working the day of the incident. She stated she provided one on one care and supervision for another resident. LVN A stated she saw Resident # 4 pushing something aggressively in his door, but could not see what, she stated when she walked down the hall, she saw Resident # 1 in the doorway of the Resident #4's room. LVN A described Resident #1 as laid with her head back and legs stretched out in her wheelchair. LVN A stated she pulled Resident # 1 out the room and called for help. LVNA stated Resident # 1 was conscience but seemed to be confused. In an interview on [DATE] at 2:22pm with LVN D, revealed one time when she tried to assist Resident # 2 with pouring the sugar, he got upset and grabbed her wrist. She stated Resident # 2 grabbed her wrist really hard and started to twist it, she stated it hurt and she yelled out in pain. LVN D stated when she yelled out Resident # 2 let her wrist go, stated her arm was red and it hurt. LVN D stated Resident # 1 was a wanderer and stated she had taken the Resident # 1 out of Resident # 2's room before maybe a week before and stated Resident # 1 was in his room while he was asleep watching him sleep. LVN D stated they would try to keep an eye on Resident # 1 throughout the day and redirect her if she went into someone's room. During a phone interview on [DATE] at 2:47pm with LVN B, revealed Resident # 1 was known to be a wanderer and had been known to wander into other resident's rooms. She stated on the day of the incident [DATE] early that day she pushed Resident # 1 off the 1 [NAME] Hall, back to the common area. She stated later she talked to Resident # 1 on the 1 [NAME] Hall but could not remember what she spoke to her about. She stated she did not remember what happened after she had spoken with Resident # 1. She stated she did not redirect Resident # 1 at that time because she was just sitting in the hall, she stated she was not bothering anyone she was just in her chair. LVN B stated she had been trained on abuse/neglect and stated the administrator is the abuse/neglect coordinator. She stated she had never seen or suspected abuse/neglect. In an interview on [DATE] at 3:10pm the ADM. stated Resident # 1 was a wanderer. He stated staff would redirect Resident # 1 when she would go into resident's rooms. The ADM. stated staff tried to keep Resident # 1 in their sight. He stated staff did not redirect Resident # 1 when she was assaulted because it was during dinner time and all staff assisted with dinner service for the other residents. In an interview on [DATE] at 4:21PM the DON stated Resident # 1 was a wanderer. She stated the resident wore a wander guard, they redirected Resident # 1, and tried to keep her in their sight the best they could. The DON stated the staff would make rounds every two hours to check on all the residents. In an interview on [DATE] at 5:00pm the ADON revealed, Resident #1 was a wanderer. She stated they often removed and redirected Resident # 1 from going into other resident's rooms and messing with their things. The ADON stated Resident # 1 wears a wander guard and stated they tried to keep an eye on her the best they could by redirecting, she stated the door alarm would go off if she got close to any of the doors. In a phone interview on [DATE] at 11:30am LE, revealed the facility contacted EMS at 5:55PM on [DATE] and they were dispatched to the facility. LE reported that Resident # 1 was assaulted by Resident #4 at the facility and was transported to the hospital for further treatment. The LE reported the resident that assaulted Resident # 1 was not arrested at the time of the incident due to his diagnosis. LE stated the case was sent to the District Attorney's office to see if charges would be filed. In a phone interview on [DATE] at 1:30PM MD, revealed that Resident # 1 died from the injuries sustained from being assaulted by another resident. He reported that Resident # 1 continued to hemorrhage (bleed) worsened and spread through other parts of Resident # 1 body, he stated Resident # 1 expired on [DATE]. Review of QAPI - (Quality Assurance and Performance Improvement) dated Nov. 2022- [DATE]. ADM. reported the incident was discussed in the meeting along with the other incidents and accidents. Record review of in-service completed [DATE], reflected staff in-serviced on Abuse/Neglect. Record review of facility Abuse /Neglect policy dated [DATE] which reflected: Our resident has the right to be free from abuse/neglect Protect our residents from neglect by anyone including but not necessarily limited to facility staff other residents, consultants, and volunteer staff from other agencies. An Immediate Jeopardy was identified on [DATE]. The ADM. was informed of the IJ on [DATE] and provided with the IJ template on [DATE] at 4:20pm. Record review on [DATE] reflects staff in-serviced on Dementia / Behavioral issues 73 staff have been in-serviced. Record review on [DATE] reflected the DON/ADON, and DON completed a training on governance and Leadership on [DATE]. Records review on [DATE] reflected staff were in-serviced on Dementia care 73 staff have been trained and 17 more staff still need to be trained. Review of records reflect 19 staff have been trained on the mealtime monitoring services. Review of records on [DATE] reflected residents identified as wander risk had been reassessed on [DATE], which indicated they were no longer a wander risk. Review of care plans on [DATE], reflected the care plans for residents identified as wander risk had been updated to reflect any new interventions. Record review on [DATE] reflected, the MD (Medical Director) was made aware of the IJ, consulted regarding the plan of removal and agreed with the plan presented. Record review on [DATE] reflected, a QAPI meeting was held on [DATE] the IJ was discussed and plan of correction. An IJ was identified on [DATE]. The IJ began on [DATE] and removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm that was not immediate Jeopardy and a severity level of isolated because (e.g.) all staff had not been trained on abuse/neglect, supervision, wandering/ elopement signs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and devices to prevent accidents for 2 of 8 (Resident #1, Resident # 4) residents reviewed for accidents and supervision. The facility failed to supervise and redirect Resident # 1 from entering Resident # 4's room resulting in Resident # 1 being assaulted by Resident # 4 on [DATE]. Resident # 1 died from the injuries sustained on [DATE]. Resident # 1 had a history of wandering behavior and would often wander into other residents rooms. Resident # 4 had a history of aggressive behaviors towards staff and residents. An IJ was identified on [DATE]. The IJ began on [DATE] and removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm that was not immediate Jeopardy and a severity level of isolated because (e.g.) all staff had not been trained on abuse/neglect, supervision, wandering/ elopement signs. This failure placed all residents at risk of accidents, hazards, hospitalization, and /or death. Findings included: Record review of Resident # 1 and Resident # 4 records are closed records review. Resident # 1 discharged to the hospital on [DATE] where she later died on [DATE]. Resident # 4 discharged from the facility on [DATE] return not expected. Record review of Resident #1's face sheet reflected she was a [AGE] year-old woman admitted to the facility on [DATE]. Resident # 1 was admitted with diagnoses of Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), Alzheimer's (a type of Dementia that affects memory, thinking and behavior), Cirrhosis of the Liver (severe scaring of the liver). Record review of Quarterly MDS dated [DATE], reflected Resident #1 had a BIMS score of 99 which indicated unable to complete assessment. Review of a Care Plan dated [DATE] reflected Resident # 1 had exit seeking behaviors and had the following interventions: Check for proper functioning of the wander guard system every shift Monitor resident for tail gaiting when visitor and staff exiting facility Reassess elopement risk at least quarterly Refer to social services as needed Use diversion activities when exit seeking behavior occurs Use verbal and if necessary physical cues for redirection to persuade exit-Convey acceptance during periods of inappropriate behavior Talk to resident during entire procedure of care seeking behaviors. Use wander guard system to alert staff of exit seeking behavior Review of Resident #4 face sheet reflected he was a [AGE] year-old man admitted to the facility on [DATE]. Resident # 4 was admitted with a diagnosis of Generalized Epilepsy ( a form of epilepsy characterized by general seizures with no apparent cause), Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), Congenital deformity of spine (the vertebrae don't form properly very early in fetal development), Contracture right elbow(an injury that causes pain and limits bending of the elbow), Unspecified Dementia(a Mental disorder in which a person loses the ability to think, remember, learn, and make decisions), Unspecified Psychosis (when there is inadequate information to make the diagnosis of a specific psychotic disorder), Moderate intellectual disabilities (intellectual and adaptive functioning that are approximately three to four standard deviations below the mean), and Schizoaffective Disorder(a combination of symptoms of schizophrenia and mood disorder, such as depression or bipolar disorder). Record review of Resident # 4 MDS dated [DATE] reflected a BIMS score of 00 (which indicated the resident does not have the cognitive ability for the assessment to be completed). Resident # 4 was ambulatory no assistance walking or with transfers. Resident #4 has a contracted arm, so he only has the use of one arm. Requires assistance dressing, some ADL's Record review of Resident #4 care plan dated [DATE], reflected a behavior to be physically aggressive. The plan reflected that Resident # 4 is very protective of his belongings and has become aggressive with staff and recently with another resident. Interventions included: Administer medications as ordered, analyze time of day, places, circumstances, triggers, and what de-escalates behavior and document. Monitor Q shift (every shift) and document observed behavior and attempted interventions Monitor/document any signs /symptoms that resident is posing a danger to self or others Staff to provide Q 15minute (every shift) or Q 1-hour (every shift) checks as directed Staff will encourage resident to keep distance from other residents that provoke agitation Record review of facility progress notes dated [DATE] - [DATE] of Resident # 4 aggressive behaviors towards others, the incidents are as follows: Incident [DATE], Resident # 4 assaulted Resident # 1 causing death. Incident [DATE], Resident # 4 assaulted another resident. Incident [DATE], Resident # 4 assaulted another resident Incident [DATE], Resident # 4 assaulted staff member LVN D In an interview on [DATE] at 4:00pm LVN C, stated Resident # 1, was a wanderer. She statedshe wore a wander guard, so this would alert them if the resident went near the exit doors. She stated they monitored by redirecting the resident and checking on her every two hours. During a phone interview on [DATE] at 5:21pm LVN A, revealed that Resident # 1, was a wanderer and they monitored as best as they could. LVN A stated they monitored by redirecting, tried to keep her close to the nurse's station, and when they completed their two- hour checks on all residents. LVN A described Resident # 4 as being pleasant when around others, stated she had heard that he was aggressive with others but stated she had never seen Resident # 4 be aggressive. During a phone interview on [DATE] at 2:47pm LVN B, revealed Resident # 1, was a wander stated they monitored by redirecting the resident and she wore a wander guard so if she went close to the doors the alarm would sound. LVN B stated Resident # 4 had been aggresive with other residents in the past, and stated also a staff member. LVN B stated Resident # 4 is usually a happy person who likes to speak to everyone when walking down the halls. In an interview on [DATE] at 2:22pm with LVN D, revealed one time when she tried to assist Resident # 4 with pouring the sugar, he got upset and grabbed her wrist. She stated Resident # 2 grabbed her wrist really hard and started to twist it, she stated it hurt and she yelled out in pain. LVN D stated when she yelled out Resident # 4 let her wrist go, stated her arm was red and it hurt. LVN D stated Resident # 1 was a wanderer and stated she had taken the Resident # 1 out of Resident #4's room before maybe a week before and stated Resident # 1 was in his room while he was asleep watching him sleep. LVN D stated they would try to keep an eye on Resident # 1 throughout the day and redirect her if she went into someone's room In an interview on [DATE] at 2:00pm with CNA A, B, and C, revealed Resident # 1, was identified as a wanderer. They reported that they monitored the resident movements by keeping her close to the nurse's station throughout the day. They reported the resident also wore a wander guard and she went close to the doors the alarm would sound and alert them. CNA A, B, and C stated they monitored Resident # 1, the best that they could. CNA A, B, and C stated Resident # 4 was usuaully happy, he liked to interact with others and wave when he walked down the halls. CNA A, B, and C stated Resident # 4 had been aggressive with other residents and with another staff member. They stated Resident # 4 was protective of his things and didn't like people messing with this things such as his hats and sun glasses that he always wore. In an interview on [DATE] at 4:45pm with DON revealed, Resident # 1, was a wanderer and staff must redirect resident. She stated they monitor the resident every two hours and check the wander guard daily to ensure that it is working. The DON described Resident # 4 as pleasant, happy guy and stated this was the first aggressive behavior she had seen by Resident # 4 since she started at the facility. In an interview on [DATE] with ADM. revealed all staff were aware that Resident # 1, was a wanderer. He stated the resident wore a wander guard that would alarm if she went near the doors. He stated Resident # 1was injured by Resident # 4 during dinner time service and the staff were passing trays to the other residents. The administrator stated they had their QAPI meeting on [DATE] and they discussed their incidents and reportable findings and that the facility had been substantiated but not cited. The administrator did not indicate that there was any discussion regarding monitoring of the other residents, how t the incident occurred and what they needed to do to prevent an incident like this from happening again. He stated they did not talk about the incident in detail. The administrator stated that he was not able to put every resident on one-to-one supervision. Records Review of in-service completed [DATE], revealed staff in-serviced on Abuse/Neglect. Review of facility Abuse /Neglect policy dated [DATE] which reflected: Our resident has the right to be free from abuse/neglect Protect our residents from neglect by anyone including but not necessarily limited to facility staff other residents, consultants, and volunteer staff from other agencies. Record Review of Wander guard Policy dated [DATE] reflected the following: 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Record Review of facility Safety and Supervision of Residents policy dated [DATE] reflected the following: 1. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee trainings, employee monitoring, and reporting process. 2. Our individualized, resident- centered approach to safety addresses safety and accident hazards for individual residents 3. The are team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Monitoring the effectiveness of interventions to include the following: a. Evaluating the effectiveness of interventions b. Modifying and replacing interventions as needed c. Ensuring that interventions are implemented correctly and consistently An Immediate Jeopardy was identified on [DATE]. The ADM. was informed of the IJ on [DATE] and provided with the IJ template on [DATE] at 4:20pm. Observation of facility video dated [DATE], reflected Resident #1 going into Resident # 4's room earlier that day with several staff on the hall never redirected. The video showed there were two staff observed in the hall prior to Resident # 1 entering Resident # 4's room. The video showed LVN B on the hall, and another unknown staff no redirection was provided. Resident #1 sustained were a busted lip that was bleeding, busted nose, one tooth was knocked out, and swelling to the left side on her forehead. Resident # 1 died from the injuries she sustained. Observation of facility video dated [DATE], reflected Resident #1 going into Resident # 4's room that day with several staff on the hall with no redirection provided. Observation on [DATE] at 12:30pm, revealed an unidentified resident wandering on the East end of the hall near the Pharmacy supply room, which was observed to be open at the time. No staff observed in the area to resident this resident. Observation on [DATE] at 4:00, revealed unidentified resident on far East end of the building, near back exit door. Resident came in conference where surveyor was working asking to be changed, no staff observed on hall, resident not redirected. In an interview on [DATE] at 3:30pm with CNA D revealed, he had been trained on abuse/neglect, wandering and supervision, resident rights. Stated the abuse /neglect protocol is to report if they see or suspect abuse /neglect to the administrator who is the abuse/ neglect coordinator. Stated they have been trained on monitoring during mealtimes, stated residents are being required to dine in their room or in the dining room so they can ensure supervision of the residents. Stated she looked at the [NAME] to see what a resident's care needs were and the nurse updated them when changes were made to the care plan. Stated rounds are made every two hours or as needed when residents use their call lights. In an interview on [DATE] at 3:40 with CNA E revealed, he had been trained on abuse/neglect, wandering and supervision, resident rights. Stated they have been trained on monitoring during mealtimes, stated residents are being required to dine in their room or in the dining room so they can ensure supervision of the residents. Stated he looked at the [NAME] to see what a resident's care needs were and the nurse updated them when changes were made to the care plan. Stated rounds are made every two hours, stated however throughout the day they are walking the halls. Stated the abuse /neglect protocol is to report if they see or suspect abuse /neglect to the administrator who is the abuse/ neglect coordinator. In an interview on [DATE] at 3:50pm with CNA F revealed, she had been trained on abuse/neglect, wandering and supervision, resident rights. Stated she looked at the [NAME] to see what a resident's care needs were and the nurse updated them when changes were made to the care plan. Stated rounds are made every two hours, stated however throughout the day they are walking the halls. Stated they have been trained on monitoring during mealtimes, stated residents are being required to dine in their room or in the dining room so they can ensure supervision of the residents. Stated the abuse /neglect protocol is to report if they see or suspect abuse /neglect to the administrator who is the abuse/ neglect coordinator. In an interview on [DATE] with DON, stated all nursing and CNA staff have been trained on how to review the [NAME] in the PCC (point click care system) and know what the care needs are for the residents. She stated the nurses would continue to train staff on changes with residents on admission and as they occur with the residents. DON stated they would continue to assess the residents for wandering and elopement risk and make changes to interventions as they go. In an interview on [DATE] with ADM. Stated was his expectation that all staff get the needed training, and they follow the care plans of the residents when providing care and supervision. He stated they would continue to monitor and make changes as needed to their facility policies and systems that are in place. Record review on [DATE] reflects staff in-serviced on Dementia / Behavioral issues 73 staff have been in-serviced. Record review on [DATE] reflected the DON/ADON, and DON completed a training on governance and Leadership on [DATE]. Records review on [DATE] reflected staff were in-serviced on Dementia care 73 staff have been trained and 17 more staff still need to be trained. Review of records reflect 19 staff have been trained on the mealtime monitoring services. Record review on [DATE] of wander assessment dated [DATE] reflected, Resident # 1 and Resident # 2 are no longer identified as risk for wandering or elopement from the facility. Records Review of care plans on [DATE], reflected the care plans for Resident # 2 reflected no changes to the current interventions in place. The care plan for Resident # 3 reflected new interventions in place and that Resident # 3 has a wander guard for wandering and elopement. Record review on [DATE] reflected, the MD was made aware of the IJ, consulted regarding the plan of removal and agreed with the plan presented. Record review on [DATE] reflected, a QAPI meeting was held on [DATE] the IJ was discussed and plan of correction. An IJ was identified on [DATE]. The IJ began on [DATE] and removed on [DATE]. The facility took action to remove the IJ before the survey began. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm that was not immediate Jeopardy and a severity level of isolated because (e.g.) all staff had not been trained on abuse/neglect, supervision, wandering/ elopement signs.